Original Articles Korean Circulation J 2000;302:153-165 심방빈맥의고주파전극도자절제술 안신기 이문형 편욱범 김성순 Radiofrequency Catheter Ablation of Atrial Tachycardia Shinki Ahn, MD, Moon Hyoung Lee, MD, Wook Bum Pyun, MD and Sung Soon Kim, MD Cardiology Division, Yonsei Cardiovascular Center, College of Medicine, Yonsei University, Seoul, Korea ABSTRACT Radiofrequency catheter ablation RFCA has been established as an effective and safe treatment modality for atrioventricular nodal reentrant tachycardia and WPW syndrome. Surgical ablation or direct current catheter ablation had been performed to cure focal atrial tachycardia AT, however, these treatments had limitations such as the need of open thoracotomy or the risk of barotrauma. RFCA could be an effective treatment modality for cure of AT. We performed RFCA for AT in 22 patients male 13, mean age 38.115.4 years among 831 patients who underwent electrophysiologic study between Jul. 1996 and May. 1999. Clinical pattern of tachycardia was paroxysmal 17 patients or incessant mean duration of symptoms, 41.142.3 months. Associated cardiac diseases were tachycardia-mediated cardiomyopathy 3 patients, aortic stenosis 1 patient and ventricular septal defect with pulmonic stenosis 1 patient. AT was induced by programmed electrical stimulation in 17 patientsat in the other 5 patients was incessant. The RFCA was successful in 17 patients 77.3%. The mean interval between atrial electrogram of mapping catheter and P wave of surface ECG was 53.524.9msec in 17 successful sites. Fractionated atrial activities were invariably found in the successful sites. Successful sites of RFCA for right AT were around coronary sinus ostium 5, crista terminalis 4, lower portion of sinus node 1, inferior portion of tricuspid annulus 1, and His area 1, respectively. In left AT, lateral portion near atrioventricular groove 2, inferoposterior portion 2 and near left atrial appendage 1 were successful site. During follow-up mean 23 months, one patient had recurrence recurrence rate 5.9%. RFCA for AT is an effective and curative treatment in selected cases. Korean Circulation J 2000;302:153-165 KEY WORDSAtrial tachycardia Radiofrequency catheter ablation. 서 론 153
대상환자 Table 1. Clinical characteristics of 22 patients with atrial tachycardia 대상및방법 Case Age / Sex Duration month Pattern of tachycardia Cardiac disease Clinical diagnosis 1 36/M 120 Incessant AT 2 33/M 8 Paroxysmal AVRT, AT 3 52/F 12 Paroxysmal AVNRT 4 51/F 9 Paroxysmal AVNRT 5 40/M 12 Paroxysmal AT 6 58/F 36 Paroxysmal AVNRT 7 50/F 36 Incessant t-cmp AT 8 14/M 36 Paroxysmal AT 9 34/F 84 Paroxysmal AT 10 62/M 36 Paroxysmal AVRT 11 50/M 14 Incessant AT 12 24/M 12 Paroxysmal WPW* 13 55/M 120 Paroxysmal AT 14 28/M 8 Paroxysmal AT 15 31/F 36 Paroxysmal AVRT 16 28/M 120 Incessant AT 17 11/M 5 Incessant VSD, PS s/p op AT 18 40/M 2 Paroxysmal AS AT 19 38/F 48 Paroxysmal AVRT 20 19/F 14 Paroxysmal t-cmp AT 21 63/M 17 Paroxysmal t-cmp WPW, Afib, AT 22 22/M 120 Paroxysmal AVRT *A case with ventricular preexcitation and typical symptom of tachycardia Afibatrial fibrillation, ASaortic stenosis, ATatrial tachycardia, AVNRTatrioventricular nodal reentrant tachycardia, AVRTatrioventricular reentrant tachycardia, PSpulmonic stenosis, t-cmptachycardia-mediated cardiomyopathy, VSDventricular septal defect, WPWWolff-Parkinson-White syndrome 154 Korean Circulation J 2000;302:153-165
전기생리학검사 (Electrophysiologic study) 원발병소의지도화 (Mapping for the focus of atrial tachycardia) 155
고주파전극도자절제술 (Radiofrequency catheter ablation) Fig. 1. Mapping for the focus of AT in the case 15. Surface ECG A showed a positive P wave in avl lead and negative P waves in II, III, avf leads, which suggested the origin of AT was around inferior portion of right atrium RA. Two decapolar catheters were placed in RA and coronary sinus CS, 2 quadripolar catheters in His, right ventricular apex RVA and a mapping catheter Map. In intracardiac electrograms, the atrial activity of low RA LRA was earlier than His and proximal portion of CS CSos. Mapping catheter showed fractionated atrial electrogram, which was earlier than those of the other atrial activities. AT was terminated at this site by RF current. 156 Korean Circulation J 2000;302:153-165
심방빈맥의특성 결과 Table 2. Findings of electrophysiologic study in 22 patients with atrial tachycardia Case Iuducibility / PES Iso Coexisting arrhythmia TCL Map-to- msec A Interval Site / Approach RF success/ Result Follow-up month total 1 No/Incessant 360 20 RA CSos/IVC 0/19 F 2 Yes/SAEST CBT 480 50 LA AVG, lateral/ta 2/ 4 S NR 38 3 Yes/SAEST AVNRT, AFL 300 30 RA CT/IVC 7/10 S NR 35 4 Yes/DAEST AVNRT 380 40 RA CT/IVC 6/ 7 S NR 35 5 Yes/SAEST DAVNP 360 45 RA CSos/IVC 2/ 4 S NR 35 6 Yes/SAEST 340 20 RA Septum/IVC 0/14 F 7 No/Incessant 400 75 LA Lateral/TS 4/ 8 S NR 32 8 Yes/SAEST 460 50 LA AVG, lateral/pfo 2/ 4 S NR 31 9 Yes/SAEST 440 70 RA CSos/IVC 29/32 S NR 28 10 Yes/TAEST 340 30 RA Septum/IVC 0/21 F 11 No/Incessant 360 60 RA CSos/IVC 1/ 5 S NR 28 12 Yes/SAEST, RAP WPW 370 70 LA UPV/TA 0/25 F 13 Yes/SAEST 490 40 RA SAN/IVC 1/ 4 S NR 26 14 Yes/SAEST 210 30 LA Inferoposterior/TA 1/ 4 S NR 25 15 Yes/SAEST, RAP 390 80 RA CSos/IVC 16/19 S NR 24 16 No/Incessant 410 20 LA UPV/TS 0/12 F 17 Yes/SAEST, RAP 360 50 RA Lateral, scar/ivc 12/22 S NR 24 18 Yes/SAEST, RAP 420 70 RA CSos/IVC 8/ 9 S R 18 19 Yes/SAEST, RAP DAVNP 370 35 RA His/IVC 17/19 S NR 7 20 No/Spontaneous 380 30 RA CT/IVC 13/15 S NR 5 21 Yes/SAEST, RAP WPW, Afib 310 30 LA Inferior septum/ta 1/ 2 S NR 3 22 Yes/JEB CBT, AVNRT 320 125 RA Inferior TVA/IVC 7/11 S NR 2 Afibatrial fibrillation, AVGatrioventricular groove, AVNRT atrioventricular nodal reentrant tachycardia, CBT concealed bypass tract, CSos ostium of coronary sinus, CT crista terminalis, DAVNP dual atrioventricular nodal physiology, Isoisoproterenol, IVCinferior vena cava, JEBjunctional escape beat, LAleft atrium, NRno recurrence, PESprogrammed electrical stimulation, PFOpatent foramen ovale, Rrecurrence, RAright atrium, RAPrapid atrial pacing, SAESTsingle atrial extrastimulus, SANsinoatrial node, TA transaortic, TAESTtriple atrial extrastimuli, TStransseptal, UPVupper pulmonic vein, WPWWolffParkinson White syndrome 157
지도화및전극도자절제술결과 Table 3. Clinically documented and induced arrhythmias in 6 patients with multiple arrhythmias Case Documented Induced Treatment Result 2 AVRT, AT AVRT utilizing left lateral concealed RF ablation of AP and AT Sucsess AP, AT 3 AVNRT AVNRT, AT, AFL(typical) RF ablation of AT, AFL and Sucsess RF modification of AVN 4 AVNRT AVNRT, AT RF ablation of AT, and RF Sucsess modification of AVN 12 Ventricular Manifest left lateral AP without VA Catheter entrapment Fail preexcitation condction, AT 21 WPW with Afib, AT AVRT with manifest dual AP, AT RF ablation of APs and AT Sucsess 22 AVRT AVRT utilizing posteroseptal concealed AP, AT, AVNRT with VAD RF ablation of CBT, AT and RF modification of AVN Sucsess Afibatrial fibrillation, AFLatrial flutter, APaccessory pathway, AVNRT atrioventricular nodal reentrant tachycardia, VAventriculoatrial, VADVA dissociation, WPWWolff-Parkinson-White syndrome Fig. 2. Atrioventricular nodal reentrant tachycardia was terminated by a premature atrial activity * originated from His area Hisd and was followed by AT Case 4. The earliest atrial activity was HRA in this recording. The AT was terminated at the lateral portion of RA around crista terminalis. 158 Korean Circulation J 2000;302:153-165
Fig. 3. Fractionated atrial electrogram recorded at successful sites. In panel A recorded by EP Lab system of Quinton in the case 7, atrial electrogam at successful site Map was markedly fractionated and distinctively earlier than the beginning of P wave of surface ECG. This prolonged, fractionated activity with low amplitude suggested the presence of slow conduction zone of AT focus. The atrial activity of Map in Panel B recorded by Cardio Lab EP 4.0 in the case 14 was significantly earlier than surface P wave AP interval30 msec and was fractionated without low amplitude signal. Sometimes, it is difficult to determine the beginning point of P wave in surface ECG because P waves were frequently merged into T wave or QRS complex. Fig. 4. Origin of AT in 17 successful patients. In right AT, 5 cases were around cristal terminalis including 1 case of sinoatrial reentrant tachycardia, 5 cases around CSos, 1 case just above the His, and 1 case at inferior portion of TVA. In left AT, 2 cases were at inferior-posterior portion of LA, 2 cases at lateral portion near AV groove and 1 case at free wall near left atrial appendage LAA. successful, failed, IASinteratrial septum, IVCinferior vena cava, PV pulmonic veins, RAAright atrial appendage, SN sinus node, SVCsuperior vena cava 159
고찰 160 Korean Circulation J 2000;302:153-165
Fig. 5. AT mimicking atrioventricular reentrant tachycardia AVRT utilizing accessory pathway Case 20. J point and beginnig of ST segment during tachycardia showed distinctive deflection, mimicking retrograde P wave A. AV conduction block C was noted during eyeball compression from 11 AV relationship B. However, the tachycardia was sustained. These findings suggested that this tachycardia was independent to AV nodal conduction. Therefore, AVRT could be ruled out. 161
Table 4. P wave morphology of 12 lead ECG in 16 patients who were successfully treated with RF catheter ablation P wave Case Site 2 7 8 14 21 3 4 13 17 19 20 5 9 11 15 22 LA LA LA LAi LAi RA RA RA RA RA RA RAi RAi RAi RAi RAi I II III AVR AVL AVF V1 V2 V3 V4 V5 V6 LAleft atrium, LAiinferior portion of LA, RAright atrium, RAiinferior portion of right atrium positive P wave, negative P wave, isoelectric P wave 162 Korean Circulation J 2000;302:153-165
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