我院在1994年11月7日为一患者行射频消融术中,经皮颈内静脉穿刺时不慎将四极电极导管送入胸腔,现报告如下。患者男性,52岁。阵发性心悸2年。查体未见明显异常。心电图示B型预激综合征。余检查无特殊。诊断为阵发性室上速、B型预激综合征。射频消融术中为标示冠状窦口位置,先行左锁骨下静脉穿刺,因血管走行变异,导线不易通过而改穿右侧颈内静脉。 In our hospital in November 7, 1994 for a patient undergoing radiofrequency ablation, percutaneous jugular vein puncture inadvertently the quadruode lead into the chest, are as follows. Male patient, 52 years old. Paroxysmal palpitations 2 years. Physical examination showed no obvious abnormalities. ECG shows B-WPW syndrome. I check no special. Diagnosis of paroxysmal supraventricular tachycardia, B-WPW syndrome. Radiofrequency ablation for the location of the coronary ostium, the first left subclavian vein puncture, because of vascular variability, the wire is not easy to pass and wear the right side of the jugular vein.