Original Articles Korean Circulation J 1998;289:1493-1501 WPW 증후군환자에서성공적인전극도자절제술후재분극이상 배장호 1 김윤년 1 한성욱 1 현대우 1 신이철 1 김기식 1 김권배 1 이상민 2 Repolarization Abnormalities after Successful Radiofrequency Catheter Ablation of Accessory Pathway in Patients with the Wolff-Parkinson-White WPW Syndrome Jang Ho Bae, MD 1, Yoon Nyun Kim, MD 1, Seong Wook Han, MD 1, Dae Woo Hyun, MD 1, Yi Chul Synn, MD 1, Kee Sik Kim, MD 1, Kwon Bae Kim, MD 1 and Sang Min Lee, MD 2 1 Department of Internal Medicine, Division of Cardiology, School of Medicine, Keimyung University, Taegu, 2 Department of Internal Medicine, Masan Samsung Hospital, College of Medicine, Sungkyunkwan University, Masan, Korea ABSTRACT Background and ObjectivesThe repolarization abnormalities, after radiofrequency catheter ablation RFCA of accessory pathway AP in patients with Wolff-Parkinson-White WPW syndrome, is commonly appeared in standard 12 lead electrocardiogram ECG as inverted T waves. We analyzed the serial ECGs after RFCA of AP in patients with WPW syndrome, in order to understand the repolarization abnormalities after RFCA. Materials and MethodThe study patients were consisted of ninety two patients mean age35 years old, male56 patients out of 157 patients whose ECGs were taken at before, immediately after, one day, one, four, eight, twelve week s after RFCA from December 1992 to July 1997. ResultsThe seventy three patients 79 out of ninety two patients showed the repolarization abnormalities and the thirteen patients 14 showed normalization of secondary T wave changes immediately after RFCA. In contrast, six patients 7 did not show any T wave changes after RFCA and they had left lateral AP. The lead that most frequently showed inverted T wave changes after RFCA was lateral lead lead I, avl in case of left lateral AP and inferior lead II, III, avf in case of other APs. The incidence of repolarization abnormalities after RFCA was significantly higher in patients whose prerfca QRS duration is longer 0.12 sec. The concordance rate of repolarization abnormalities after RFCA was 86 63 patients of 73 patients showing repolarization abnormalities after RFCA. The normalization of repolarization abnormalities after RFCA was acquired in sixty four patients 94 out of sixty eight patients who showed repolarization abnormalities and followed up to twelve weeks after RFCA. The mean time interval to the normalization of repolarization abnormalities after RFCA was 4.33.2 weeks. The time interval to the normalization of repolarization abnormality after RFCA was not related with age, AP or prerfca QRS duration. ConclusionThe ECG lead, in which the repolarization abnormalities occurs after RFCA, is related with the location of the AP. The repolarization abnormalities after RFCA were more common in patients with longer prerfca QRS duration. The repolarization abnormalities after RFCA could not be understood only by cardiac memory. Korean Circulation J 1998;289:1493-1501 KEY WORDSWolff-Parkinson-White syndrome Repolarization abnormalities. 1493
서론 재료및방법 대상 1494 심전도분석 Table 1. Characteristics of the study patients Numbers n 92 Age yr 3513 Sex male 56 61% Site of AP left lateral LL 34 37% left anterolateral LAL 7 8% left posterolateral LPL 14 15% left posterior LP 2 2% right lateral RL 6 7% right anterolateral RAL 7 8% right anteroseptal RAS 2 2% right posteroseptal RPS 13 14% right posterior RP 4 4% right posterolateral RPL 3 3% QRS duration sec 0.120.02 APaccessory pathway Korean Circulation J 1998;289:1493-1501
Fig. 1. Classification of the sites of accessory pathway according to intracardiac mapping 4 categories. Table 2. Relation between accessory pathway location and the site of T wave changes after radiofrequency catheter ablation T wave change Location of accessory pathway LL RL Post Ant Total n T wave inversion 63 67 97 89 79 Inf (II, III, avf) 3 7 3 50 31 86 6 67 43 47 Lat (I, avl) 18 44 18 20 Precordial (V1-6) 4 10 1 17 1 11 6 7 Inf & Precordial 1 2 4 11 1 11 6 7 T wave normalization 22 33 3 11 14 Inf 1 2 1 1 Lat 1 2 2 33 1 11 4 4 Precordial 6 15 6 6 Inf Precordial 1 2 1 1 Ant Lat 1 3 1 1 No change 6 15 6 7 Total 41 45 6 7 36 39 9 10 92 100 LLleft lateral, RLright lateral, Postposterior, Antanterior, Infinferior, Latlateral 1495
도자절제술후 T 파변화 결 Table 3. Relation between age and T wave changes after radiofrequency ablation in patients with WPW syndrome Age yr 과 No T wave changes normalization T wave inversion Total n % 20 1 9 2 18 8 73 11 100 30 2 8 2 8 20 83 24 100 40 1 4 6 25 17 71 24 100 50 2 12 1 6 14 82 17 100 50 0 0 2 13 14 88 16 100 Total 6 7 13 14 73 79 92 100 No significant statistical difference among any age groups Table 4. Relation between QRS duration or sex and T wave changes after radiofrequency catheter ablation in patients with WPW syndrome Variables QRS duration* No changes n6 T wave normalization n13 T wave inversion n73 0.12 n25 4 16% 7 28% 14 56% 0.12 n67 2 3% 6 9% 59 88% Sex Male n56 6 11% 9 16% 41 73% Female n36 0 0% 4 11% 32 88% *p0.003, QRS durationexpressed as second Fig. 2. Serial changes of standard 12-lead electrocardiography in patient who has WPW syndrome with right posteroseptal accessory pathway. Abefore RF ablation, B l day after RF ablationt wave inversions in lead II, III, avf, V5 and V6 were developed after RF ablation. Note the T wave inversion in lead V5 and V6 which is not concordant with previous QRS vector. 1496 Korean Circulation J 1998;289:1493-1501
ble 4). 술후 T파 역전이 생기는 빈도를 성별에 따라 비 에 따른 술후 T파 역전이 나타나는 빈도에는 유의한 차 교해 볼 때 56명의 남자 환자중 41명(73%), 36명의 여 이가 없었다(Table 4). 자 환자중 32명(88%)에서 술후 T파 역전이 생겨 성별 술후 T파 역전이 생긴 73명의 환자에서 T파 역전과 Table 5. Concordance of T wave changes with previous QRS vector in patients who showed postablation T wave inversion Ant LL Post RL Total Concordant Sites of AP 5 ( 63) 24 ( 92) 31 ( 89) 3 ( 75) 63 ( 86) Not concordant 3 ( 37) 4 ( 11) 1 ( 25) 10 ( 14) 35 (100) 4 (100) Total, n (%) QRS duration (sec) Concordant Not concordant 8 (100) 2( 8) 26 (100) 73 (100) <0.12 0.12 12 ( 86) 51 ( 86) 2 ( 14) Total, n 14 (100) AP accessory pathway, Ant anterior, LL left lateral, Post posterior, RL right lateral 8 ( 14) 59 (100) Fig. 3. Serial changes of standard 12-lead electrocardiography in 36 year-old female who has WPW syndrome with left lateral accessory pathway. A before RF ablation, B (l day after RF ablation) no definite T wave changes compared with baseline electrocardiogram. Fig. 4. Serial changes of standard 12-lead electrocardiography in 55 year-old male patient who has WPW syndrome with left anterolateral accessory pathway. A before RF ablation, B (3 hours after RF ablation) complete normalization of previous T wave inversion shortly after radiofrequency ablation. 1497
Fig. 5. Serial changes of standard 12-lead electrocardiography in patient who has WPW syndrome with right posterior accessory pathway. Abefore RF ablation, B 1 day after RF ablationt wave was inverted, C 7 weeks after RF ablationcomplete normalization of inverted T wave in inferior leads. Table 6. Relation between age of the patients and the time interval to the normalization of T wave inversion after radiofrequency ablation 술후 T파변화의추적검사 1498 Age yr 20 n6 Time interval weeks, meansd 3.22.8 30 n16 5.44.1 40 n16 3.43.0 50 n12 3.82.5 50 n14 4.82.6 Total n64 4.33.2 No significant statistical difference among any groups Table 7. Relation between variables and the time interval to the normalization of T wave inversion after radiofrequency catheter ablation Variables Location of AP Ant n7 Post n30 LL n24 RL n3 Right n27 left n37 QRS duration sec 0.12 n11 Time interval weeks, meansd 3.43.3 5.13.2 3.53.0 4.33.6 4.73.4 3.93.0 4.82.6 0.12 n53 4.13.3 APaccessory pathway, Antanterior, Postposterior, LLleft lateral, RLright lateral Korean Circulation J 1998;289:1493-1501
고찰 1499
1500 결 중심단어 REFERENCES 1) Harrison TR. Principles of internal medicine. 14th ed. New York McGraw-Hill Co1998. p.1242. 2) Kalbfleisch SJ, Sousa J, El-Atassi R, Calkins H, Langberg J, Morady F. Repolarization abnormalities after catheter ablation of accessory atrioventricular connections with radiofrequency current. J Am Coll Cardiol 1991181761-6. 3) Wood MA, DiMarco JP, Haines DE. Electrocardiographic abnormalities after radiofrequency catheter ablation of accessory bypass tracts in the Wolff-Parkinson-White syndrome. Am J Cardiol 199270200-4. 론 Korean Circulation J 1998;289:1493-1501
4) Helguera ME, Pinski SL, Sterba R, Trohman RG. Memory T waves after radiofrequency catheter ablation of accessory atrioventricular connections in Wolff-Parkinson- White syndrome. J Electrocardiol 199427MB, Blanco HH, Elizari MV, Lazzari JO, Davidenko KM. Electrotonic modulation of the T wave and cardiac memory. Am J Cardiol 198250213-22. 5) Braunwald E. Heart disease. 5th ed. Philadelphia W.B. Saunders Co1997. p.136. 6) Gould L, Venkataraman K, Goswami MK, Gomprecht RF. Pacemaker-induced electrocardiographic changes simulating myocardial infarction. Chest 197363829-32. 7) Engel TR, Shah R, DePodesta LA, Frankl WS, Krause RL. T-wave abnormalities of intermittent left bundle branch block. Ann Intern Med 197889204-6. 8) Sato FI, Hirai M, Hayashi H, Yoshida Y, Yanagawa T, Tomita Y, et al. Relationship between QRS duration and repolarization abnormalities in patients with Wolff-Parkinson-White syndrome. J Electrocardiol 199629301-8. 1501