高周波カテーテルアブレーションで根治した薬剤抵抗性潜在性右前中隔副伝導路の10カ月乳児例　第28巻02号0136頁

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1 症例報告 PEDIATRIC CARDIOLOGY and CARDIAC SURGERY VOL. 28 NO. 2 ( ) 高周波カテーテルアブレーションで根治した薬剤抵抗性潜在性右前中隔副伝導路の 10 カ月乳児例藤田修平 1), 中村太地 1), 臼田和生 2) 3), 渡辺一洋市田蕗子 3) 1), 畑崎喜芳富山県立中央病院小児科 1), 富山県立中央病院内科循環器 2), 3) 富山大学小児科 Key words: anteroseptal accessory pathway, atrioventricular reentrant tachycardia, infant Successful Radiofrequency Catheter Ablation of a Concealed Anteroseptal Accessory Pathway in a 10-month-old Infant with Refractory Atrioventricular Reentry Tachycardia Shuhei Fujita 1, Taichi Nakamura 1, Kazuo Usuda 2, Kazuhiro Watanabe 3, Fukiko Ichida 3, Kiyoshi Hatasaki 1 1 Department of Pediatrics, Toyama Prefectural Central Hospital, Toyama, Japan, 2 Department of Cardiology, Toyama Prefectural Central Hospital, Toyama, Japan, 3 Department of Pediatrics, Toyama University, Toyama, Japan Although the incidence of atrioventricular reentry tachycardia (AVRT) using the right anteroseptal accessory pathway is low, the risk of atrioventricular block by radiofrequency catheter ablation (RFCA) of right anteroseptal accessory pathway is high. A 10-month-old infant with narrow QRS tachycardia was noted to have narrow QRS tachycardia at 280 bpm when she was referred to a general pediatrician for fever. The tachycardia was refractory to ATP and verapamil injection, per os administration of flecainide and bisoprolol, and frequent cardioversion and intravenous infusion of amiodarone were required. She was referred to our hospital for RFCA. An electrophysiological study (EPS) was performed, and the earliest ventriculoatrial (V-A) conduction was demonstrated near the His bundle electrogram, and retrograde conduction did not demonstrate decreased conduction properties. The atrial electrogram revealed a reset phenomenon by a single extra ventricular stimulus during tachycardia. From these results, AVRT using a right anteroseptal accessory pathway near the compact atrioventricular node was suspected. V-A conduction disappeared easily with catheter-induced mechanical trauma (bumping) at the earliest atrial activation site. We performed a low energy test application of radiofrequency energy at the earliest atrial activation site where the His potential was recorded. A junction rhythm appeared during radiofrequency applications. V-A conduction did not recur after catheter-induced mechanical trauma, so we applied radiofrequency application at the site. V-A conduction was completely eliminated, and it was impossible to induce AVRT. After RFCA, there were no abnormalities of atrioventricular node function. In infants with small cardiac dimensions, radiofrequency catheter ablation was possible and useful for a right anteroseptal accessory pathway. 要旨 bpm narrow QRS ATP EPS VA His His 日本小児循環器学会雑誌第 28 巻第 2 号

2 137 VA VA bumping His junctional rhythm VA VA Bump VA はじめに症例症例 10 主訴家族歴および既往歴現病歴 9 narrow QRS 2 mg/kg/d 9 narrow QRS narrow QRS narrow QRS cardioversion 1 J/kg 1 30 narrow QRS cardioversion 1 J/kg 1 2 J/kg 1 3 mg/kg/day 1 mg/ day 5 narrow QRS cardioversion 1 J/kg 1 2 J/kg 1 5 mg/kg 5mg/kg/day 入院時現症 72 cm 9.6 kg 98/54 mmhg 138 / 20 / SpO2 99 顔貌胸部 I II 腹部四肢入院時検査所見 1) 胸部エックス線検査 CTR 47 2) 心電図 118 bpm QRS 0.06 PQ bpm narrow QRS II III avf P ATP AV Fig. 1 A-C 3) 心臓超音波検査 LVIDd 23 mm LVIDs 12 mm IVS 4 mm LVPWs 6 mm LVFS 0.48 LVEF83 4) 血液検査 WBC 11,100/ l RBC / l Hb 11.8 g/dl HCT 35. Plt / l TP 6.5 g/dl ALB 4.5 g/ dl AST 45 IU/L ALT 36 IU/L ALP 402 IU/L LD 245 IU/L CK 78 IU/L -GT 16 IU/L T-Bil 0.4 mg/dl BUN 4 mg/dl CRE 0.2 mg/dl Na 139 meq/l K 4.3 meq/l Cl 107 meq/l CRP 0.04 mg/dl TSH 2.11 IU/ml F-T3 3.6 pg/ml F-T4 1.2 ng/dl BNP 19.8 pg/ ml AMD 100 ng/ml DEA 50 ng/ml 平成 24 年 3 月 1 日 69

138 A B C Fig.1 入院後経過および外来経過 Electrocardiogram.

rhythm, 118 beat per minutes (bpm) and no delta wave.

(C) E C G s h owe d n a r row Q RS ta c hyc a rd i a stopped with AV block

入院第 6 病日に電気生理学検査カテーテルアブ入院後患児の頻拍発作はフレカイニド β遮断薬等レーションを施行した右大腿静脈より 5Fr 8Fr 左

アミオダロン持続静注が必要となってきており難治静脈より挿入した 5Fr sheath から 1.

3 138 A B C Fig.1 入院後経過および外来経過 Electrocardiogram. ( A ) Re s t i n g e l e c t ro c a rd i o g r a m ( E C G ) showed sinus rhythm, 118 beat per minutes (bpm) and no delta wave. (B) ECG showed narrow QRS tachycardia at 280 bpm. (C) E C G s h owe d n a r row Q RS ta c hyc a rd i a stopped with AV block after administration of ATP. 入院第 6 病日に電気生理学検査カテーテルアブ入院後患児の頻拍発作はフレカイニド β遮断薬等レーションを施行した右大腿静脈より 5Fr 8Fr 左の従来の薬物治療に不応であり頻回の cardioversion 大腿静脈より 4Fr sheath をそれぞれ挿入した右大腿アミオダロン持続静注が必要となってきており難治静脈より挿入した 5Fr sheath から 1.6Fr 電極カテーテ性上室頻拍と判断した高周波カテーテルアブレール PATHFINDER mini 6 Japan Lifeline Tokyo ションでの根治の可能性があり適応となり得ると判断 Japan を 3 本挿入しそれぞれ HRA His RVA へ配置した心電図モニター下に病棟内管理としアミオダした CS カテーテルは左大腿静脈より右ジャドキンロン投与は中止ビソプロロール内服のみ継続としたスカテーテルとガイドワイヤーを用いて 1.6Fr 電極カ 70 日本小児循環器学会雑誌第28巻第２号

5 A-C VA 2 考察 Koch 7 bumping Fig.2 Catheter positions. Catheters were positioned in HRA, RVA, CS and His bundle. (A) RAO, (B) LAO.

4 139 PATHFINDER mini 6 Japan Lifeline Tokyo Japan Fig. 2 A, B His jump up narrow QRS HR 250 bpm TCL 240 ms His5-6 Fig. 3 His reset ATP EPT Steero standard Boston Scientific Natick MA VA Fig. 4 His W 5 VA VA Bumping AV VA bumping 50 7W 21 Fig. 5 A-C VA 2 考察 Koch 7 bumping Fig.2 Catheter positions. Catheters were positioned in HRA, RVA, CS and His bundle. (A) RAO, (B) LAO. HRA: high right atrium, RVA: right ventricular apex, CS: coronary sinus, RAO: Right anterior oblique protection, LAO: left anterior oblique protection 平成 24 年 3 月 1 日 71

CS: coronary sinus, STIM: stimulus Fig.4 Intracardiac records during accessory pathway mapping on ventricular pacing.

5 140 Fig.3 Intracardiac records during narrow QRS tachycardia. The earliest retrograde atrial activation was recorded in HBE 5-6. I: ECG lead I, II: ECG lead II, V1; ECG lead V1, HRA: high right atrium, HBE: his bundle electrogram, RVA: right ventricular apex, CS: coronary sinus, STIM: stimulus Fig.4 Intracardiac records during accessory pathway mapping on ventricular pacing. ECG showing ventriculoatrial (V-A) dissociation after bumping (arrow). A showed retrograde V-A conduction followed by sinus rhythm. 72 日本小児循環器学会雑誌第 28 巻第 2 号

potential was recorded. (C) Catheter position of RFCA.

6 141 A. B. C. Fig.5 Catheter position and intracardiac records of radiofrequency catheter ablation (RFCA) site. (A) Sinus rhythm. A very small His bundle electrogram was recorded at ABL. (B) Ventricular pacing. A continuous ventriculoatrial (V-A) conduction and accessory pathway potential was recorded. (C) Catheter position of RFCA. ABL: ablation catheter 8 8 Mandapati Pecht 88 9 Schaffer accelerated junctional rhythm 7 10, 11 Catheter-induced mechanical trauma bumping 12, 13 bumping 12, 13 Mahaim fiber bumping 14 bumping 11 Bumping bumping 平成 24 年 3 月 1 日 73

7 142 bumping 結参考文献 1 Ko J, Deal B, Stasburger J: Supraventricular tachycardia mechanisms and their age distribution in pediatric patients. Am J Cardiol 1992; 69: Jackman W, Wang X, Friday K, et al: Catheter ablation of accessory atrioventricularpathways (Wolff-Parkinson-White syndrome) by radiofrequency current. N Engl J Med 1991; 324: Kuck K, Schulter M, Geiger M, et al: Radiofrequency current catheter ablation of accessory atrioventricular pathways. Lancet 1991; 337: Nakagawa H, Jackman W: Catheter ablation of paroxysmal supraventricular tachycardia. Circulation 2007; 116: Schaffer M, Silka M, Ross B, et al: Inadvertent atrioventricular block during radiofrequency catheter ablation. Results of the pediatric radiofrequency ablation registry. Circulation 1996; 94: Blaufox A, Felix G, Saul J, et al: Radiofrequency catheter ablation in infants <18 months old when is it done and how do they fare? Short-term data from the pediatric ablation registry. 語 Circulation 2001; 104: Mandapati R, Berul CI, Triedman JK, et al: Radiofrequency catheter ablation of septal accessory pathways in the pediatric age group. Am J Cardiol. 2003; 92: Calksin H, Yong P, Miller J, et al: Catheter ablation of accessory pathways, atrioventricular nodal reentrant tachycardia and the atrioventricular junction final results of a prospective, multicenter clinical trial. Circulation 1999; 99: Pecht B, Maginot KR, Boramanand NK, et al: Techniques to avoid atrioventricular block during radiofrequency catheter ablation of septal tachycardia substrates in young patients. J Interv Card Electrophysiol 2002; 7: Tada H, Naito S, Nogami A, et al: Successful catheter ablation of an anteroseptal accessory pathway from the noncoronary sinus of Valsalva. J Cardiovasc Electrophysiol 2003; 14: Balasundaram R, Rao H, Asirvatham SJ, et al: Successful targeted ablation of the pathway potential in the noncoronary cusp of the aortic valve in an infant with incessant orthodromic atrioventricular reentrant tachycardia. J Cardiovasc Electrophysiol. 2009; 20: Belhassen B, Viskin S, Fish R, et al: Catheter-induced mechanical trauma to accessory pathways during radiofrequency ablation: incidence, predictors and clinical implications. J Am Coll Cardiol. 1999; 33: Chiang CE, Chen SA, Wu TJ, et al: Incidence, significance, and pharmacological responses of catheter-induced mechanical trauma in patients receiving radiofrequency ablation for supraventricular tachycardia. Circulation. 1994; 90: Cappato R, Schlüter M, Weiss C, et al. Catheter-induced mechanical conduction block of right-sided accessory fibers with Mahaim-type preexcitation to guide radiofrequency ablation. Circulation.1994; 90: 日本小児循環器学会雑誌第 28 巻第 2 号

Symposium 46 I I II II III III 1 12 54/ narrow QRS tachycardia 139/ P V1 HIS 5 6 HIS 3 4 HIS 1 2 CS 9 10 CS 7 8 CS 5 6 CS 3 4 CS 1 2 RV 3 4 RV 1 2 100

Symposium 46 I I II II III III 1 12 54/ narrow QRS tachycardia 139/ P V1 HIS 5 6 HIS 3 4 HIS 1 2 CS 9 10 CS 7 8 CS 5 6 CS 3 4 CS 1 2 RV 3 4 RV 1 2 100 Symposium 46 Inappropriate Sinus Tachycardia1 inappropriate sinus tachycardiaistp 100/ 1 IST 2 IST IST atrio ventricular nodal reentrant tachycardiavnrt IST 1 26 2011 24 2013 2013 7 54/ 1 narrow QRS 139/aVFP1

高周波カテーテルアブレーションで根治した薬剤抵抗性潜在性右前中隔副伝導路の10カ月乳児例 第28巻02号0136頁

高周波カテーテルアブレーションで根治した薬剤抵抗性潜在性右前中隔副伝導路の10カ月乳児例　第28巻02号0136頁