经剑突下穿刺猪尾导管心包引流并腔内化疗治疗恶性心包积液

随着恶性肿瘤发病率的升高 ,恶性心包积液也有增多趋势。恶性心包积液以积液量大、不易控制为特点 ,患者常死于心包填塞。我们自 1 994年以来 ,采用 Seldinger穿刺法 ,经剑突下途径 ,置入猪尾导管行心包引流同时予以腔内化疗 ,共收治 1 3例 ,取得了良好的效果 ,现报告如下。1　对象与方法1 .1 　 对象1 3例 ,男 7例 ,女 6例 ,年龄 35～ 69(平均 56)岁。原发病为肺癌 6例 ,食管癌 3例 ,乳腺癌 2例 ,胃癌 1例 ,纵隔淋巴瘤 1例。 1 3例中 ,5例以心包积液为首发症状 ,经心包穿刺及临床检查后确诊为恶性肿瘤心包转移 ;另外 8例首先确诊原发病 ,…     

导管消融治疗心房颤动的新策略与新趋势

心房颤动(atrial fibrillation)简称房颤,是临床最常见的快速性心律失常之一,人群发病率达2‰~6‰,随着年龄增加,房颤有逐渐增加的趋势,据统计,     

冠状窦肌袖及其与左心房肌连接的解剖学研究

目的　观察冠状窦肌袖及其与左心房之间的肌性连接。方法　解剖 7个国人心脏标本 ,沿冠状窦长轴纵切 ,通过连续的大组织切片观察冠状窦肌袖及其与左心房之间的肌性连接。结果所有标本均可见形态与左房肌相同的肌袖 ,长度 2 1～ 35mm ,厚度 0 2～ 1 7mm。均见肌袖与左房肌之间的肌性连接。肌连接在大小部位上差异很大。有的仅有 1～ 2个大肌束 ;有的肌连接多而宽 ,和左房肌互相融合。同时观察到在冠状窦和左房肌之间的脂肪中可见许多小肌束。结论　围绕冠状窦有丰富的肌袖 ,其与左房间通过数目不等的肌纤维进行连接。冠状窦肌袖及其与左房间的肌连接构成了左右心房间传导通路的基质。     

肺静脉口外环状消融并电学隔离左上腔静脉治疗阵发性心房颤动一例

左上腔静脉起源的阵发性心房颤动（房颤）是少见的，本文值得一读。但对作者们所用的标测方法—三维导航和双Lasso导管指导下的标测，有点看法。采用Lasso导管标测是需要的，有助于较准确地发现和确定消融靶点，但是何必用双Lasso导管呢？国内、外许多专家学者，只用一根Lasso导管已可达到标测的目的。编者参加了今年九月在北京举办的“国际心血管病论坛”，有幸与来自德国的KuckKH教授相聚，编者曾问Kuck教授（双Lasso导管标测的创导者之一）请教“双Lasso导管标测的主要益处是什么？”Kuck教授回答说双Lasso导管标测是“研究性”（investigational）的，有利于发现线性消融线上的漏点（gap）。鉴于Lasso导管价格昂贵（2万多人民币一根），我国的医保制度尚待完善，射频导管消融术治疗房颤的费用许多患者难以承受。更何况双Lasso导管!因此，在射频导管消融房颤的操作中，作为“常规”，没有必要采用双Lasso导管标测技术。[编者按]     

EnSite-NavX三维标测系统及临床应用

EnSite-NavX是三维接触标测系统,由三对NavX体表电极、信号分配器、信号处理器、计算机工作站及数据计时模块组成。利用三对NavX体表电极形成三维电场定位心腔内导管位置,通过标测导管记录到的电场、心电信号,经过信号处理器和计算机工作站后构筑心腔的三维图像。可应用于心律失常的激动标测、电压标测和心房颤动的碎裂电位标测。     

致心律失常性右室心肌病患者Epsilon波的检出率

Objective To investigate the prevalence of Epsilon wave in patients with arrhythmogenic right ventrieular cardiomyopathy (ARVC). Methods The Epsilon wave was detected in 32 patients [24 men, mean age (42.3±13.3) years] with ARVC using three different electrocardiography (ECG) recording methods: standard twelve leads ECG (S-ECG), right precordial leads ECG (R-ECG) and Fontaine bipolar precordiai leads ECG (F-ECG). The Epsilon wave was defined as wiggle, small spike wave and smooth potential between the end of the QRS complex and the beginning of the ST segment. Results Epsilon wave was detected in 37.5%, 37.5% and 50.0% patients with ARVC by S-ECG, R-ECG and F-ECG respectively. The detection rates derived from the three recording methods were similar(P ＞ 0.05). The Epsilon wave was only detectable by S-ECG in one case, by R-ECG in three cases, and by F-ECG in five cases. The detection rate of Epsilon wave was 50.0% by combined use of S-ECG and R-ECG (SR-ECG), 56.3% by combined use of S-ECG and F-ECG (SF-ECG), and 65.6% by combined use of the three recording methods (SRF-ECG). The detection rate was significantly higher by SF-ECG (56.3%) and SRF-ECG (65.6%) than by S-ECG alone (37.5%, all P ＜0.05). Most Epsilon waves detected by the S-ECG, R-ECG and F-ECG were small spiked waves. Conclusion Combined use of S-ECG, F-ECG and R-ECG could increase the detection rate of Epsilon wave in patients with ARVC.     

植入型心律转复除颤器治疗恶性室性心律失常的疗效评价

目的评价单中心40例植入型心律转复除颤器(ICD)治疗恶性室性心律失常的疗效及安全性。方法40例恶性室性心律失常包括室性心动过速(室速)或心室颤动(室颤)患者接受ICD治疗,男性35例,女性5例,平均年龄(49±15)岁,成功随访35例,应用体外程控仪获得ICD储存资料并结合临床随访资料进行分析。结果40例患者均成功植入ICD;35例患者平均随访25个月,其中26例患者共记录室速和室颤事件763阵,ICD成功除颤224阵(成功率99．1％),抗心动过速起搏1次成功终止室速375阵(成功率71．8％),低能量同步转复22阵(成功率100％);2例患者因窦性心动过速和心房颤动伴快速心室反应发生误放电4次。术后大多数患者联合应用抗心律失常药物。至随访期末,死亡4例,3例死于顽固性心力衰竭,1例死于肺栓塞。结论ICD联合应用抗心律失常药物能有效治疗恶性室性心律失常,预防心脏性猝死。     

导管消融终止无休止特发性左室室性心动过速伴先天性QT延长综合征心室颤动风暴一例

患女性，37岁。无家族性心脏猝死史，持续心悸6个月伴发作性晕厥4d。心电图记录为持续性呈右束支阻滞样图形伴电轴上偏室性心动过速（室速），偶尔间隙窦性心律、晕厥发作。在当地医院心电监护为心室颤动（室颤）共5次，每次用电复律转复，后转院途中及急诊室多次发生室颤并行除颤复律。多次查血钾正常，连续12天心电监护80％时间为室速，每天都有室颤，1～5次／d不等，每次发作均需电复律终止。如图1所示，电复律后立即又转变成室速，     

具有良好变时作用的持续性房性异位心律:临床特征、电生理机制及射频导管消融

目的介绍具有良好变时作用的房性异位心律(C-EAR)这一特殊类型的心律失常,分析其临床特征、可能的电生理机制及导管消融方法。方法共4例患者(男性3例),临床拟诊房性心动过速(房速)收住院,基础节律均为异位房性心律。其中1例既往有房间隔缺损修补术病史,余均无器质性心脏病史。常规穿刺置入导管行心内电生理检查,术中记录基础节律、最快节律及心动过速的心内电图。是否射频消融根据电生理检查的结果。所有患者术前、术后均行动态心电图检查。结果4例患者C-EAR分别位于右后间隔、右中间隔、三尖瓣环9点钟和左下肺静脉开口处。C-EAR基础状态平均房率为(84±19)次/min;临床或术中发现的最快房率平均为(198±20)次/min。病例1和病例2术中诱发出和基础节律不同源的房速,其中病例1合并围绕右心房侧壁手术疤痕折返的房速,消融未成功;病例2合并希氏束旁房速,消融成功。病例1和病例2的基础C-EAR未作消融。病例3和病例4的房速与C-EAR同源,病例3消融失败,病例4消融成功转为稳定窦性心律。4例患者的动态心电图显示,C-EAR随昼夜节律波动,根据生理需要升降,体现出良好的变时性作用。平均最慢房率(68±20)次/min,平均最快房率为(134±17)次/min,日平均房率的平均值为(96±13)次/min。结论C-EAR是一种特殊节律,它是由异位起搏细胞的自律性增加所致。如在此基础上合并触发活动或局部微折返则可形成同源的心动过速。由于C-EAR具有良好的变时性作用,在不合并同源性心动过速时,无需消融治疗。     

致心律失常性右室心肌病患者Epsilon波的检出率

Objective To investigate the prevalence of Epsilon wave in patients with arrhythmogenic right ventrieular cardiomyopathy (ARVC). Methods The Epsilon wave was detected in 32 patients [24 men, mean age (42.3±13.3) years] with ARVC using three different electrocardiography (ECG) recording methods: standard twelve leads ECG (S-ECG), right precordial leads ECG (R-ECG) and Fontaine bipolar precordiai leads ECG (F-ECG). The Epsilon wave was defined as wiggle, small spike wave and smooth potential between the end of the QRS complex and the beginning of the ST segment. Results Epsilon wave was detected in 37.5%, 37.5% and 50.0% patients with ARVC by S-ECG, R-ECG and F-ECG respectively. The detection rates derived from the three recording methods were similar(P ＞ 0.05). The Epsilon wave was only detectable by S-ECG in one case, by R-ECG in three cases, and by F-ECG in five cases. The detection rate of Epsilon wave was 50.0% by combined use of S-ECG and R-ECG (SR-ECG), 56.3% by combined use of S-ECG and F-ECG (SF-ECG), and 65.6% by combined use of the three recording methods (SRF-ECG). The detection rate was significantly higher by SF-ECG (56.3%) and SRF-ECG (65.6%) than by S-ECG alone (37.5%, all P ＜0.05). Most Epsilon waves detected by the S-ECG, R-ECG and F-ECG were small spiked waves. Conclusion Combined use of S-ECG, F-ECG and R-ECG could increase the detection rate of Epsilon wave in patients with ARVC.