An unexpected intracardiac echocardiography finding on the cavotricuspid isthmus.
An unexpected intracardiac echocardiography finding on the cavotricuspid isthmus.
复制标题
心内超声心动图在三尖瓣峡部意外发现。
DOI：
10.1111/jce.12314
复制
发表时间：
2014
影响因子：
2.7
通讯作者：
Bilchick,KennethC
中科院分区：
文献类型：
--
作者：
Porterfield,Christopher;Ferguson,JohnD;Bilchick,KennethC
一名60岁男性因症状性阵发性房颤接受导管消融术。患者有远端心肌梗死病史，表现为心源性休克，需要紧急4支血管冠状动脉旁路移植术，包括右冠状动脉（RCA）隐静脉移植术。虽然他没有房扑的临床病史，但在成功的肺静脉隔离后，通过心房短阵起搏诱发了涉及三尖瓣环峡部（CTI）的典型逆时针房扑。CTI的相控阵心内超声心动图（ICE）（图1）显示一条大血管（箭头）在CTI的内侧（图A）和外侧（图B）突出到右心房腔。该血管与冠状窦（未显示）不同，冠状窦在更靠后的平面中可见，十极诊断导管进入其管腔。仅在该较大血管位置处的三尖瓣环峡部上施加导管压力即可终止房扑，这表明通过覆盖该血管的薄瘢痕心房心肌的缓慢传导可能易于诱发典型房扑。在双平面冠状动脉造影期间，该血管被证实是RCA的静脉移植物（图1，C和D），消融导管（箭头）直接覆盖血管，如ICE图像（图B）所示。考虑到该患者三尖瓣环峡部消融术的可能不良后果，我们选择推迟三尖瓣环峡部消融术。
A 60-year-old male was referred for catheter ablation of symptomatic paroxysmal atrial fibrillation. The patient had a history of remote myocardial infarction presenting with cardiogenic shock and requiring emergent 4-vessel coronary artery bypass grafting, including a saphenous vein graft to the right coronary artery (RCA). Although he had no clinical history of atrial flutter, typical counterclockwise atrial flutter involving the cavotricuspid isthmus (CTI) was induced with atrial burst pacing after successful pulmonary vein isolation.Phased array intracardiac echocardiography (ICE) of the CTI (Fig. 1) showed a large vessel (arrow) protruding into the right atrial lumen on both the medial (panel A) and lateral (panel B) aspects of the CTI. This vessel was distinct from the coronary sinus (not shown), which was visualized in a more posterior plane with the decapolar diagnostic catheter seen entering its lumen. The atrial flutter terminated with just catheter pressure on the CTI at the location of this larger vessel, suggesting that slow conduction through the thin scarred atrial myocardium overlying this vessel likely predisposed to the inducibility of typical atrial flutter. During biplane coronary angiography, this vessel was confirmed to be the vein graft to the RCA (Fig. 1, panels C and D) with the ablation catheter (arrowhead) directly overlying the vessel, as seen also in the ICE images (panel B). Considering the possible adverse consequences of CTI ablation in this patient, we elected to defer ablation of the CTI.