梗死性室性异位心搏的临床及心电学特点

探讨梗死性室性异位心搏 (IVEB)的临床及心电学特点。对 2 4例在急性心肌梗死 (AMI)时出现IVEB的患者与同期住院的 71例无IVEB的AMI患者进行回顾性对照分析 ,并比较IVEB和同期与梗死充分进展期窦性心律的QRS ST T波群形态学改变。结果 :①IVEB的QRS波常呈右束支阻滞形态 (RBBBM) ,除Q波型AMI外 ,非Q波型AMI亦可发生IVEB ;②下 (后 )壁伴或不伴右室AMI、大面积AMI、梗死后心功能差、梗死早期 (<6h)及接受溶栓治疗冠状动脉再通者易发生IVEB ;③与同期窦性心律比较 ,IVEB梗死导联Q波出现及ST段抬高提早 ,且更具有AMI的特征 ;④IVEB可发生于心肌酶谱升高及窦性心律典型AMIECG图形出现之前 ,其对AMI的早期诊断及定位优于同期窦性心律。结论 :IVEB并非罕见 ,它有利于AMI的早期诊断与定位     

持续性心房颤动经导管射频消融治疗的方法探讨(附三例报告)

探讨经导管射频消融治疗持续性心房颤动 (简称房颤 )的可行性。 3例房颤患者房颤持续时间 2个月至 1年4个月。术前口服胺碘酮 ,1例转为窦性心律伴频发房性早搏 (简称房早 ) ,1例转为房早与短阵房颤和阵发心房扑动 (简称房扑 ) ,1例转为房早与阵发房性心动过速 (简称房速 )。经导管作点状消融或点状消融加房扑线性消融 ,2例术中房早消失 ,1例房早显著减少 ,经快速心房刺激或静脉点滴异丙肾上腺素均不能诱发房颤。 1例术后有短阵房颤发作 ,服用莫雷西嗪 ,房颤未再发作。结论 :某些持续性房颤用药物后可转复成窦性心律伴频发房早、房扑或房速 ,局部单点消融或单点消融加线性消融可以达到治疗目的。     

Characteristics of Complex Fractionated Electrograms in Nonpulmonary Vein Ectopy Initiating Atrial Fibrillation/Atrial Tachycardia

Background: Nonpulmonary vein (PV) ectopy initiating atrial fibrillation (AF)/atrial tachycardia (AT) is not uncommon in patients with AF. The relationship of complex fractionated atrial electrograms (CFAEs) and non‐PV ectopy initiating AF/AT has not been assessed. We aimed to characterize the CFAEs in the non‐PV ectopy initiating AF/AT. Methods: Twenty‐three patients (age 53 ± 11 y/o, 19 males) who underwent a stepwise AF ablation with coexisting PV and non‐PV ectopy initiating AF or AT were included. CFAE mapping was applied before and after the PV isolation in both atria by using a real‐time NavX electroanatomic mapping system. A CFAE was defined as a fractionation interval (FI) of less than 120 ms over 8‐second duration. A continuous CFAE (mostly, an FI < 50 ms) was defined as electrogram fractionation or repetitive rapid activity lasting for more than 8 seconds. Results: All patients (100%) with non‐PV ectopy initiating AF or AT demonstrated corresponding continuous CFAEs at the firing foci. There was no significant difference in the FI among the PV ostial or non‐PV atrial ectopy or other atrial CFAEs (54.1 ± 5.6, 58.3 ± 11.3, 52.8 ± 5.8 ms, P = 0.12). Ablation targeting those continuous CFAEs terminated the AF and AT and eliminated the non‐PV ectopy in all patients (100%). During a follow‐up of 7 months, 22% of the patients had an AF recurrence with PV reconnections. There was no recurrence of any ablated non‐PV ectopy during the follow‐up. Conclusion: The sites of the origin of the non‐PV ectopies were at the same location as those of the atrial continuous CFAEs. Those non‐PV foci were able to initiate and sustain AF/AT. By limited ablation targeting all atrial continuous CFAEs, the AF could be effectively eliminated.     

The Role of Atrial Electrical Remodeling in the Progression of Focal Atrial Ectopy to Persistent Atrial Fibrillation

Although atrial fibrillation- (AF) induced changes in atrial refractoriness (atrial electrical remodeling) have been demonstrated in a number of different animal models, the clinical significance of this process is unknown. We describe a patient in whom there has been documented progression of atrial ectopy to persistent AF accompanied by evidence of atrial electrical remodeling, with reversal of remodeling following successful ablation of the focal source of AF. A second patient with focal AF, but with a "nonfocal" appearance on the ECG, is also described. These cases illustrate: (1) the possibility that a significant proportion of younger patients with idiopathic persistent AF may well have a focal source as the underlying abnormality; and (2) atrial electrical remodeling reverses following ablation of the underlying source.     

阵发性心房颤动的动态心电图特征研究

目的 探讨阵发性心房颤动发生的动态心电图特征. 方法 对38例阵发性心房颤动患者和24例非阵发性心房颤动患者的动态心电图进行分析,测定和计算房性期前收缩偶联间期和房性期前收缩指数. 结果 阵发性心房颤动共发作291次,其中221次由房性期前收缩诱发（75.95%）.诱发心房颤动的房性期前收缩与未诱发心房颤动的房性期前收缩比较,偶联间期较短,期前收缩指数较小,差异有统计学意义（P〈0.05）.心房颤动发作前1h房性期前收缩和短阵房性心动过速频率增加.35.75%阵发性心房颤动发生时出现明显的长短周期现象. 结论 房性期前收缩是阵发性心房颤动发生的主要因素,长短周期现象是阵发性心房颤动发生的重要电生理机制.     

房性早搏前PR段和ST段压低患者的临床和心电图分析

目的观察房性早搏(PAC)前PR段和ST段压低患者的临床和心电图(ECG)特征。方法分析PAC前PR段和ST段压低332例(观察组)的临床和ECG表现,并与558例PAC前无PR段和ST段压低(对照组)进行比较。结果①PR段和ST段压低导联分布广,以Ⅰ、Ⅱ、Ⅲ、aVF、V2～V6导联常见,V3、V4导联出现率最高,且PR段和ST段压低最显著。②观察组的PAC有如下特点:联律间期(CI)短且固定、提前指数(PI)小、多数呈PonT现象,PAC的P(P′)波时限长、P′波多呈高尖或切迹,绝大多数PAC的PR段和ST段也压低;PAC成对及连续发生或阵发心房扑动和心房颤动均较多;PAC发生前心动周期多不稳定;观察组年龄较大,窦性P波电压较高及时限较大,房内阻滞较多。以上指标与对照组比较差异均有显著性意义。结论 PR段和ST段压低是心房电不稳定的表现,具有这一特征的PAC属高危PAC,常常伴有其他更为严重的房性心律失常。     

Effects of High-Frequency Atrial Pacing in Atypical Atrial Flutter and Atrial Fibrillation

Atypical atrial flutter has, hitherto, been relatively refractory totermination by rapid atrial pacing. High-frequency pacing (HFP) in theatrium, for termination of atrial flutter or atrial fibrillation (AF), andthe electrophysiologic effects related to it have not been examined. Weexamined the clinical efficacy, safety, and electrophysiologic mechanisms ofHFP using 50-Hz bursts at 10 mA applied at the high right atrium in patientswith atypical atrial flutter (group 1) or AF (group 2), using a prospectiverandomized study protocol. Four burst durations (500, 1000, 2000, and 4000ms) were applied at the high right atrium repetitively in random sequence in22 patients with spontaneous atrial flutter or AF. Local and distant rightand left atrial electrogram recordings were analyzed during and after HFP.HFP resulted in local and distant right and left atrial electrogramacceleration in 8 of 10 patients (80%) in group 1 but caused lessfrequent local atrial electrogram acceleration (6 of 12 patients) and nodistant atrial electrogram effects in group 2 (p < .05 versus group 1).The HFP protocol was effective in arrhythmia termination in 6 of 10patients in group 1 but in no patient in group 2 (p < .05 versus group1). Standard HFP protocol applied at the high right atrium can frequentlyalter atrial activation in both atria and can terminate atypical atrialflutter. Efficacy in AF is limited, probably due to limitedelectrophysiologic actions beyond the local pacing site.     

Electrocardiographic markers of structural heart disease and predictors of death in 2332 unselected patients undergoing outpatient Holter recording.

AIMS: To test the hypothesis that the QS interval of ventricular ectopic beats (VEBs) (ventricular ectopic QS interval, VEQSI) would provide a marker for the presence of structural heart disease and a predictor of mortality. METHODS AND RESULTS: We interviewed and examined 2332 patients undergoing Holter ECG monitoring for clinical indications. In persons with VEBs, the morphologies were counted and the QS interval was measured for each of these morphologies. The duration of the broadest VEB, measured from the QRS onset in the derivation showing the earliest onset to its end in the derivation showing the latest termination, was taken as that patient's VEQSI. Survival was ascertained from public health records. Of 15 electrocardiographic variables pre-selected as potential prognostic indicators, VEQSI demonstrated the strongest association with the presence of structural heart disease (P = 0.013). Thirty-four persons died in 16 +/- 4 months follow-up. Univariate predictors of mortality are age, history of myocardial infarction, maximum heart rate, QS interval, the number of VEB morphologies, and the VEQSI. On multivariate analysis, only age (P < 0.001) and the number of VEB morphologies (P = 0.02) predicted mortality. CONCLUSION: VEQSI predicts the presence of structural heart disease. The number of VEB morphologies in a Holter recording predicts all-cause mortality.     

心室壁心肌肿瘤的临床和心电图特点

目的 :总结心室壁心肌肿瘤的临床和心电图特点 ,意旨早期诊断。　　方法 :对 1992年 12月～ 1999年 7月 5例经心脏影像检查发现并经手术和病理证实的心室壁心肌肿瘤患者的临床和心电图特点进行总结分析。　　结果 :本组 5例经病理证实为心室壁心肌肿瘤 ,其中 ,左心室心肌海绵体瘤 ,脂肪瘤、浸润性脂肪瘤、左心室和双心室心肌纤维瘤各 1例。 5例均以室性心动过速 (VT)为首发临床表现 ,心室率在 16 0～ 2 0 0次 /分 ;心电图 (ECG)均有酷似心肌梗塞改变 ,包括异常 Q波 2例 ,ST段抬高 2例 ,T波深度倒置 5例 ,又均无明确的心肌梗塞史 ;而且 ,肿瘤部位与 ECG异常所在导联和 VT起源部位基本一致 ,其中 1例经心内电生理证实。　　结论 :1对临床上以 VT为主要表现 ,并有 ECG酷似心肌梗塞改变又无明确心肌梗塞病史的患者 ,应高度疑诊为心室壁心肌肿瘤 ,并行影像学检查确诊。 2 ECG示酷似心肌梗塞所累及导联和 VT起源部位对心室壁心肌肿瘤有定位价值     

房性心动过速的射频导管消融术治疗

目的：为治疗房性心动过速（房速）,对8例患者进行了射频导管消融术（RFCA）治疗。方法：采用两根大头消融导管,在房速发作时标测心房最早激动点放电消融。结果：8例房速（包括房速伴心房扑动及房速伴房室结折返性心动过速各1例）RFCA治疗全部成功,无并发症;其中4例在冠状静脉窦口附近、2例在右心房侧壁、2例在右心耳处放电消融成功,成功靶点局部电位（A波）较体表心电图P波平均提前34.23±5.23（22～46）ms。结论：心房激动顺序标测是房速消融的基本方法,AP间期≥30ms的部位可作为试消融靶点;对房速伴其他类型心动过速者可一次消融成功。     

室房逆传对窦房结功能及心房肌电活动影响及其意义的实验研究

目的:探讨室房逆传(VAC)对兔窦房结功能低下动物模型窦房结功能及心房肌电活动的影响.方法:选用40只健康新西兰大耳白家兔,其中32只成功制作窦房结功能低下动物模型,以200次/分的起搏频率起搏右心室,将家兔分为1:1VAC组(22只)、非1:1VAC组(10只).观察心室起搏1 h,2 h,4 h,7 d后窦房结功能低下家兔模型右心房压、心房有效不应期、心房激动时间、心肌波长指数、校正窦房结恢复时间的变化,并比较两组上述指标的差别.结果:①1:1VAC组心室起搏1 h后右心房压明显升高(P＜0.01),心房有效不应期、心房激动时间、心肌波长指数、校正窦房结恢复时间无明显变化(P＞0.05);2 h后右心房压继续升高(P＜0.01),校正窦房结恢复时间、心房激动时间延长(P＜0.01),心房有效不应期缩短(P＜0.01),心肌波长指数减小(P＜0.01);4 h后上述指标变化更明显(P＜0.01);7 d后右心房压恢复至原来水平(P＞0.05),心房有效不应期、心房激动时间、心肌波长指数、校正窦房结恢复时间变化更明显(P＜0.01).②非1:1VAC组心室起搏1 h后右心房压明显升高(P＜0.01),校正窦房结恢复时间、心房有效不应期、心房激动时间、心肌波长指数无明显变化(P＞0.05);2 h、4 h后右心房压进一步升高(P＜0.01),校正窦房结恢复时间、心房有效不应期、心房激动时间、心肌波长指数无明显变化(P＞0.05);7 d后右心房压恢复至原来水平(P＞0.05),心房有效不应期、心房激动时间缩小(P＜0.05),校正窦房结恢复时间、心肌波长指数无明显变化(P＞0.05).③1:1VAC组与非1:1VAC组比较:1 h时两组间右心房压、校正窦房结恢复时间、心房有效不应期无明显变化(P＞0.05),但1:1VAC组心房激动时间延长(P＜0.05)、心肌波长指数减小(P＜0.05);2 h时右心房压、心房有效不应期无明显变化(P＞0.05),1:1VAC组校正窦房结恢复时间、心房激动时间明显延长(P＜0.01),心肌波长指数明显减少(P＜0.01);心室起搏4 h,7 d后右心房压无明显变化(P＞0.05),但1:1VAC组心房有效不应期、校正窦房结恢复时间、心房激动时间、心肌波长指数变化更明显(P＜0.01).结论:VAC对窦房结功能及心房肌电活动能产生不良影响.病态窦房结综合征患者应尽量避免使用VVI起搏器,最好安装生理性起搏器.     

双源性并行心律心电散点图图形特征分析

目的：观察双源性并行心律的心电散点图特征,探讨其鉴别诊断的意义。方法：选择已明确诊断的7例双源性并行心律患者的心电散点图资料进行回顾性分析,分别与单源性早搏、双源性早搏及单源性并行心律的心电散点图特征进行对比。结果：共分为6组（每组各7例）,其特征是：1组（单源性房性早搏）,呈三分布,窦性节律位于45°线上;2组（双源性房性早搏）呈五分布,窦性节律位置不变,早搏前后点分别位于其两边,图形对称呈双分布,1、2组B线斜率均在0-1之间,其斜率无显著差异（P＞0.05）;3组（单源性室性早搏）,呈四分布图形,窦性节律位于45°线上,早搏前后点分别趋向平行于X、Y轴,4组（双源性室性早搏）呈六分布,窦性节律位置不变,与单源性室早不同之处在于,其早搏前后点呈对称双分布,3、4组B线斜率均趋向于0,其斜率也无显著差异（ P＞0.05）;5组（单源性并行心律）图形特征为沿垂直于45°线的四分布图形,早搏点集垂直于45°线,早搏前点、后点集分别垂直于X、Y轴;6组（双源性并行心律）图形为沿垂直于45＆#176;线的七分布图形,图形与单源性并行心律相似,5、6组间B线斜率均趋向于∞,无显著差异（P＞0.05）,不同之处在于呈双分布;5、6组B线斜率明显大于1、2组[（∞）比（4.78±0.19）],1、2组B线斜率又显著大于3、4组（0.36±0.06）, P均＜0.01。结论：双源性并行心律心电散点图特征与单源性并行心律,单（双）源性房、室早搏图形均有显著差异,有助于并行心律的鉴别诊断。     

The use of atrial overdrive and ventricular rate stabilization pacing algorithms for the prevention and treatment of paroxysmal atrial fibrillation: the Pacemaker Atrial Fibrillation Suppression (PAFS) study.

AIMS: The PAFS study is a randomized, multicentre investigation of the effects of third generation anti-atrial fibrillation pacemaker algorithms in patients with paroxysmal atrial fibrillation (PAF). METHODS AND RESULTS: 182 patients (72 +/- 9 years, 55% male) with at least three symptomatic episodes of PAF within prior 3 months resistant to two anti-arrhythmics were enrolled. A pacemaker-derived atrial fibrillation (AF) burden of 1-50% was required in the initial induction phase. Seventy-nine patients fulfilled these criteria and were randomized to four, month-long phases in a crossover design. Algorithm phases were 'rate soothing' on, 'ventricular rate stabilization' on, and 'All on', which included these two algorithms plus post-AF response. The algorithm phases were compared to 'All off' dual chamber universal mode (DDD 60) for the analysis. Forty-two percent of patients enrolled in the monitoring phase had no AF. The percentage of AF induced by premature atrial contractions (PACs) was significantly reduced by rate soothing from 25 to 17% (P < 0.05). There was no significant change in AF burden, AF episode number, quality of life, or symptoms with any algorithm (P = ns). CONCLUSION: The rate-soothing algorithm by atrial overdrive pacing reduced PAC-initiated PAF. However, there was no overall change in AF burden, PAF episodes, patient symptoms, or quality of life. Forty-two percent of PAF patients did not show any AF after enrollment, suggesting that bradycardia pacing alone eliminates AF.     

心电图肢体导联室壁激动时间诊断高血压左室肥厚的价值

评价心电图（ＥＣＧ）肢体导联室壁激动时间（ＶＡＴ）诊断左室肥厚（ＬＶＨ）的价值。方法以超声心动图（Ｅｃｈｏ）为标准,对９６例高血压患者左室重量（ＬＶＭ）进行测定,将邻近心电轴之肢体导联ＶＡＴ与Ｅｃｈｏ测定结果进行比较并分析其诊断ＬＶＨ的价值。结果（１）ＬＶＭ与ＥＣＧ心电轴邻近之肢体导联ＶＡＴ有极显著正相关（ｒ＝０．８７及０．７３,Ｐ〈０．０１）,（２）以肢体导联ＶＡＴ≥０．０４ｓ作为ＬＶＨ作为ＬＶ     

Electrocardiographic Assessment of Incident Atrial Fibrillation in Hemodialysis Patients

The prevalence and incidence of atrial fibrillation in hemodialysis patients have recently increased, but there are few evident predictors of incident atrial fibrillation in hemodialysis patients. The purpose of this study was to determine whether electrocardiographic findings can predict the development of atrial fibrillation in hemodialysis patients. A cohort of 299 patients (age, 63.1 ± 14.0 years; men, 59.2%; duration of hemodialysis, 80.3 ± 77.7 months) on hemodialysis therapy in December 2004 was included. To determine the incidence of atrial fibrillation, electrocardiographic findings were checked regularly every 1–3 months through December 2009. To detect paroxysmal atrial fibrillation, we examined electrocardiograms any time a patient had cardiac symptoms. Cox proportional hazard analysis was used to determine independent variables for the onset of atrial fibrillation. At the time of enrollment, 37 patients had pre‐existing atrial fibrillation, for a prevalence rate of 12.4%. On the other hand, newly developed atrial fibrillation during the 5‐year follow‐up was determined in 45 patients, for an incidence rate of 4.37/100 patient‐years. In multivariate analysis, age (hazard ratio, 1.04; 95% confidence interval, 1.01 to 1.07) and the presence of a P‐terminal force >0.04 mm/s as an electrocardiographic finding (hazard ratio, 4.89; 95% confidence interval, 2.54 to 9.90) were independently associated with new‐onset atrial fibrillation. The prevalence and incidence rates of atrial fibrillation are high in maintenance hemodialysis patients. Age and the presence of a P‐terminal force >0.04 mm/s as an electrocardiographic finding may predict new‐onset atrial fibrillation in these patients.     

射频导管消融治疗的特发性室性心律失常心电图特征分析

目的：探讨不同起源的特发性室性期前收缩（PVCs）和（或）室性心动过速（VT）的心电图特征,提出鉴别流程。方法根据射频导管消融PVCs/VT有效靶点或心室最早激动点的X线胸片进行定位,分析不同起源PVCs/VT的12导联心电图QRS波群。结果828例接受导管消融,580例起源于右心室,248例起源于左心室,左、右心室起源者胸导联移行指数＜0的分别占97.58%及7.24%;左和右心室流出道起源者下壁导联多数呈R型,V1上,多数右心室流出道起源者呈rS型,右室间隔起源呈QS型,主动脉瓣上起源者常呈rS或RS型;下壁导联上,左前分支起源者常呈qR型,左后分支起源者常呈rS型。结论结合体表心电图胸导联移行指数、下壁导联和V1上的QRS波群特征可初步判断特发性PVCs/VT的起源部位。