40例Ebstein畸形患儿的心电图分析

目的通过分析40例小儿三尖瓣下移畸形的心电图，探讨小儿三尖瓣下移畸形的心电图特点。方法分析40例三尖瓣下移畸形的心电图变化；并与其它50例房间隔缺损、50例各种紫绀型先天性心脏病心电图比较；并对三尖瓣下移畸形组中不同心功能级别的患儿（Ⅰ～Ⅱ级、Ⅱ级以上）的心电图进行分析。结果右房大、右束支阻滞、一度房室阻滞、V1导联R’波电压低、右胸导联出现q波伴T倒置、B型预激综合征、阵发性心动过速史与对照组有显著性差异（p〈0．01）。结论三尖瓣下移畸形的心电图特点对诊断和鉴别诊断有重要价值。     

长P—R间期型文氏型房室传导阻滞伴不定型心室内传导阻滞

患者男性 ,１７岁。因心悸、气促半天就诊。４个月前患者因三尖瓣下移畸形 (Ｅｂｓｔｅｉｎ畸形 )在外院手术治疗。１２导联心电图 (图１Ａ)示 :窦性Ｐ波 ,Ｐ＿Ｐ间期相等 ,频率１０８次／ｍｉｎ ,Ｐ＿Ｒ间期０．４０ｓ,Ⅱ、Ⅲ、ａＶＦ导联Ｐ波增高有切迹 ,振幅高０．３０ｍＶ ,时间为０．１３ｓ。ＱＲＳ波群Ⅰ、ａＶＬ导联呈挫折Ｒ型 ;Ｖ５、Ｖ６导联呈ｒＳ型且ｓ波顿挫 ;Ｖ１呈ＱＳ型 ,ＱＲＳ时间长达０．１６ｓ。各导联均可见提前出现宽大畸形的ＱＲＳ波群 ,虽然前面有Ｐ波 ,但Ｐ＿Ｒ间期没有达到下传最短Ｐ＿Ｒ间期的０．４０ｓ ,考虑为…     

Ebstein畸形合并房间隔缺损、右侧三房心及右侧显性房室旁道一例

患者男 ,31岁 ,因突发性晕厥 1次入院。心电图示窦性心律、Ｂ型预激综合征 ,晕厥发作时院外心电图示心房颤动伴旁道下传。二维超声心动图心尖 4腔心切面显示Ｅｂｓｔｅｉｎ畸形 ,三尖瓣隔瓣下移 2 9ｃｍ ,右心房内见一纤维肌膜将右心房分成二部分 ;在纤维肌膜的中部可探测到血流 ;房间隔中部见一 0 7ｃｍ的连续中断 ,并可探测到左向右分流 ;二氧化碳声学造影示房间隔中部右心房侧充盈缺损 ,大部分血流左向右分流 ,少部分右向左分流。讨论　Ｅｂｓｔｅｉｎ畸形又称三尖瓣下移畸形 ,是指三尖瓣隔瓣与后瓣下移附着在心尖的右室壁上 ,前瓣位置…     

双房室旁道合并Mahaim纤维(附一例分析)

报道１例束室纤维合并双房室旁道的电生理表现。患者有心动过速史１５年，心电图示右侧游离壁显性旁道，分别于三尖瓣环８点半和５点半处消融阻断旁道，原心电图发生了改变，但存在Ｄｅｌｔａ波。上述两条旁道消融前，ＰＲ间期均为０．０６ｓ，心房递增刺激Ｄｅｌｔａ波增大，房室传导无文氏现象。两条房室旁道消融后，ＰＲ间期为０．１０ｓ、ＡＨ间期１００ｍｓ、ＨＶ间期２０ｍｓ。心房递增刺激时ＡＨ间期逐渐延长且出现文氏型房室阻滞，ＨＶ间期不变、预激程度不变，提示为Ｍａｈａｉｍ纤维（束室支）。心室刺激时逆传Ａ波在Ｈｉｓ束电图最早，提示Ｈｉｓ束逆传。三尖瓣环上未能标测到Ａ、Ｖ波融合。心房、心室刺激未能诱发心动过速。     

VDD起搏治疗幼儿完全性房室阻滞(附一例报告)

一例３．５岁的女性幼儿因室间隔缺损修补术致迟发性完全性房室阻滞（ＣＡＶＢ）而安置ＶＤＤ起搏器。经锁骨下静脉途径埋置单根心房感知、心室触发起搏电极，使之于右房内塑形并贴靠房壁；起搏器埋于同侧皮下胸大肌筋膜上囊袋内。术中测得起搏阈值０．１Ｖ、脉宽０．４ｍｓ、电极阻抗５２０Ω、Ａ波振幅１．５ｍＶ、Ｖ波振幅１０．６ｍＶ，Ａ波感知设定０．２５ｍＶ。术后房室同步起搏率１００％，临床症状改善。表明ＶＤＤ起搏器不仅埋置简便，而且具有房室同步、频率应答等生理性起搏特点，是治疗幼儿ＣＡＶＢ的理想起搏方式。     

《思考心电图之74》答案

本图在宽大畸形的ＱＲＳ波群中隐约可见Ｐ波连续存在 ,Ｐ＿Ｐ频率为１３０次／ｍｉｎ,Ｐ Ⅱ呈双峰 ,前峰大于后峰 ,两峰间距＞０．０４ｓ,Ｐ波时间≥０．１１ｓ,ＰＶ 高尖达０．３ｍＶ ,示左右心房负荷过重。Ｒ＿Ｒ间期长短变化无明显规律性 ,短Ｒ＿Ｒ间期互差０．０４ｓ,中行两次长Ｒ＿Ｒ间期分别为０．４４和０．５２ｓ,上行Ｒ８＿Ｒ９及Ｒ９＿Ｒ１０均为０．９２ｓ,是０．２３ｓ的整倍数 ,提示节奏点外出阻滞。本例的心电图诊断为 :窦性心动过速 ,左右心房肥大 ,三度房室传导阻滞 ,室性心动过速伴外出阻滞。另外 ,还有较多同志认为 :Ⅱ导…     

心房扑动合并房室交接区三层阻滞

心房扑动合并房室交接区三层阻滞龚国君胡孟红患者男性，１７岁。临床诊断：法乐四联症，图１示Ｐ波消失，代之以Ｆ波，频率２３０次／分，Ｖ１Ｆ波振幅高达０４ｍＶ，Ｆ－Ｒ间期由０１９ｓ０２６ｓ０５０ｓＯＣ，Ｒ－Ｒ间期由０８８ｓ１０２ｓ１?..     

射频消融术治疗三尖瓣下移畸形并房室折返性心动过速射频消融术治疗三尖瓣下移畸形并房室折返性心动过速

８例三尖瓣下移畸形并右侧旁路患者行射频消融，平均室上速发作病史１１年。成功消融７例共８条旁束。结果表明：射频消融术前先行右室造影有利于消融靶点定位，射频消融术是治疗三尖瓣下移畸形并房室折返性心动过速安全、有效的方法。     

间歇性B型预激合并完全性右束支阻滞

间歇性Ｂ型预激合并完全性右束支阻滞卞士平患者男性，７０岁。因反复发作胸骨后疼痛５天住院。临床诊断冠心病。心电图示（图１）：窦性心律，心率６０次／分，Ｖ１导联为连续记录，Ｖ１ａＲ１～４；Ｖ１ａＲ３～４；Ｖ１ｂＲ３～６及、Ｖ５Ｒ１～４的Ｐ－Ｒ间期为０．１...     

爱勃斯坦畸形合并右侧隐匿性慢旁路伴左室室速的射频消融治疗

爱勃斯坦综合征为先天性三尖瓣膈瓣下移畸形 ,多数合并右侧显性室上性心动过速 ,我们经射频消融术根治了一例罕见的爱勃斯坦畸形合并右侧隐匿性慢旁路伴左室特发性室速 ,报告如下 :女性患者 ,2 9岁 ,反复阵发性心悸十五年 ,近半年每周发作 2 - 3次或每天均发作 ,持续最长可达 2 - 3天 ,静注异搏定可终止发作。查体 :口唇发绀 ,心界不大 ,心率 6 8次 分 ,节律整齐 ,三尖瓣区闻Ⅲ 6级收缩期杂音。既往心电图窦性心律示右束支传导阻滞 ,有宽ＱＲＳ心动过速 ,Ｒ -Ｐ′不明显。心脏Ｂ超示三尖瓣隔叶下移距二尖瓣前叶根部约 3 2ｃｍ。食管心房调…     

Right atrial reduction for tachyarrhythmias in Ebstein's anomaly in infancy.

A 20-month-old girl with Ebstein's anomaly developed supraventricular paroxysmal tachycardia, which seemed to be a result of the wall tension of the giant right atrium. Right atrial resection reduced the wall tension and overall dimensions of the right atrium and finally resolved the tachycardia and ectopic electrical conduction. Six-year follow-up electrocardiograms confirmed continuing normal sinus rhythm without occurrence of supraventricular paroxysmal tachycardia or other ectopic electrical activity The follow-up echocardiograms showed the size of the right atrium to be unchanged from the time of operation. There are few data in the available literature about performing right atriotomy to resolve a tachyarrhythmia associated with Ebstein's anomaly and none, to the best of our knowledge, about performing right atrial resection for this purpose.     

Radiofrequency catheter ablation of accessory pathway in a patient with Ebstein's anomaly and atrial septal defect--a case report

The authors report the case of a 57-year-old woman with Ebstein's anomaly and atrial septal defect. She was referred to their hospital for treatment of refractory paroxysmal wide QRS tachycardia. Her 12-leads ECG in sinus rhythm showed ventricular preexcitation of type B Wolff-Parkinson-White syndrome. In a baseline electrophysiological study, a wide QRS tachycardia with right bundle branch block configurations was induced. This tachycardia was orthodromic atrioventricular reciprocating tachycardia with a right inferior accessory pathway. Radiofrequency current was successfully delivered at the inferior site of the atrialized right ventricle. Radiofrequency catheter ablation seems to be useful for supraventricular tachycardia in patients with Ebstein's anomaly and atrial septal defect.     

Electrocardiogram in dilated cardiomyopathy

The authors describe the main electrocardiographic features in 90 cases of dilated cardiomyopathy. The patients were divided into tree groups: in group I were the patients with electrocardiographic signs of left ventricular hypertrophy, in group II the patients with complete left bundle branch block and in group III the cases with right bundle branch block, was held in the group I 64 patients (71%), in the group II 22 (24.6%) and in the group III four case (4.4%). Seventy two cases (80%) showed arrhythmias. Atrial fibrillation was observed in 20 patients (28%), supraventricular tachycardia in two (3%), atrioventricular block, of the 1st and 2nd degree, in eight (11%), ventricular arrhythmias in 63 (87.5%) and supraventricular arrhythmias in 42 (58%). In the 64 patients, with left ventricular hypertrophy, 60 (93.75%) showed very important S waves in, at least two right precordial leads. Fourty four patients (73.3%) had rS pattern in right precordial leads, from V1 to V4, with the R waves in V5 and V6 with normal, low and height amplitude. A first degree left bundle branch block was recorded in 16 cases (25%), a pathologic Q waves in 22 (37.5%), low voltage in limb leads in 24 (37.5%), left atrial enlargement in 36 (56%), right atrial enlargement in two (3%) and atrial fibrillation in 10 (16%). In the 22 patients from the group II six (27%) had left atrial enlargement, two (9%) had right atrial enlargement and six (27%) atrial fibrillation. In the four patients from group III two (50%) had an incomplete right bundle branch block, two (50%) the complete form and all had atrial fibrillation.     

Subcostal M-mode echocardiography of the right atrial wall in the diagnosis of cardiac arrhythmias

The M-mode echocardiogram of the right atrial (RA) wall can be easily recorded in each person from the subcostal location. In a normal RA wall motion pattern, atrial contraction is represented by a markedly prominent posterior motion. The presence or absence of atrial contractions in the subcostal RA wall echocardiogram, their amplitude, and their timing may help in the diagnosis of cardiac arrhythmias with the simultaneously recorded non-diagnostic electrocardiogram. Flat and hidden P waves can be accurately identified throughout the cardiac cycle. It is possible to distinguish between atrial, ventricular, and nodal premature beats and to recognize atrial fibrillation, atrial flutter, paroxysmal atrial tachycardia, paroxysmal atrial tachycardia with block, atrioventricular (AV) nodal tachycardia, and supraventricular tachycardias with aberrant ventricular conduction. The diagnosis of wandering pacemaker, AV dissociation, sinoatrial block, and AV block is facilitated. On the basis of study of 60 patients with various rhythm disturbances, it was concluded that analysis of the subcostal RA wall echocardiogram is a new, helpful noninvasive approach in the diagnosis of cardiac arrhythmias.     

Ebstein's anomaly with the Wolff-Parkinson-White syndrome

Thirty-three patients were studied with Ebstein's anomaly, associated to Wolff-Parkinson-White syndrome with the purpose of analyze their electrophysiologic characteristics. In this patients the right preexcitation was before the activation of the right ventricle mass, overshadowing the manifestations of the right bundle branch block (usual in patients with Ebstein's anomaly without preexcitation). In conclusion the absence of manifestations of right bundle branch block in the presence of Ebstein's anomaly diagnosed by hemodynamic study or echocardiography let us think in the coexistence of the preexcitation and suggest the pertinent electrophysiologic study; as the association of supraventricular tachycardia in this group is very high (94%) most of them paroxysmal orthodromic tachycardia.     

Mechanisms of Transition Between Double Paroxysmal Supraventricular Tachycardias

INTRODUCTION: Coexistence of double tachycardias in one patient has been infrequently reported. Furthermore, the mechanisms of transition between double paroxysmal supraventricular tachycardias have not been well studied. METHODS AND RESULTS: Thirty-five patients with two paroxysmal supraventricular tachycardias were studied. Group IA consisted of 3 patients with spontaneous transition between AV reciprocating tachycardia (AVRT) and AV nodal reentrant tachycardia (AVNRT). Group IB consisted of 13 patients without spontaneous transition between AVRT and AVNRT. Group IIA consisted of 5 patients with spontaneous transition between AVNRT and atrial tachycardia (AT). Group IIB consisted of 14 patients without spontaneous transition between AVNRT and AT. The absolute values of differences between the two tachycardia cycle lengths were significantly smaller in patients with than in those without transition between the two tachycardias (25+/-8 msec vs 90+/-46 msec, P < 0.05, IA vs IB; 21+/-25 msec vs 99+/-57 msec, P < 0.01, IIA vs IIB). The cutoff point of 25 msec had 80% positive predictive value for transition between the two tachycardias. Transition between two tachycardias occurred due to a spontaneous premature atrial complex (30%), conduction block at one limb of tachycardia (20%), or tachycardia-induced tachycardia (50%). Absence of transition between two tachycardias might be explained by the absence of a spontaneous premature atrial complex, longer cycle length of the first tachycardia, larger difference between two tachycardia cycle lengths, or induction of each tachycardia under different situations. CONCLUSION: Double supraventricular tachycardias with similar tachycardia cycle lengths are vulnerable to transition between different tachycardias.     

Ebstein's anomaly in association with anomalous nodoventricular conduction. Pre-operative and intra-operative electrophysiological studies.

A 13 year old girl with Ebstein's anomaly was investigated for refractory paroxysmal tachycardias and ventricular pre-excitation. Intracardiac electrophysiological studies demonstrated that ventricular pre-excitation was due to conduction in an anomalous nodo-ventricular pathway. Tachycardia occurred as a result of re-entry within the A-V node with pre-excitation during tachycardia due to conduction in the nodo-ventricular pathway. These tachycardias were controlled initially by medical therapy but because of increasing frequency of attacks, occasionally requiring D.C. conversion, further electrophysiological studies and epicardial mapping were undertaken. The epicardial surface of the right ventricle and right atrium were mapped during tachycardia. The results of the studies confirmed that a direct anomalous atrio-ventricular pathway was not present and that re-entrant tachycardia did not involve an accessory pathway of this type. A rapid atrial pacing system was implanted and paroxysmal tachycardias have been successfully controlled.     

Electrocardiographic criteria for differentiating aberrancy and ventricular extrasystole in chronic atrial fibrillation: validation by intracardiac recordings

Many electrocardiographic criteria have been proposed for the differentiation of ventricular extrasystole and supraventricular conduction with aberrancy in atrial fibrillation but the validity of these have not been confirmed by intracardiac studies. We recorded His bundle electrograms in nineteen patients (eleven men, eight women) referred for diagnosis of abnormal QRS complexes in the context of chronic atrial fibrillation. Of 1,068 wide QRS complexes analyzed, 91% proved to be of ventricular origin. Electrocardiographic criteria which were specific for ventricular extrasystole included: left bundle branch block morphology, right bundle branch block morphology with a monophasic R in lead V1 or an RS or QS pattern in lead V6, presence of a "compensatory pause", i.e., compensatory cycle (V2-V3) longer than the average cycle length of ten normally conducted beats preceding the abnormal complex (927 +/- 317 vs 780 +/- 199, mean +/- SD in msec. p less than 0.005), frontal QRS axis of the abnormal complex directed superiorly or to the right and the presence of a "short-long" cycle sequence. Right bundle branch morphology with a triphasic R in lead V1 or QRS pattern in V6 and concordant initial vector in lead V1 or in more than one ECG leads were very specific for supraventricular conduction with aberrancy. Analysis of coupling interval and Ashman's phenomenon, i.e., the long-short cycle sequence, were not specific for supraventricular conduction with aberrancy. We conclude that in digitalis-treated patients with chronic atrial fibrillation the majority of abnormal QRS complexes are of ventricular origin. The diagnosis of ventricular extrasystole or aberrancy can be made using a single ECG lead (V1) and applying a combination of easily applied criteria.     

Catheter Ablation for the Treatment of Paroxysmal Supraventricular Tachycardia

Catheter Ablation for PSVT. Radiofrequency catheter ablation has evolved into a front-line curative therapy for patients who have paroxysmal supraventricular tachycardia secondary to Wolff-Parkinson-White syndrome, AV nodal reentrant tachycardia, and atrial tachycardia. In patients with accessory pathways, cure rates exceed 90% in almost all anatomic locations. Equally high success rates are noted in patients with atriofascicular pathways and the permanent form of junctional reciprocating tachycardia. Complications secondary to catheter ablation of accessory pathways occur in 1% to 3% of patients and include cardiac perforation, tamponade, AV block, and stroke. In patients with AV nodal reentrant tachycardia, selective slow pathway ablation is curative in over 95% of patients with a very low risk of AV block. Atrial tachycardias originating in both the left and right atria can he successfully ablated in over 80% of patients. Given the overall effectiveness of this procedure, radiofrequency catheter ablation should be considered as front-line therapy in patients with recurrent or drug-refractory paroxysmal supraventricular tachycardia. Although an effective therapy, the risks and benefits of this procedure need to be assessed in all patients who are candidates for this procedure.     

Paroxysmal supraventricular tachycardia initiated by a swallowing-induced premature atrial beat

We report a unique patient in whom electrophysiologic studies elucidated the mechanism of a rare form of swallowing-induced atrioventricular reentrant tachycardia, and for whom successful surgical ablation of an accessory pathway abolished intractable episodes of palpitation. A 64-year-old man was incapacitated by frequent attacks of palpitation following swallowing. Electrocardiograms documented paroxysmal supraventricular tachycardias initiated by a premature atrial beat or beats following swallowing. During electrophysiologic studies swallowing consistently induced premature atrial beats which in turn initiated a sustained atrioventricular reentrant tachycardia incorporating a retrogradely conducting left-sided concealed accessory pathway. The atrial activation sequence related to the premature atrial beats and the morphology of the premature P waves suggested that premature atrial beats originated in the right atrium. The mechanism of induction of premature atrial beats following swallowing remains obscure in our patient. Antiarrythmic drugs failed to prevent induction of sustained tachycardias during sequential electrophysiologic studies. The patient underwent successful surgical ablation of the accessory pathway and is free from palpitation 15 months after the surgery.