Original Articles 27 4 1997 후중격에위치한우회로의전극도자절제술 Abstract 이문형 안신기 구본권 장길진 김건영 김성순 오동진 Catheter Ablation of The Posteroseptal Accessory Pathways Moon Hyoung Lee, M.D., Shinki Ahn, M.D., Bon Kwon Ku, M.D., Kil Jin Jang, M.D., Geon-young Kim, M.D., Sung Soon Kim, M.D., F.A.C.C. Cardiology Division, Yonsei Cardiovascular Center Yonsei University, College of Medicine, Seoul, Korea Dong-Jin Oh, M.D. Department of Internal Medicine, College of Medicine, University of Hallym, Seoul, Korea BackgroundThe ablation of accessory pathwaysaps using radiofrequencyrf energy has been established as a primary modality of treatment for atrioventricular reentrant tachycardia with proven safety and high rate of success. However, the ablation of posteroseptalps APs had been recognized as being more difficult to ablate than those in other location because of the complex three dimensional anatomy of the posterior space, and multifarious approaches have been proposed. We analyzed electrophysiologic characteristics and results of catheter ablation of 70 consecutive patients, who underwent RF ablation of PS APs with or without booster direct currentdc shock. MethodsThe AP location was confirmed to be in the PS region, ablation was attepmted at the atrial aspect of the tricuspid annulus adjacent to the coronary sinus ostium, within the coronary sinus including middle cardiac vein, or underneath the mitral annulus close to the septum using retrograde transaortic approach if deemed necessory. A continuous, unmodulated sine wave radiofrequency generator was used as the source of energy for ablation. The site was considered optimal for ablation when the electrogram obtained from the ablation catheter had one or more of the following characteristics1 short VA intervals with an AV ratio of 1.0 and discrete, high frequency potentials or fractionated electrograms between local atrial and ventricular deflectionsaccessory pathway potential2 ventricular activation occurred simultaneously with or earlier than the delta wave during sinus rhythm with manifest preexcitationand 3 atrial activation occurred simultaneously with or earlier than that recorded in the reference coronary sinus electrogram during retrograde AP conduction. Succeccful criteria was complete loss of anterograde and retrograde AP conduction. 407
ResultsSeventy consecutive patientsmale 44, female 26 with PS APs underwent catheter ablation. Manifest preexcitation was present in 40 patients and concealed APs in 30. Two patients had double APs. AP conduction was successfully eleminated in 60 of 70 cases at initial attemptsuccess rate 85.7. Successful ablation sites of 60 patients were as follows29 at the left PS region, 14 at the margin of the coronary sinus ostium, 8 in the proximal portion of the coronary sinus, 6 at the ticuspid annulus, and 3 at the inferomedial portion of right atium. The mean shortest VA interval in successful group was shorter than that in failed group8519msec versus 10022msec. Recurrence was noted in 8 patients13.3 during a mean follow-up period of 33.113.3 months. Five patients with recurrence and two patient of unsuccessful initial attempt underwent the second catheter ablation and 5 patients were successful. Complications occurred in 11 patientstransient high degree AV block in 8, pneumothorax in 2, and transient cerebral ischemic attack in one patient. ConclusionThese data suggested that posteroseptal APs could be ablated at the left side or the right side PS region in similar proportion. This series, even though it included learning period, showed slightly lower success rate87.5 than that of total APs success rate in our experience 90.8. Therefore a firm grasp of the anatomic characteristic of the posterior space and meticulous mapping may facilitate the achievement of successful results in the ablation of posteroseptal accessory pathways. KEY WORDSCatheter ablation Posteroseptal accessory pathways. 서 론 연구대상및방법 1. 연구대상 408
었다. 68명은 기질적 심장질환이 없는 환자였으며 1 명은 승모판막대치술을 시행받은 환자였으며 1명은 dextrocardia였다. 임상적으로 확인된 빈맥은 전향성 방실회귀빈맥이 60예, 심실조기흥분증후군에 동반된 심방세동이 12예 이었다. 2. 연구방법 1) 전기생리학적 검사 임상적으로 빈맥이 확인된 모든 환자에서 표준 12 유도 심전도 및 흉부 X-선 촬영을 하고 필요한 경우 에는 심장초음파를 시행하여 기질적 심장질환의 유무 를 확인하였다. 시술전 환자와 보호자에게 시술의 목적, 방법 및 시술과 연관된 후유증을 설명하고 시술에 대 한 동의서를 얻었다. 시술전 최소 48시간전에 검사 및 시술에 영향을 미칠 수 있는 모든 항부정맥 제제의 투 여를 중지하였고 8시간 이상 금식토록 하였다. 시술중 혈전색전증을 예방하기 위해 헤파린을 시술 초기에 3 000단위를 정주하였고 매 1시간마다 1000단위를 추 가로 정주하였다. 전기생리학적검사는 국소마취하에 경피적으로 좌측 혹은 우측의 쇄골하 정맥을 통하여 7F decapolar 전 극도자(Daig Corporation Minnetonka, MN)(2-mm interelectrode distance)를 관정맥동 내부로 삽입하여 근위부(9 10번 전극)를 관정맥동 입구에 위치시켜 승 모판륜 부위의 심내전기도(intracardiac electrogram) 를 기록하였으며 우측 및 좌측 대퇴정맥을 통하여 세 Fig. 1. Radiograms of transcatheter mapping posteroseptal region. Right anterior oblique(top) and left anterior oblique(bottom) views are shown during mapping posteroseptal aspect of tricuspid anulus(ta) and left ventricle(lv). Intracardiac catheters are positioned in high right atrium (HRA), His bundle(hb), right ventricular apex (RV), and coronary sinus(cs). 개의 6F quadripolar 전극도자(Daig Corporation Minnetonka, MN)를 삽입하여 각각 우심실 첨부, 우심방 상부 및 His 속 근처에 위치시키고 전기자극 및 심내전 2) 후중격 방실우회로의 진단 기도 기록을 하였다(Fig. 1). 심전도는 lead I, avf, V1을 우회로의 전향성 및 역향성 전도 특성(anterograde 심장내 각부위로부터의 전기도와 동시에 multichannel and retrograde conduction properties)은 우심방과 oscilloscope recorder(vr-12, EVR, Electronics for 우심실에서 incremental pacing, extrastimulation te- Medicine, 혹은 EP Lab, Quinton electrophsiology chnique을 이용하여 판정하였으며 후중격 방실우회로 Corp.)을 이용하여 100mm/sec의 속도로 기록하였다 의 진단기준은 다음과 같이 하였다. 빈맥시 혹은 우심 (30 500Hz band pass). Programmed electrical sti- 조율(right ventricular pacing)시 좌측과 우측의 후중 mulation은 programmable stimulator(bloom DTU- 격부 지도화 작업을 통해 가장 짧은 surface QRS- 201 Bloom Associates, Ltd. 혹은 EP-3, EP Medi- atrial interval이 후중격부에서 관찰될 때 후중격부 cal Inc., Budd Lake, NJ.)를 이용하여 자극전기는 2 우회로로 규정하였고, X-선 투시상 삼첨판막의 후중 msec 동안 pacing threshold의 2배의 전류로 투여하 격부와 관정맥동 입구 및 좌측으로 1 cm까지로 국한 였다. 하였다(Fig. 1). 409
3) 방실우회로의전극도자절제술 4) 성공적인전극도자절제술의확인 Fig. 2. Local electrogram from one patient during tachycardia. Arightposteroseptum, Bcoronary sinus ostium, Cmiddle cardiac vein, Dleft posteroseptum. CSd, CS2, CS3, CS4 and CSos, bipolar electrograms recorded from distal, second, third, fourth and distal electrodesfrom tip of decapolar electrodes catheter that was placed in coronary sinushisp and Hisd, proximal and distal His bundle electrogram HRA, high right atrial electrogrammap, electrogram from mapping catheter, I and V1, surface electrographic lead I and V1. 410
Fig. 3. Recording from same patient as in Fig. 2 shows successful radiofrequency ablation at left posteroseptum within two seconds. Arrow, start of currentstar, loss of accessory pathway conduction with termination of orthdromic reentrant tachycardia. Abbreviations as in Fig. 2. 5) 전극도자절제술후추적관찰 결과 1. 대상환자및전기생리학적검사성적 Table 1. Successful site of ablationn=60 Left side Right side Successful site Coronary sinus, ostium Coronary sinus, proximal Tricuspid valve annulus Inferomedial portion of RA RAright atrium Number of cases% 29 48.3% 31 51.7% 14 23.3% 8 13.3% 6 10.0% 3 5.0% 2. 전극도자절제술성적 411
Table 2. Clinical and electrophysiologic parameters in successful patients and failed atients Successful cases n60 Failed cases n10 p-value MaleFemale 4119 28 ManifestedConcealed 3327 73 Ageyrs 3915 4317 NS VA interval at Hisms 12319 12618 NS Shortest VA intervalms 8519 10022 0.05 VAventricular atrial Fig. 4. Anatomy of posteroseptal region. These representations are schematic cranial views of heart before and after removal of atrium from AV junctionleft and right, respectively. right atrium and coronary sinus form unit that wraps around left atrium. Interatrial sulcus is to the far left of interventricular sulcus. Note that inferior wall of right atrium lies directly on posterior-superior processdashed lines, a part of left ventricle that is confined by fibrous trigone(anterior), septal anulus of tricuspid valveright and mitral anulusleft. 3. 합병증 4. 추적관찰소견 고안 412
Table 3. Results of accessory pathway catheter ablation in Yonsei cardiovascular centerfrom Jun. 1991 to Jul. 1995 Location of AP Number of APs Success Rate Left free wall 296 286 96.6% Posteroseptal 70 60 85.7% Right free wall 85 66 77.6% Anteroseptal 18 14 77.8% Midseptal 7 7 100.0% Total 476 432 90.8% 413
Table 4. Successful ablation sites in literature review Auther(year) left PS(%) Right PS(%) No of success / No of APs (%) Schluter et al. 1) 17/21 (81%) Jackman et al. 2) 41/43 (95%) Calkins et al. 3) 41/44 (93%) Dhala et al. 4) 47/48 (98%) Schluter et al. 5) 131/140 (94%) Wen et al. 6) 112/116 (96%) Our data 60/70 (86%) 요약 연구배경 : 방법 : 결과 : 414
결론 References 1) Schluter M, Geiger M, Seibels J, Duckeck W, Kuck KH: Catheter ablation using radiofrequency current to cure symptomatic patients with tachyarrhythmias related to an accessory atrioventricular pathway. Circulation 84:16 44-1661, 1991 2) Jackman WM, Wang X, Friday KJ, Roman CA, Moulton KP, Beckman KJ, Mcclelland JH, Twidale N, Hazlitt A, Prior MI, Margolis PD, Calame JD, Overholt ED, Lazzara R:Catheter ablation of accessory AV pathways(wolff- Parkinson-White syndrome) by radiofrequency current. N Engl J Med 324:1605-1611, 1991 3) Calkins H, Langberg J, El-Atassi R, Leon A, Kou W, Kalbfleisch S, Morady F:Radiofrequency catheter ablation of accessory AV connections in 250 patients:abbreviated therapeutic approach to Wolff-Parkinson-White syndrome. Circulation 85:1337-1346, 1992 4) Dhala AA, Deshpande SS, Bremner S, Hempe S, Sra JS, Blanck Z, Akhtar M, Jazayeri M:Transcatheter ablation of posteroseptal accessory pathways using a venous approach and radiofrequency energy. Circulation 90:1799-1810, 1994 5) Kuck KH, Schluter M, Cappato R, Weiss C, Hebe J, Seibels J, Jakel KT:Ablation of septal accessory pathways, In Catheter ablation of arrhythmias. Zipes DP. p249, New York, Futura Publishing Company, Inc, 1994 6) Wen MS, Yeh SJ, Wang CC, King A, Lin FC, Wu D: Radiofrequency ablation therapy of the posteroseptal accessory pathway. Am Heart J 132:612-620, 1996 7) Cobb FR, Blumenschein SD, Sealy WC, Boineau JP, Wagner GS, Wallace AG:Successful surgical interruption of the bundle of Kent in a patient with Wolff-Parkinson- White syndrome. Circulation 38:1018-1029, 1968 8) Sealy WC, Mikat EM:Anatomical problems with identification and interruption of posterior septal Kent bundles. Ann Thorac Surg 36:584-595, 1983 9) Cox JL:The status of surgery for cardiac arrhythmias. Circulation 71:413-417, 1985 10) Guiraudon GM, Klein GJ, Gulamhusein S, Jones DL, Yee R, Perkins DG, Jarvis E:Surgical repair of Wolff-Parkinson-White syndrome:a new closed-heart technique. Ann Thorac Surg 37:67-71, 1984 11) Guiraudon GM, Klein GJ, Sharma AD, Jones DL, McLellan DG:Surgical ablation of posterior septal accessory pathways in the Wolff-Parkinson-White syndrome by a closed heart circuit. J Thorac Cardiovasc Surg 92:4 06-413, 1986 12) Morady F, Scheinman MM, Winston SA, DiCarlo LA, Davis JC, Griffin JC, Ruder M, Abbott JA, Eldar M:Efficacy and safety of transcatheter ablation of posteroseptal accessory pathways. Circulation 72:170-177, 1985 13) 김성순 : 심장부정맥에대한전극도자절제술. 대한의학협회지 35:673, 1992 14) Huang SK, Bharati S, Graham AR, Lev M, Marcus FI, Odell RC:Closed-chest catheter desiccation of the atrioventricular junction using radiofrequency energy:a new method of catheter ablation. J Am Coll Cardiol 9:349-358, 1987 15) Reddy GV, Schamroth L:The localization of bypass tracts in Wolff-Parkinson-White syndrome from the surface electrogram. Am Heart J 113:984-993, 1987 16) Jackman WM, Friday KJ, Fitzgerald DM, Bowman AJ, Yeung-Lai-Yai JA, Lazzara R:Localization of left free wall and posteroseptal accessory AV pathways by direct recording of accessory pathway activation. PACE 12: 204-214, 1989 17) Durrer D, Schuilenberg RM, Wellens HJ:Pre-excitation revisited. Am J Cardiol 25:690-697, 1970 18) Ho S, Gupta I, Anderson RH, et al:aneurysm of the coronary sinus. Thorax 36:686-689, 1983 19) Gerlis LM, Davis MJ, Boyle R, et al:pre-excitation due to accessory sinoventricular connections associated with coronary sinus aneurysm. Br Heart J 53:314-322, 1985 20) Guiraudon GM, Guiraudon CM, Klein GJ, et al:the coronary sinus diverticulum:a pathologic entity associated with the Wolff-Parkinson-White syndrome. Am J Cardiol 62:733-735, 1988 21) Stamato N, Goodwin M, Foy B:Diagnosis of coronary sinus diverticulum in Wolff-Parkinson-White syndrome using coronary angiography. PACE 12:1589-1591, 1989 415
22) McGiffin DC, Masterson ML, Stafford WJ:Wolff-Parkinson-White syndrome associated with a coronary sinus diverticulum:ablative surgical approach. PACE 13:9 66-969, 1990 23) Connelly DT, Rowland E, Ahsan AJ, et al:low energy catheter ablation of a posteroseptal accessory pathway associated with a diverticulum of the coronary sinus. PA- CE 14:1217-1221, 1991 24) Lesh MD, Van Hare G, Kao AK, et al:radiofrequency catheter ablation for Wolff-Parkinson-White syndrome associated with a coronary sinus diverticulum. PACE 14: 1479-1484, 1991 25) Haissaguerre M, Clementy J, Warin JF:Catheter ablation of atrioventricular reentrant tachycardias, In Cardiac electrophysiology. Zipes DP, Jalife J. p1487, Pennsylvania, W.B. Saunders Company, 1995 416