Kottkamp H, Hindricks G, Borggrefe M, Breithardt G
Department of Cardiology and Angiology, Hospital of the Westfälische Wilhelms-University, Münster, Germany.
J Cardiovasc Electrophysiol. 1997 Apr;8(4):451-68. doi: 10.1111/j.1540-8167.1997.tb00812.x.
Radiofrequency catheter ablation has been established as a first-line curative treatment modality in patients with symptomatic AV nodal reentrant tachycardia (AVNRT). The successful sites of stepwise catheter ablation approaches of the so-called fast and slow pathways strongly suggest that AVNRT involves the atrial approaches to the AV node. The typical fast pathway ablation sites are located anterosuperior toward the apex of the triangle of Koch, which also contains the compact AV node, whereas the usual slow pathway ablation sites are located posteroinferior toward the base of the triangle of Koch at a greater distance to the compact AV node and bundle of His. Accordingly, ablation studies with large patient cohorts have demonstrated that fast pathway ablation carries a higher risk of inadvertent complete AV block. Thus, the slow pathway is clearly the primary target site, and fast pathway ablation is rarely necessary. Different approaches for slow pathway ablation have been elaborated: anatomically oriented stepwise techniques, ablation guided by double potentials recorded within the area of the slow pathway insertion, and combined techniques. The modern concept of AVNRT suggests that this arrhythmia involves the highly complex three-dimensional nonuniform anisotropic AV junctional area. Accordingly, mapping and ablation studies demonstrated that the anterior approach is not identical with fast pathway ablation, and the posterior approach is not identical with slow pathway ablation. Therefore, it is essential for interventional electrophysiologists to familiarize themselves with the anatomic and electrophysiologic details of this complex and variable specialized AV junctional region. In this review, the anatomic and pathophysiologic aspects of the AV junctional area as they relate to interventional therapy are summarized briefly, and the catheter techniques for ablation of the so-called fast and slow AV nodal pathways for the treatment of AVNRT are described.
射频导管消融已被确立为有症状的房室结折返性心动过速（AVNRT）患者的一线根治性治疗方式。所谓快径和慢径的逐步导管消融方法的成功部位强烈提示，AVNRT涉及心房至房室结的路径。典型的快径消融部位位于科赫三角顶点的前上方，该区域也包含致密房室结，而通常的慢径消融部位位于科赫三角底部的后下方，距离致密房室结和希氏束较远。因此，对大量患者队列的消融研究表明，快径消融导致意外完全性房室传导阻滞的风险更高。因此，慢径显然是主要靶点，很少需要进行快径消融。已经阐述了不同的慢径消融方法：解剖学导向的逐步技术、在慢径插入区域记录的双电位引导下的消融以及联合技术。AVNRT的现代概念表明，这种心律失常涉及高度复杂的三维非均匀各向异性房室交界区。因此，标测和消融研究表明，前入路与快径消融不同，后入路与慢径消融不同。因此，介入电生理学家必须熟悉这个复杂多变的特殊房室交界区的解剖和电生理细节。在这篇综述中，简要总结了房室交界区与介入治疗相关的解剖和病理生理方面，并描述了用于治疗AVNRT的所谓快慢房室结径路消融的导管技术。
