AVNRT的消融

曹娥江 2012-09-11

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AVNRT的消融

2012-08-02

确认导管进入冠状静脉窦后，在 x线右前斜30°时可见导管在进入冠状窦时有一个明显的向左上转折点而确定为窦口位置，将导管后撤至近端电极位于窦口处，由于冠状窦内滞留的导管较少并保持一定向上的张力以使导管尽可能贴近冠状窦口上缘，近端一对电极记录冠状窦口处A 波，代表Koch三角的X线解剖底部和激动时间。His束导管以远端电极记录到清晰H 波后反复调整导管位置以记录到最大H 波（大于0.5mv）为标准确定His束部位。行心房及心室递增和程序刺激以诱发室上性心动过速，明确为慢快型房室结折返性心动过速后置入大头导管，于冠状窦口上缘至三尖瓣环侧标测，记录到小A大V 波，A波后可见延迟电位行射频消融，如果无交界性心律出现，靶点向冠状窦口上、下方移动，向上不超过冠状窦口至His束连线下1/3，向下至冠状窦口下缘，以上均无效则将大头导管置于窦口内，每次消融后，重复诱发窗口，以慢径消失为成功靶点。

The location of the compact part of the atrioventricular (AV) node and the rightward and leftward inferior extensions of the AV node are
superimposed on the right-sided view of the AV septal junction in the same human heart.

Posterior to Tendon of Todaro — Slow/Fast (S/F) AVNRT
Inferior Triangle of Koch or CS — Slow/Slow (S/S) AVNRT

慢快型为房室结慢径前传，快径逆传，AH 间期通常≥200ms. During typical AVNRT, atrial and ventricular activations occur almost simultaneously. The AH interval is relatively long (more than 200 milliseconds) and the HA interval is relatively short (less than 70 milliseconds), resulting in a short RP tachycardia.

快慢型为房室结快径前传，逆传呈典型慢径逆传顺序（CS窦口水平A波领先），AH间期通常小于HA间期，且 AH间期<200ms；

慢慢型为房室结慢径前传，逆传呈典型慢径逆传顺序，AH间期通常≥200ms。

FIGURE 13–15 Entrainment of typical atrioventricular nodal reentrant tachycardia (AVNRT) with right ventricular (RV) apical pacing. The post-pacing interval supraventricular tachycardia cycle length (PPI ? SVT CL) is more than 115 msec, and the ΔVA interval (VA pacing ? VA SVT ) is more than 85 msec. The atrial activation sequence during ventricular pacing is identical to that during AVNRT. No QRS fusion is observed. Cessation of ventricular pacing is followed by an A-V response. PCL = pacing CL.

FIGURE 13–18 Ablation of the slow atrioventricular node (AVN) pathway.

Upper panel, Right anterior oblique (RAO) and left anterior oblique (LAO) fluoroscopic views of typical catheter setup during atrioventricular nodal reentrant tachycardia (AVNRT) ablation. The ablation catheter (ABL) is positioned at the slow pathway location in the lower portion of the triangle of Koch, away from the His bundle (HB) and anterior to the coronary sinus (CS) (those landmarks are defined by the HB and CS catheters, respectively).

Lower panel, Intracardiac recordings during ablation of the slow pathway. Note the sharp (blue arrow, left lower panel) and broad (red arrow, right lower
panel) potentials recorded between the atrial and ventricular electrograms at the ablation sites. Those potentials were suggested to reflect activation of the slow pathway (slow pathway potentials).