超声心动图评价束支传导阻滞患者左右心室间收缩失同步

目的探讨定量组织多普勒及频谱多普勒成像观察束支传导阻滞患者左右心室间心肌收缩运动失同步的应用价值。方法完全性右束支(RBBB)及完全性左束支传导阻滞者(LBBB)各20例,正常对照者20例。测量右室游离壁、室间隔、左室侧壁基底段收缩的起始(TO)、达峰(TS)及终止时间(TSe);肺动脉瓣(PETP)与主动脉瓣的射血前间期(PETA)及其时间差(PETd)。结果RBBB组的右室壁TO、TS及PETP较正常组显著延迟(P<0.001),PETd为(43±8)ms。LBBB组的室间隔和侧壁的TO、TS、TSe及PETA均较正常组显著延迟(P<0.001),PETd为(-45±22)ms。结论定量组织多普勒能够观察到心室电-机械耦联情况,结合频谱多普勒对血流动力学的测定,可以综合评价左右心室间运动的失同步。     

速度向量成像技术对肺动脉高压下心室收缩失同步性的评估北大核心CSCD

目的探讨速度向量成像技术衍生的应变、应变率评估肺动脉高压患者的右室收缩功能及心室内、心室间收缩同步性。方法35例正常人和64例肺动脉高压患者,应用速度向量成像技术进行超声检查及应变、应变率分析。测量各节段心肌的收缩应变及应变率,测量QRS波顶点到每一节段应变、应变率的收缩期峰值时间,记录为达峰时间。计算右室6节段应变、应变率达峰时间标准差,评估患者右室失同步性。比较左、右室游离壁基底段的应变、应变率达峰时间,两者时间差即左、右室收缩延迟,提示心室间失同步性。结果与对照组比较,肺动脉高压组的右室各节段及整体收缩应变、应变率减低,出现右室收缩非同步[应变达峰时间标准差：对照组（28±20）ms对重度肺动脉高压组（61±62）ms,P=0．003]。在肺动脉高压组,与左室游离壁基底段相比,右室对应节段的应变率达峰时间明显提前：[对照组（13±13）ms对肺动脉高压组（-49±14）ms．P〈0．01]。结论肺动脉高压降低右室心肌收缩功能,导致右室内及双心室间收缩不同步;速度向量成像技术可以用于肺动脉高压治疗过程中右室功能监测。     

组织同步成像评价缺血性心肌病患者左心室心肌运动不同步状况

目的 探讨组织同步成像(TSI)技术评价缺血性心肌病(ICM)患者心室运动不同步状况的临床应用价值.方法 ICM患者38例,分为两组:A组不伴左束支传导阻滞(LBBB)26例,B组伴LBBB 12例.26例健康查体者为对照组.在7S1模式下,根据二维图像颜色对比各组各节段心肌运动情况,计算左室12个节段收缩期达峰速度时间的标准差(Ts-SD)、舒张早期达峰速度时间的标准差(Te-SD)、收缩期达峰时间差值(Ts max-min)、舒张期达峰时间差值(Te max-min),以评价各组心室内同步性.结果 ①TSI检查对照组91.8%节段运动无延迟,8.2%节段运动轻度延迟.在所有ICM患者中,心肌表现为绿～黄～红浓度明显不均分布,黄色或红色的节段数较对照组明显增多.②ICM组左室12节段Ts-SD、Ts max-min均明显大于对照组(P<0.05).ICM组内比较,B组患者的收缩同步性更差(P<0.05).③ICM组左室12节段Te-SD、Te max-min均明显大于对照组.ICM组内比较,B组ICM患者的舒张同步性更差(P相似文献   

速度向量成像评价左束支传导阻滞患者左心室收缩同步性

目的探讨速度向量成像（VVI）技术评估左束支传导阻滞（LBBB）患者左室心肌收缩同步性的临床应用价值。方法LBBB患者15例和健康志愿者30例,常规测量左室舒张末期内径（LVDd）、收缩末期内径（LVDs）、舒张末期容积（LVEDV）、收缩末期容积（LVESV）和射血分数（LVEF）。在系列心尖长轴及胸骨旁短轴观上,VVI成像显示左室速度向量图。心尖长轴观测量各节段收缩期纵向速度达峰时间（Tvl）,胸骨旁短轴观测量收缩期径向速度达峰时间（Tvr）和环向应变达峰时间（Tsc）,计算上述各达峰时间的标准差（Tvl-SD,Tvr-SD,Tsc-SD）及任意两节段间最大达峰时间差值（Tvl-diff,Tvr-diff,Tsc-diff）。结果①与对照组相比,LBBB组LVESV显著增加（P〈0.05）,LVEF显著降低（P〈0.05）,而LVDd、LVDs、LVEDV测值两组间比较差异无统计学意义。②LBBB组各节段Tvl、Tvr、Tsc测值及Tvl-SD、Tvr-SD、Tsc-SD、Tvl-diff、Tvr-diff、Tsc-diff测值均显著高于对照组的相应测值（P〈0.05或0.01）。③LBBB组前间隔心尖段Tvr测值最小,左室侧壁心尖段Tvr测值最大,两者间比较差异有统计学意义（P〈0.01）。结论LBBB患者左室心肌在纵向、径向与环向上均存在显著的收缩不同步。VVI技术为评价LBBB患者左室心肌收缩同步性,观察左室心肌收缩序列异常提供了一种新的方法。     

组织同步显像评价左心室内收缩失同步

目的 应用组织同步显像(TSI)观察左心室内心肌收缩运动失同步,探讨快速准确判定心室内运动不协调的方法。 方法 收集完全性左束支传导阻滞患者(LBBB组)28例及正常志愿者(对照组)28名,以TDI测量左心室12节段的收缩达峰时间(Ts),计算收缩达峰时间的标准差(Ts-SD)。分别设定不同的TSI处理时间,根据二维图像显示的色彩计算TSI积分。 结果 与对照组相比,LBBB组Ts延长,Ts-SD增大,TSI积分明显增加。LBBB组共有36个节段(36/336,10.71%)存在严重收缩后收缩(PSS)现象。TSI处理时间设定在收缩期时与等容舒张期时的严重PSS节段的平均TSI积分与仅设定在收缩期时差异有统计学意义(3.60±0.37 vs 2.30±0.48,P<0.001)。 结论 在正确设定处理时间的前提下,利用TSI可以直观评价左心室心肌收缩运动不同步。     

超声心动图评价左心室收缩失同步

目的 应用组织多普勒及常规超声心动图观察左束支传导阻滞患者左心室心肌收缩运动失同步.方法 完全性左束支传导阻滞者(LBBB)20例,正常对照者20例.定量组织多普勒测量左室基底及中段共12个节段的收缩达峰时间(TS),并计算其变异系数(标准差/均值)作为收缩不同步指数(SDI).同时测量心肌做功指数(MPI)、左室射血分数(EF)及充盈时间(FT).结果 与正常组相比,LBBB组的患者左室收缩明显延迟,12个节段TS的均值明显延长(P<0.001).其SDI显著增大(P<0.001).LBBB组的MPI增大,EF、FT均显著减小(P<0.001).结论 LBBB患者的左室壁各节段出现不同程度的收缩延迟,对左室的整体功能存在影响.定量组织多普勒观察心室电-机械耦联情况,结合对左室整体功能的测定,可以综合评价左心室收缩的失同步.     

组织速度成像评价心肌运动协调性

目的应用组织速度成像评价左心室各室壁之间和左室与右室之间在时间和方向上的同步和协调性。方法选择29例正常人,在组织速度成像模式下,应用心尖四腔观对右室基底段、室间隔基底段和侧壁基底段的时间速度曲线进行分析,评价右室与左室室间隔和侧壁心肌的同步运动;对左室室间隔、侧壁、下壁、前壁、前间隔和后壁基底段和中段的时间速度曲线进行分析,评价左室内心肌的同步运动。结果在快速射血起始时间、收缩达峰时间、R波至Sm终止时间、R波至快速充盈起始时间和R波至心房收缩终止时间左室各室壁基底段和中段,以及同一室壁基底段和中段之间差异均无显著性意义(P>0.05)。右室与侧壁之间的快速射血起始时间差异存在显著性意义(P<0.05),右室与室间隔之间的快速射血起始时间差异存在极显著性意义(P<0.001)。右室与室间隔、右室与侧壁在收缩达峰时间均差异存在极显著性意义(P<0.001)。在R波至Sm终止时间,R波至Em起始时间和R波至Am终止时间右室与左室之间差异无显著性意义。左室各室壁之间和左室与右室之间在收缩期和舒张期心肌的运动方向保持一致。结论组织速度成像能同时显示同一心动周期不同室壁心肌运动的时间间期和运动方向,它不仅能评价左室内各室壁之间的同步运动,还能评估右室与左室之间的同步运动。组织速度成像能够无创、快速和实时评价心脏运动的协调性。     

组织同步化显像技术评价右束支传导阻滞患者心室同步性与收缩功能

目的探讨组织同步化显像技术在评价右束支传导阻滞患者心室同步性与收缩功能中的应用价值。方法24例右束支传导阻滞患者为研究组,25例正常成年人为对照组。应用GE Vivid7彩色超声诊断仪、心肌组织速度显像及分析软件分析两组组织同步化图像,测量心肌收缩速度达峰值时间(T,经心率校正后为TC)及峰值速度(V)。结果①研究组右心室速度曲线具明显特征,其中2/3患者的等容收缩波延迟出现且振幅高于S波;②研究组达峰时间较对照组延长,除后间隔外,余节段的延长均具有统计学意义;③研究组左室达峰时间的标准差(TSD)较对照组大(45.34±18.63)ms对(39.97±11.17)ms,P=0.037,右左心室间达峰时间最大差(TRV-LV)亦较对照组大(118.29±38.25)ms对(91.43±48.54)ms,P=0.04;④研究组除左心室侧壁基底段心肌速度小于对照组(5.06±1.79)cm/s对(6.45±1.57)cm/s,P<0.05外,余节段差异无统计学意义。结论组织同步化显像可以快速、稳定地评价右束支传导阻滞患者的心室同步性和收缩功能,经心率校正后的达峰时间受客观因素影响小,为临床评价心室同步性提供了稳定可靠的指标。     

组织多普勒成像评价右心室心尖部及右室流出道起搏的同步性

目的采用组织多普勒成像（TDI）检测右室心尖部起搏（RVAP）、右室流出道起搏（RVOTP）对于左室同步性的影响与比较。方法 2008年3月2010年3月20例安置RVAP患者及20例安置RVOTP患者术后3个月行TDI检测,将左室12节段收缩达峰时间的标准差（TS-SD）、6个基底段收缩达峰时间差值、左室12个节段中任意两个节段收缩达峰时间最大差值作为同步化参数。结果 TDI结果显示,两组之间同步性参数比较,有统计学意义（P〈0.01）。结论 RVAP会导致左室内收缩不同步,TDI技术可以准确评价左室收缩同步性。     

实时三平面定量组织速度成像技术评价冠心病患者心室收缩同步运动

目的:探讨实时三平面定量组织速度成像技术对评价冠心病患者左右心室壁收缩同步运动的临床价值.方法:同步实时采集行冠脉造影139例患者(分4组)心尖四腔观、心尖两腔观和心尖左室长轴观的组织速度动态图像,测量左右心室壁基底段收缩达峰时间(Ts)并计算室内及室间收缩不同步差量进行对比研究.结果:部分左室壁基底段Ts在组间比较中有统计学差异(P＜0.01或P＜0.05),室内及室间收缩不同步差量的组间比较无统计学差异(P＞0.05),室间隔Ts对冠状动脉狭窄≥50％的诊断价值最高(P＜0.01).结论:实时三平面定量组织速度成像技术可较准确评价心室壁收缩同步运动,对诊断缺血心肌的敏感性高于常规超声心动图.     

Color Doppler tissue velocity imaging can disclose systolic left ventricular asynchrony independent of the QRS morphology in patients with severe heart failure

A QRS width greater than 120 ms is assumed to be a marker of inter- and intraventricular asynchrony in severe heart failure (HF) patients. Color Doppler tissue velocity imaging (c-TVI) with a time resolution of 10 ms was used to study regional left ventricular (LV) longitudinal systolic contraction pattern in HF patients with left and right bundle branch block (LBBB and RBBB) and in patients with normal QRS width. We studied 12 women and 23 men with severe HF, with a mean age of 66 +/- 11 years in New York Heart Association functional Class 2.9 +/- 0.6. Twenty patients had LBBB and 10 of those were accepted for cardiac resynchronization therapy by biventricular pacing (CRT). Ten patients had normal QRS width, and five had RBBB. In the echocardiographic apical four chamber view, regional peak LV tissue velocities and regional LV time differences of peak tissue velocities were compared at basal and mid-LV segments. There were no significant differences in regional mean peak tissue velocities among the patient groups. In patients with LBBB accepted for CRT, the LV lateral free-wall movement at basal LV was 29 ms delayed during main systole, almost significantly different from LBBB patients not accepted for CRT (P = 0.075). Even in HF patients with normal QRS width or RBBB, significant asynchronous longitudinal LV contraction was observed. Conclusions: For the detection of regional longitudinal LV contraction asynchrony in patients with severe HF, supplementary methods to the surface ECG, such as c-TVI, are strongly recommended.     

Cardiac Resynchronization Therapy in Non‐Left Bundle Branch Block Morphologies

Introduction: In select patients with systolic heart failure, cardiac resynchronization therapy (CRT) has been shown to improve quality of life, exercise capacity, ejection fraction (EF), and survival. Little is known about the response to CRT in patients with right bundle branch block (RBBB) or non‐specific intraventricular conduction delay (IVCD) compared with traditionally studied patients with left bundle branch block (LBBB). Methods: We assessed 542 consecutive patients presenting for the new implantation of a CRT device. Patients were placed into one of three groups based on the preimplantation electrocardiogram morphology: LBBB, RBBB, or IVCD. Patients with a narrow QRS or paced ventricular rhythm were excluded. The primary endpoint was long‐term survival. Secondary endpoints were changes in EF, left ventricular end‐diastolic and systolic diameter, mitral regurgitation, and New York Heart Association (NYHA) functional class. Results: Three hundred and thirty‐five patients met inclusion criteria of which 204 had LBBB, 38 RBBB, and 93 IVCD. There were 32 deaths in the LBBB group, 10 in the RBBB, and 27 in the IVCD group over a mean follow up of 3.4 ± 1.2 years. In multivariate analysis, no mortality difference amongst the three groups was noted. Patients with LBBB had greater improvements in most echocardiographic endpoints and NYHA functional class than those with IVCD and RBBB. Conclusion: There is no difference in 3‐year survival in patients undergoing CRT based on baseline native QRS morphology. Patients with RBBB and IVCD derive less reverse cardiac remodeling and symptomatic benefit from CRT compared with those with a native LBBB. (PACE 2010; 590–595)     

组织多普勒成像评价左束支传导阻滞时不同步心室活动

目的超声评价左束支传导阻滞(LBBB)患者局部心肌的纵向运动。方法超声测量15例LBBB患者和15例正常人各瓣环，获得纵向上不同时相的峰值速度(VS、VE、VA)、持续时间(IVC、S、IVR、D)、最大时间-速度积分(TVImax)和最大下移距离(Dmax)，以及心电图QRS波起点到S波起点的时间(Q-Sb)、到S波顶点的时间(TTP)、E波的减速时间(Edc)等。结果LBBB患者左室室间隔、下后壁和前壁瓣环VS、VE、TVImax、Dmax明显减低，Q-Sb、TTP明显延长；左室室间隔、下后壁的IVC、IVR延长，D缩短，IVC／S增高。结论LBBB时左室激动顺序异常，引起左室整体和局部舒缩功能异常；左室各壁出现不同程度的收缩延迟，心室内不同步明显；右室收缩延迟不明显，左、右心室间明显不同步。     

Electrophysiologic characteristics of sudden QRS axis deviation during orthodromic tachycardia. Role of functional fascicular block in localization of accessory pathway.

We analyzed the effect of functional fascicular block (FFB) on ventriculoatrial conduction time (VACT) during orthodromic tachycardia (OT) in 32 patients with single accessory pathway (AP) of the Kent bundle type. The location of AP was left free wall (LFW-AP) in 21 patients, left posteroseptal in 6, right free wall in 2, and right anteroseptal in 3. FFB either alone or in combination with functional left or right bundle branch block (LBBB or RBBB) occurred predominantly at the onset of OT and was initiated with ventricular extrastimulus technique more often than with atrial extrastimulation. In patients with LFW-AP, isolated functional left anterior fascicular block (LAFB) produced significant prolongation in VACT (15-35 ms). A similar magnitude of VACT increase (20-35 ms) was also observed when LAFB was associated with RBBB. Although 25-45-ms prolongation in VACT occurred with functional LBBB and normal axis, an additional 20-55-ms VACT increase was seen when LAFB accompanied LBBB. Functional LAFB, alone or in combination with bundle branch block, however, did not prolong VACT in patients with other AP locations. Furthermore, left posterior fascicular block did not produce prolongation of VACT in any of the cases. It is concluded that in patients with the Wolff-Parkinson-White syndrome, evaluation of VACT during functional LAFB provides important information regarding AP localization and a clear separation of LFW-AP from all other locations.     

Reinitiation of ventricular macroreentry within the His-Purkinje system by back-up ventricular pacing - a mechanism of ventricular tachycardia storm

BACKGROUND: We describe immediate reinitiation of macroreentry ventricular tachycardia (VT) involving the His-Purkinje system by ventricular pacing from the electrode of an implantable cardioverter defibrillator (ICD) as a mechanism of VT storm refractory to ICD therapy. METHODS AND RESULTS: Repetitive reinitiation of bundle branch reentry tachycardia (BBRT), interfascicular tachycardia, or both VTs by ventricular pacing was identified in four ICD patients presenting with VT storm or incessant VT. All patients had a pre-existing prolonged HV interval (75 +/- 9 ms) and left bundle branch block (LBBB) or bifascicular block during sinus rhythm. The VTs included BBRT with LBBB in three patients and interfascicular tachycardia with right bundle branch block (RBBB) and left anterior or left posterior fascicular block in two patients. The paced beats from the ICD electrode exhibited a LBBB pattern of depolarization in two patients and a RBBB contour in V1 and V2 with left axis deviation in two patients. The QRS complex during pacing from the ICD electrode closely resembled that of the recurrent VT in all four patients suggesting that the pacing site of the ICD electrode was in proximity to the myocardial exit site of the bundle fascicle used for antegrade conduction during the reinitiated VT. Ventricular pacing from the ICD electrode after termination of the VT apparently encountered the retrograde refractoriness of this bundle fascicle and allowed immediate re-propagation of the wavefront orthodromically along the VT circuit. BBRT was eliminated by ablation of the right bundle branch. Successful ablation of the interfascicular tachycardias was achieved by targeting (1) an abnormal potential of the distal left posterior Purkinje network or (2) a diastolic potential during VT in the midinferior left ventricular (LV) septum. CONCLUSIONS: Repetitive reinitiation of BBRT and interfascicular tachycardia by ventricular pacing from the ICD electrode should be considered as a mechanism of VT storm refractory to ICD therapy in patients with a pre-existing conduction delay within the His-Purkinje system.     

冠状动脉狭窄对应左室心肌纵向运动位移和同步化的定量研究

目的 应用组织追踪（TT）和组织同步化成像（TSI）技术探讨冠状动脉狭窄程度与局部心肌运动位移及同步化之间的定量关系。方法 对19例冠状动脉造影证实的冠状动脉狭窄患者（狭窄组）和21例正常人（对照组）左室心肌的12个节段测量TT曲线的收缩期峰值位移（Ds）、R波至收缩期峰值位移时间（T—ds）和TSI的收缩达峰时间（Ts）。结果 中度狭窄组DS在左室基底段和中间段与正常组比较，差异有统计学意义（P〈0．05或P〈0．01）；T-ds在中、重度狭窄组与正常和轻度狭窄组之间差异均有统计学意义（P〈0．01）；Ds、T—ds和Ts在轻度狭窄组与正常组比较差异均无统计学意义。结论 TT技术能较准确地检出中、重度冠状动脉狭窄患者静息状态下的异常心肌节段，但TT和TSI对轻度冠状动脉狭窄的检出似无显著作用。