複雜性先天心臟病術前術後心律不整之電生理學機轉：以同步電位及之體結構定位法研究(3/3)

Abstract

先天心臟病病兒常合併心傳導系統異 常。這些傳導異常性質可能導致臨床不整 脈，進而影響其預後。此外，經開心手術 成功矯治後的先天性心臟病兒，由於手術 瘢痕等問題易有心房或心室繞行性頻脈， 藥物治療相當困難。 本研究探討先天性心臟病術前術後之 心律不整，（1）其型態以其特殊之機轉（2） 以傳統心電生理檢查方法及電燒灼術治療 之可行性，以及（3）以Electroanatomical mapping （CARTO system）輔助之不整脈 定位及燒灼術之適應性。由1993 年到2001 年，共33 位接受心電生理檢查病兒（占所 有病兒10%）合併有先天性心臟病。有三 位病兒之頻脈必須採用CARTO system 輔 助之定位與燒灼（二例心房繞行頻脈，一 例心室繞行頻脈）。在術前之病兒，兩側 右心房症病兒有相當高的概率合併一種相 當特殊的心頻脈， 我們稱之為AV nodal-to-AV nodal tadycardia。反之，兩側 左心房症病兒易有竇房結及房室結功能不 良。此外，先天矯正型大血管轉位病也有 常有上心室頻脈。這些術前心律不整大多 可以傳統之電生理檢查方法與電燒灼術等 予以根治，然而先天性心臟病兒術後之頻 脈若與開刀瘢痕有關，則復發率高，且常 須輔以須輔以CARTO system。但即使如 此，復發率仍偏高。 CARTO system 由於尺寸較大，不適用 於較小兒童，且其導管價格極為昂貴。因 此，較適用於開心手術後繞行性頻脈之定 位與燒灼。

Background. Congenital heart disease may be associated with conduction system abnormalities that may lead to clinical arrhythmias and significant morbidity. Methods. Patients with congenital heart disease who had clinical arrhythmias were enrolled. Standard electrophysiological study and mandatory interventions, including radiofrequency ablation and pacemaker implantation, were performed under propofol anesthesia. Electroanatomical mapping were used when standard electrophysiological study failed to identify or eliminate theclinical arrhythmias. Results. From 1993 to 2001, a total of 33 out of 317 (10%) patients received standard electrophysiological study for clinical arrhythmias were found to be associated with congenital heart disease. Carto system (electroanatomical mapping) was required in three patients, due to postoperative reentrant atrial tachycardia in two and reentrant ventricular tachycardia in one. In preoperative evaluation, the right atrial isomerism was closely associated with supraventricular tachycardia that has been characterized as AV nodal-to-AV nodal tachycardia. In contrast, patients with left atrial isomerism were highly possible to develop sick sinus syndrome and AV conduction disturbance. Patients with corrected transposition of great arteries could also be associated with atrial flutter, atrial tachycardia or AV nodal reentrant tachycardia. Postoperative cardiac patients could develop reentrant tachycardia attributed to accessory pathways or incisional atrial or ventricular reentrant tachycardia. The incisional reentrant tachycardia carried high recurrence risks even using the CARTO system Conclusion. Patients with certain types of congenital heart diseases, including heterotaxy syndrome and corrected transposition of great arteries tended to have clinical arrhythmias during childhood and should be managed before surgical intervention. Postoperative incisional reentrant tachycardia carried high recurrence rate even with CARTO system assisted RF ablation.