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Radiofrequency catheter ablation for arrhythmia

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Radiofrequency catheter ablation is the application of electrode catheter, the radiofrequency energy into the heart, through the thermal effect of radiofrequency energy, the origin of arrhythmia focus or maintain the key parts of arrhythmia damage, so as to achieve the purpose of radical cure of arrhythmia.

definition

Its scope of application is tachyarrhythmia. Radiofrequency catheter ablation has become the first choice for the treatment of various tachyarrhythmias.

Operation name

Radiofrequency catheter ablation for arrhythmia

Indications

1. Adult indications (1) clear indications: ① patients with preexcitation syndrome complicated with paroxysmal atrial fibrillation (AF) and rapid ventricular response leading to hemodynamic disturbance, or with dish filling heart failure (CHF). ② Patients with recurrent atrioventricular reentrant tachycardia (AVRT), atrioventricular junction reentrant tachycardia (AVNRT), atrial tachycardia (atrial tachycardia), typical atrial flutter (atrial flutter) and idiopathic ventricular tachycardia, or with CHF or hemodynamic disorder. ③ Atypical atrial flutter, frequent attacks, ventricular rate is not easy to control (only limited to the medical center with experience and necessary equipment). ④ Inappropriate sinus tachycardia (sinus tachycardia) with tachycardic cardiomyopathy. ⑤ Atrioventricular junction ablation was performed in patients with chronic atrial fibrillation and tachycardia cardiomyopathy. ⑥ The authors of recurrent surgical incision reentrant atrial tachycardia (only in the medical center with experience and necessary equipment). (2) relative indications: ① preexcitation syndrome with paroxysmal atrial zygomatic ventricular rate. ② Although there is no evidence of tachycardia, patients with obvious chest tightness have been excluded. ③ The patients who are engaged in special occupation (such as driver, aerial work, etc.), or have the need of further education, employment, etc. ④ AVRT, AVNRT, atrial tachycardia, typical atrial flutter and idiopathic ventricular tachycardia (including repetitive monomorphic ventricular tachycardia) had fewer episodes and mild symptoms. ⑤ Patients with recurrent paroxysmal atrial fibrillation, severe symptoms, poor effect of drug prevention, and willing to cure (limited to medical centers with experience and necessary equipment). ⑥ The patients with fewer attacks and severe symptoms of atrial flutter. ⑦ Inappropriate sinus tachycardia repeated attacks, drug treatment effect is not good. ⑧ Patients with ventricular tachycardia after myocardial infarction, frequent episodes, poor or intolerable drug treatment (only in medical centers with experience and necessary equipment). ⑨ Frequent ventricular premature beats, severe symptoms, affect life, work or study, drug treatment ineffective. 2. Indications for children (1) clear indications: (1) age 4 years old: atrial tachycardia, tachycardia with persistent or recurrent attack, hemodynamic disorder, ineffective treatment of various antiarrhythmic drugs; AVRT, idiopathic ventricular tachycardia, tachycardia with persistent or recurrent attack, hemodynamic disorder; preexcitation syndrome with syncope; preexcitation syndrome with atrial fibrillation with tachycardia (3) AVNRT: 7 years old, tachycardia with persistent or recurrent attack and hemodynamic disorder. (2) relative indications: ① age 4 years old: atrial tachycardia, tachycardia with persistent or recurrent attacks, hemodynamic disorders, except amiodarone, antiarrhythmic drug treatment is ineffective; AVRT, idiopathic ventricular tachycardia, tachycardia with persistent or recurrent attacks, no hemodynamic disorders; preexcitation syndrome with atrial fibrillation, but ventricular rate is not fast. ③ AVNRT: aged 7 years, tachycardia was persistent or recurrent. ④ For AVRT and AVNRT before operation of congenital heart disease, radiofrequency ablation before operation can shorten operation time and reduce operation risk. ⑤ Acquired persistent atrial flutter after operation of congenital heart disease is caused by hemodynamic changes of residual malformation after cardiac operation, which is the true sense of reentrant atrial tachycardia.

Contraindications

1. Adult contraindications (1) patients with dominant bypass but without tachycardia or other symptoms. (2) the effect of inappropriate sinus tachycardia drugs is good. (3) patients with paroxysmal atrial fibrillation have good therapeutic effect or mild symptoms. (4) frequent ventricular premature beats, symptoms are not serious, does not affect life, work or learners. (5) ventricular tachycardia after myocardial infarction, when the heart rate is not fast, and drugs can prevent the occurrence. Contraindications for children (1) patients younger than 4 years old: ① AVRT, AVNRT, typical atrial flutter, although tachycardia is persistent or recurrent, but there is no hemodynamic disorder. ② patients with dominant right free wall accessory pathway had less tachycardia episodes and mild symptoms. (2) patients over 4 years old: (1) patients with persistent or recurrent atrial tachycardia, hemodynamic disorder, and effective antiarrhythmic drugs except amiodarone. 2 AVRT, AVNRT, idiopathic ventricular tachycardia, tachycardia attack frequency is less, symptoms are mild. (3) atrial tachycardia occurred after operation of congenital heart disease, but it was definitely caused by hemodynamic changes of residual malformation after operation.

get ready

1. Routine preparation before operation (1) detailed medical history, pay attention to whether there is a history of intracardiac electrophysiological examination and catheter ablation. (2) comprehensive physical examination, pay attention to peripheral arterial pulsation and peripheral vascular murmur. (3) complete blood routine, liver function, renal function, bleeding time, coagulation time, pathogenic microorganisms and their markers of blood borne diseases. (4) chest X-ray and echocardiography were performed to determine whether there was organic heart disease, whether there was anatomical malformation of the heart, and to evaluate the cardiac function. Peripheral vascular ultrasound should be performed in patients with suspected peripheral vascular malformation, peripheral vascular thrombosis or thrombotic peripheral vasculitis. (5) all the electrophysiological data of the patients were comprehensively reviewed, including the ECG of sinus rhythm and arrhythmia attack, Holter, esophageal electrophysiological examination and the results of previous intracardiac electrophysiological examination. (6) patients should stop taking all antiarrhythmic drugs at least 5 half lives before operation. (7) the operation process, success rate, complications, recurrence rate and operation cost were explained to the patients and their families within 24 hours before operation, and informed consent was signed. Those who need general anesthesia should inform the anesthesiology department (for example, those who are 9 years old but are extremely nervous and are not expected to cooperate fully during the operation should be given intravenous sedative anesthetics during the operation). (8) skin preparation and cleaning were performed in bilateral inguinal area and bilateral cervicothorax 24 hours before operation. (9) fasting 4 hours before operation. If general anesthesia is needed, fasting 12 hours before operation and water prohibition 4 hours before operation. (10) 0.5h before the operation, at least one intravenous infusion channel should be established to meet the needs of intraoperative intravenous medication. Special preparation (1) patients with atrial fibrillation and persistent atrial flutter should complete transesophageal echocardiography within one week before operation to determine whether there is thrombosis in the left atrium. (2) for patients who want to use 3D mapping system (such as carto or Navix) during operation, it is suggested to conduct multi-slice CT or electron beam CT examination one week before operation to reconstruct the cardiac cavity to guide 3D mapping during operation. (3) patients who had been taking warfarin orally before operation should stop warfarin 3-4 days before operation and change to subcutaneous injection of low molecular weight heparin (e.g. Kesai 1mg / kg). Subcutaneous injection of LMWH was stopped 12 hours before operation. (4) patients who need to use contrast agent during operation (such as patients with atrial fibrillation who need to use contrast agent during atrial septal puncture and pulmonary venography) were given iodine allergy test within 24 hours before operation.

method

1. Intracardiac electrophysiological examination

(1) placement of mapping electrode catheter: through inferior vena cava (femoral vein puncture in general), multipolar electrode catheter (2 or 4 poles in general) was placed in high right atrium, his tract and right ventricular apex. Through the superior vena cava (usually through internal jugular vein or subclavian vein), the multipolar electrode catheter (usually 4 or 10 poles) was inserted into the coronary sinus. for ablation of atrial flutter, it is recommended to place a 20 pole electrode catheter (halo catheter) in the right atrium to map the activation sequence of the right atrial free wall; for ablation of atrial fibrillation, it is often necessary to puncture the atrial septum and place a 10 pole ring mapping electrode catheter (Lasso catheter) in the pulmonary vein orifice to map the pulmonary venous potential. if the electrode catheter has to enter the left ventricle through femoral artery (such as ablation of left bypass and left ventricular tachycardia), 2000 u heparin will be injected intravenously after femoral artery puncture, and then 1000 u heparin will be injected intravenously every hour; if atrial septum puncture is required, 4000-5000 u heparin will be injected intravenously after successful atrial septum puncture, and then 1000 u heparin will be injected intravenously every hour. (2) electrophysiological examination: the contents of basic electrophysiological examination are atrial programmed stimulation (S1S2 stimulation and s1s2s3 stimulation are commonly used), atrial graded incremental stimulation (s1s1 stimulation), ventricular programmed stimulation and ventricular graded incremental stimulation. The purpose is: first, to induce tachycardia; second, to understand the electrophysiological characteristics of sinus rhythm and atrioventricular conduction system of tachycardia, as well as the activation sequence of atrial and ventricular parts during tachycardia, so as to clarify the diagnosis and electrophysiological mechanism of tachycardia. if the basic electrophysiological examination fails to induce tachycardia, intravenous infusion of isoprenaline and other drugs can be used to increase the heart rate by about 30%, and then atrial and cardiac pacing can be performed

Chinese PinYin : Su Cheng