双极食管心电图对间隔部隐匿性旁路的诊断价值

目的比较单极食管心电图和双极食管心电图对间隔部隐匿性旁路的诊断价值。方法选择经心内电生理检查和射频消融术证实的19例间隔部隐匿性旁路患者。消融术前经食管心房调搏诱发阵发性室上性心动过速发作,记录发作前后体表12导联心电图、单极食管心电图、双极食管心电图。分别观察P波形态、极性、P波与QRS波群关系,测量P波振幅、时限,以心内电生理检查结果为标准分析单极食管心电图和双极食管心电图对间隔部隐匿性旁路的诊断率差异。结果单极食管心电图P波无极性变化,双极食管心电图P波可根据需要调整极性。双极食管心电图和单极食管心电图的P波振幅分别为（0.58±0.12）mV和（0.36±0.11）mV（P<0.05）,P波时限分别为（96±11）ms和（99±14）ms。单极食管心电图和双极食管心电图对间隔部隐匿性旁路的诊断符合率分别为58%和89%（P<0.05）。结论双极食管心电图记录的P波振幅大于单极食管心电图,并能更清晰的显示P波、P波和QRS之间的关系,对间隔部隐匿性旁路的诊断优于单极食管心电图。     

预激综合征患者发生阵发性心房颤动机制的探讨

目的通过分析预激综合征患者旁道的电生理特性以及消融旁道后P波离散度(Pd)的计算,探讨预激综合征发生阵发性心房颤动(简称房颤)的机制。方法分析预激综合征合并旁道介导的阵发性心动过速患者127例。根据既往有无阵发性房颤(PAF)发作将患者分为PAF组(23例)和无PAF组(NPAF,104例)2组进行分析。电生理检查测定旁道的前传和逆传不应期。消融成功术后24h描记12导联心电图测量P波最大时限(Pmax)、P波最小时限(Pmin),计算Pd。结果消融前PAF组旁道前传和逆传不应期较NPAF组短(前传:265.3±42.5msvs331.4±38.7ms;逆传:255.8±46.7msvs317.5±31.7ms;P均<0.05)。消融术后心电图Pmax和PdPAF组显著长于NPAF组(Pmax:135.2±12.5msvs120.4±8.7ms;Pd:51.6±10.3msvs32.7±6.7ms;P均<0.05)。结论旁道有效不应期缩短和窦性激动在心房内的非均质传导在预激综合征患者房颤发生中可能起重要作用。     

利用单极标测在心房颤动时消融显性房室旁道

对12例预激综合征患者在心房颤动时以单极标测指导消融房室旁道，其中左侧显性旁道9例、右侧显性旁道3例。在消融成功的靶点图上，单极标测的心室激动较体表心电图QRS波群显示预激成分最明显的Delta波平均提前46±7ms。全部病例消融成功。平均随访7．9±5．1个月，除1例右侧旁道4个月后恢复旁道前向传导需再次消融外，其余11例常规和动态心电图既未见Delta波，也无房室折返性心动过速和心房颤动发生。结果提示对于心房颤动合并显性房室旁道的患者，采用单极标测，其图形易于迅速辨认、测量方法亦简单，用以指导消融成功率高。     

食管心电图对隐匿性预激旁道的诊断和定位的探讨

目的 探讨食管心电图对室上性心动过速时隐匿性预激旁道的诊断和定位标准。方法 观察124例经射频导管消融证实的隐匿性预激旁道合并室上性心动过速时食管心电图改变与旁道诊断定位的关系,并与56例经射频导管消融证实的房室结双径路作对照。结果 隐匿性旁道的食管心电图示有PESO′波,R－PESO′间期≥80ms,无文氏传导现象,但常出现束以传导阻滞,且符合Coumel-Slama定律。如以PR′与PS′波位置关系为隐匿性旁道定位标准,定位准确率均达86％以上。结论 食管心电图有助于隐匿性旁道的诊断和粗略定位。     

食管心电图诊断宽QRS心动过速1例

患者男性,40岁。体表心电图示阵发性宽QRS心动过速。为明确心动过速时心房与心室激动的关系记录食管导联心电图。在患者咽部喷散1％丁卡因,表面麻醉后从鼻孔插入食管电极约35cm,根据食管内单极心电图略微调整电极深度,使食管内心电图的P波振幅最大。采用双极食管电极导管,电极间距为2cm。将2个电极接日本Kohden RM-6000型8道生理记录仪生物电放大器,时间常数选择为3ms,滤波选择为30Hz,该导联为食管内双极导联(ESO-DP);以食管电极导管的近端电极接体表心电     

不规则性交替性房间束结间束传导阻滞

患者男性,45岁。临床诊断:冠心病。心电图描记:窦性心律,P波规律出现,P-P间期0.64s,P-R 0.13s,QRS时限形态正常,ST略下移。可见3种形态P波;①P波呈双峰,时限0.12s,第1峰振幅0.10mV,第2峰振幅0.20mV,第2峰高于第1峰,峰距>0.04s,为房间束传导阻滞;②P波高尖,振幅0.15mV,时限0.10s,为结间束传导阻滞;③P波     

两种方法逆行P波检出率的对比研究

为提高逆行P波(p~-波)检出率,用食管调搏法和常规心电图法对比观察37例隐匿性旁道参与的室上性心动过速患者Ⅰ、Ⅱ、V_1导联p~-波的检出率和极性确定率。结果提示:食管调搏法的p~-波检出率和极性确定率(100％、100％)远高于常规心电图法(46.8％、36.9％)(P<0.01)。认为食管调搏是鉴别室上速机制和无创伤定位隐匿性旁道的简便、可靠的手段。     

显性房室旁道射频消融术后QRS波群高频成分的变化及意义

探讨房室旁道电位的电物理特性 ,同时借助房室旁道这一除极顺序异常的天然模型 ,印证心室激动传导异常产生高频成分这一机制。选择显性房室旁道伴房室折返性心动过速患者 4 0例 ,采用信号平均技术及多采样率线性小波转换技术 ,对射频消融前、后体表心电图窦性心律时 QRS波群全程及起始部 4 0 ms进行三维频谱分析 ,观察高频能量 (E1 )、甚高频能量 (E2 )、频谱的最高上限频率 (Fmax)及 QRS时限 (QRSI)等参数的变化。结果 :QRS波群全程 E1 、E2 、Fmax射频消融前后相比无统计学差异。而 QRSI射频消融前后相比差异显著 (12 3± 15 msvs86± 9ms,P<0 .0 0 1)。QRS波群起始部 4 0 ms的 E1 、E2 、Fmax术前分别为 1.2 3 7± 0 .4 5 9,0 .74 8± 0 .2 5 3 ,3 66± 4 9Hz;术后分别为 0 .73 2± 0 .2 95 ,0 .3 64± 0 .161,3 0 9± 3 8Hz,与术前相比差异显著 (P均 <0 .0 1)。结论 : 旁道激动心室是高频成分产生的一种机制 , 冲动沿旁道下传 ,心室激动时间延长 , 心室预激波是一种含高频成分和高频能量较多的电信号 ,其频率可达 4 0 0 Hz以上 ,提示在心内电生理标测时采用较高频率的滤波带 ,可能使旁道电位显示更清晰。     

一种简便的右侧显性旁道体表心电图定位方法

建立一种新的简便的右侧显性旁道体表心电图定位方法。对 67例右侧显性旁道且QRS波时限≥ 0 .1 2s的患者进行研究。旁道的体表心电图定位采用aVR及标准III导联 ;旁道的位置均经成功的射频消融证实。结果 :采用本法判断间隔旁道及非间隔旁道的灵敏度、特异度及准确性分别为 86.67%、75 .68%及 80 .60 % ;并且可对旁道进行进一步定位 ,其灵敏度为 5 5 .5 6%～ 95 .45 % ,特异度为 86.67%～ 97.37% ,准确性为 83.5 8%～ 89.5 5 %。结论 :新的右侧显性旁道体表心电图定位方法具有较高的准确性 ,并且简单易行。     

经食管心房调搏对隐匿性房室旁道的定位诊断价值

目的:探讨经食管心房调搏对隐匿性房室旁道的诊断和定位特征。方法:回顾分析360例经心内电生理检查确诊为隐匿性房室旁道患者,总结其经食管心房调搏的特征表现。结果:Ⅰ导联P'倒置定位诊断左侧旁道的灵敏度为69%,特异度为98%;V1导联P'波直立定位诊断左侧旁道的灵敏度为71%,特异度为88%,V1导联P'双向定位诊断左侧旁道的灵敏度为14%,其特异度为95%,RP'ERP'V1诊断左侧旁道的灵敏度为82%,特异度为99%。Ⅰ导联P'直立诊断右侧旁道的灵敏度为75%,特异度为93%,V1导联P'倒置诊断右侧旁道的灵敏度为65%,特异度为99%,RP'ERP'V1诊断右侧旁道的灵敏度为82%,特异度为100%。结论:分析Ⅰ、V1导联P'特点和测量对比RP'E及RP'V1对隐匿性旁道诊断和粗略左右旁道定位具有重要价值。     

体表与食管心电图在隐匿性房室旁路诊断及定位中的价值

目的探讨诊断隐匿性房室旁路的简易方法。方法110例经心内电生理确诊并成功消融的隐匿性房室旁路患者。术前行食管心房调搏检查,观察S2R2有无跳跃性延长;记录心动过速时的体表心电图,观察逆传P波的方向及形态;同步记录食管与V1导联心电图,观察P波在V1(P-V1)及食管导联(P-E)的先后顺序。结果110例中106例S2R2呈逐渐延长。67例左侧旁路房室折返性心动过速时P-E先于P-V1,39例右侧旁路P-V1先于P-E,4例中间隔旁路P-E与P-V1几乎同时出现。且不同部位的房室旁路在不同导联上逆传P波形态不同,并有显著差别。结论隐匿性房室旁路可根据心动过速时的体表心电图P波的方向及形态作出初步诊断,结合食管与V1导联同步心电图以及食管调搏结果可基本确定诊断。     

The use of temporary atrial wire electrodes to record atrial electrograms in patients who had cardiac surgery

The use of temporary atrial electrodes after surgery provides the medical staff with a valuable diagnostic tool in patients who have undergone open heart surgery. Recording a unipolar or bipolar atrial EG is a simple procedure that can be performed at bedside with an ECG machine. The bipolar recording lead has specific advantages over a unipolar recording lead. The use of a bipolar recording lead simplifies the identification of the P wave during rapid tachycardias and atrioventricular dissociation. The use of unipolar and bipolar atrial EGs recorded simultaneously and sequentially can be used to identify atrial rhythm and ascertain the atrioventricular relationship. Nurses need to integrate unipolar and bipolar EGs as part of their baseline assessment.     

阵发性室上性心动过速时ST－T改变的临床意义

回顾性分析经射频消融治疗的４１８例阵发性室上性心动过速（ＰＳＶＴ）发作时的体表１２导联心电图，以了解ＳＴ－Ｔ改变的临床意义。结果表明３０５例房室折返性心动过速（ＡＶＲＴ）中，ＳＴ段下移≥２ｍｍ且持续≥８０ｍｓ和（或）Ｔ波倒置者有１８１例（５９．３４％），明显高于房室结折返性心动过速（ＡＶＮＲＴ）患者（２８／１１３，２４．７８％）Ｐ＜０．００５。并且此差异不能被心率所矫正。此外左游离壁旁道患者ＳＴ段压低多分布在Ｖ３～Ｖ６导联，而右后和左后隔旁道患者倒置的Ｔ波和（或）ＳＴ段压低多发生于Ｉ、ＩＩ、ａＶＦ导联。提示ＰＳＶＴ时心电图上ＳＴ－Ｔ改变可作为区分ＡＶＲＴ和ＡＶＮＲＴ的一个有用指标，并且可能还有粗略的旁道定位价值     

Utility of the filtered bipolar esophageal lead in the diagnosis of arrhythmias

Electrophysiologic study was performed in 25 patients with tachycardia or bradycardia attacks. The coronary sinus (CS) and filtered bipolar esophageal electrograms were recorded simultaneously to compare the phase of atrial activations. During sinus rhythm and high right atrial pacing, the esophageal and proximal CS atrial activations were nearly simultaneous but earlier by 26 +/- 5 msec on the average than the distal CS atrial activations. During reciprocating tachycardia due to reentry using a left-side accessory atrioventricular pathway for retrograde conduction the esophageal and CS atrial activations occurred earlier than the low septal right atrial activation, so the esophageal lead can be used as a substitute for the CS lead to clarify the eccentric retrograde atrial activation sequence. By using the filtered bipolar esophageal lead, the interval from Q wave on the surface electrocardiogram to the first rapid deflection in the esophageal atrial activation (Q-AESO interval) was measured in 15 patients with supra-ventricular tachycardia. All patients with reciprocating tachycardia due to reentry using a left side accessory atrioventricular pathway had Q-AESO intervals between 100 to 130 msec and four of five patients with a right side accessory atrioventricular pathway for retrograde conduction had Q-AESO intervals between 130 to 150 msec. In contrast, all patients with reentry in the atrioventricular node had Q-AESO intervals between 30 to 60 msec. The esophageal lead is also of value in the prompt diagnosis of atrial flutter and ventricular tachycardia, since the esophageal electrograms readily reveal the relationship between atrial and ventricular activations. In conclusion, the filtered bipolar esophageal lead provides a non-invasive method for the quick diagnosis of various arrhythmias.     

双大头电极间放电成功消融后间隔旁道(附一例报告)

报道１例采用在双大头电极之间放电成功消融后间隔旁道的病例。该例有心动过速病史８年，特殊检查未见心脏结构异常。心电图示显性Ｂ型预激。心内标测为连接左房与右室的后间隔旁道。采用常规单大头电极分别在三尖瓣环右房侧、二尖瓣环左室侧及左房侧反复放电均未成功。改用与单大头电极放电相同位置的三尖瓣环右房侧与二尖瓣环左室侧的双大头电极之间放电，功率１５Ｗ、阻抗９８Ω，放电３ｓ后ｄｅｌｔａ波消失，巩固放电至９９ｓ而获得成功。此例说明，在单大头电极放电失败后采用在双大头电极之间放电可以进一步提高导管射频消融后间隔旁道的成功率     

Radiofrequency catheter ablation of septal accessory atrioventricular pathways.

OBJECTIVE--Septal accessory atrioventricular pathways are recognised as being more difficult to ablate than pathways in other locations. This paper describes an experience of 48 consecutive patients with septal accessory pathways who had catheter ablation with radiofrequency current. PATIENTS AND METHODS--There were 28 male and 20 female patients, mean (SD) age 35 (17). 43 patients had a single accessory pathway and 5 patients had multiple accessory pathways. Pre-excitation was present in 37 patients, and 11 patients had concealed accessory pathways. 21 patients had had a previous electrophysiological study. Catheter ablation was undertaken with radiofrequency current delivered by a standard unipolar technique or by delivery of current across the septum (the bipolar technique). RESULTS--The median total procedure time was 167 (83) minutes including a 30-40 minute observation period after the abolition of conduction by the accessory pathway. The median total fluoroscopic time was 56 (30) minutes. 42 (88%) out of 48 patients had successful ablation of the pathway during the first session. In the six patients in whom the procedure failed, five had a midseptal pathway and one had a right anteroseptal pathway. A second attempt at ablation was made in two patients and succeeded in both. In total, 49 accessory pathways were successfully ablated in 44 (92%) out of 48 patients. The bipolar technique was used in 11 patients and succeeded in 10 patients. Standard unipolar current delivery had previously failed in seven of the 11 patients. Complications developed in two patients with a mid septal pathway (one with complete atrioventricular block and the other with a small pericardial effusion). CONCLUSION--Radiofrequency catheter ablation of septal accessory pathways is efficacious and safe. The procedure time can be shortened and success rate can be increased after improvement of the technique--that is, consideration of a bipolar approach for energy delivery in difficult cases.     

U Wave during Supraventricular Tachycardia: Simulation of a Long RP Tachycardia and Hiding the Common Type AVNRT

The main tool for the differentiation of supraventricular tachycardia is the 12‐lead electrocardiogram (ECG). Especially differentiating the atrioventricular nodal reentrant tachycardia (AVNRT) from the atrioventricular reentrant tachycardia (AVRT) due to concealed accessory pathway or from an atrial tachycardia (AT) is very important for catheter setting and ablation approach in an electrophysiological study. In our case we saw the occurrence of a U wave during tachycardia—simulating a pseudo P wave. This mimicked a long RP‐tachycardia, although it was a common type AVNRT.     

经上腔静脉途径射频消融右侧前上和前间隔房室旁道

报道经上腔静脉途径射频消融右侧前上和前间隔房室旁道的体会。 13例右侧前上或前间隔单一房室旁道患者 ,常规下腔静脉途径消融未能成功 ,失败原因包括 :消融电极与心肌接触不良或难以固定于三尖瓣环上。改经上腔静脉途径成功消融阻断所有房室旁道。平均放电 1.8± 0 .7次 ,输出功率 33± 4W ,消融靶点电图振幅明显高于下腔静脉途径 (1.4± 0 .3mVvs 0 .6± 0 .4mV ,P <0 .0 5 )。术后随访 17± 9个月 ,无 1例复发。作者认为对经下腔静脉途径消融失败的右侧前上和前间隔房室旁道采用上腔静脉途径消融可获得成功。     

Sensing and pacing with floating electrodes in the right atrium and right atrial appendage

Unipolar and bipolar floating atrial electrograms from 58 pacemaker patients were recorded and compared. Twenty-four floating unipolar electrodes and 29 floating bipolar electrodes were used at mid-right atrial level and five orthogonal atrial J leads within the right atrial appendage. Each signal was analyzed in the time domain: peak to peak deflection of P wave and QRS complex, duration of P wave and QRS complex and slew rate; and in the frequency domain: maximum of the energy spectrum and frequency at which a decrease of 3 dB from the maximal amplitude occurred. Atrial P (1.31 +/- 0.94 mV, mean +/- SD) and QRS (1.0 +/- 0.56 mV) waves from unipolar floating electrodes were comparable, whereas they were significantly different from bipolar floating electrodes (1.15 +/- 0.77 mV and 0.25 +/- 0.39 mV). Amplitudes of P waves from orthogonal J leads were largest (3.1 +/- 2.6 mV) and QRS complexes (0.21 +/- 0.13 mV) smallest. The P waves had the highest frequency content (17.1 +/- 19.4 Hz). It is concluded that atrial electrograms from orthogonal electrodes (bipolar or orthogonal J) offer superior sensing characteristics because of the large amplitude P wave and discriminating power between P and QRS waves (P/QRS voltage 15:1). An orthogonal J lead can thus be used for P synchronous pacing at the atrial level, whereas an orthogonal ventricular lead can be used for rate-response pacing systems.     

Electrogram patterns predictive of successful catheter ablation of accessory pathways. Value of unipolar recording mode

BACKGROUND. Transcatheter electrical ablation has been used in the treatment of arrhythmias, and most experience has been obtained by ablating the normal atrioventricular conduction system. Less information is available on ablation of atrioventricular accessory pathways. METHODS AND RESULTS. Catheter ablation of overt accessory pathways was attempted in 135 patients with 142 distinct pathways, including 21 right parietal or anteroseptal, 47 posteroseptal, and 74 left lateral pathways. We sought to identify the type and value of electrophysiological parameters associated with successful ablation outcome. For this purpose, the unipolar recording mode was used in addition to bipolar anterograde and retrograde parameters. With a mean follow-up of 16 +/- 6 (mean +/- SD) months, fulguration was successful in eliminating preexcitation in 129 patients (96%), including all seven with two distinct accessory pathways. The first ablation attempt was successful in 110 patients, and two or more attempts were performed in 25 patients. Bipolar electrograms associated with success of fulguration showed a shorter atrioventricular conduction time (40 +/- 13 versus 53 +/- 17 msec, p less than 0.0001) and an earlier main ventricular deflection relative to delta wave onset (-1.7 +/- 10 versus 5 +/- 7 msec, p less than 0.001) than electrograms associated with unsuccessful outcome. The only parameter dealing with retrograde conduction (i.e., ventriculoatrial conduction time during reciprocating tachycardia) was not predictive (86 +/- 17 versus 93 +/- 17 msec). Neither was the atrial to ventricular electrogram amplitude ratio. Two unipolar parameters were found to be predictive of successful outcome: 1) The three different patterns PQS, P-QS, P-rS of unipolar waves recorded at the annulus were associated with respective success rates of 97%, 78%, and 55% (p less than 0.001). 2) Intrinsic deflection timing occurred -4 +/- 8 and 6 +/- 7 msec relative to delta wave onset in successful attempts and in failures, respectively (p less than 0.001). Logistic regression analysis revealed a single independent factor predictive of success, the unipolar pattern (p = 0.03), with an odds ratio of 7:1 (PQS pattern versus P-rS pattern). In the group of 18 patients who underwent a first unsuccessful but second successful attempt, comparison of electrograms revealed no difference in the ventriculoatrial conduction time but a significant improvement in anterograde parameters and unipolar pattern distribution. CONCLUSIONS. Some distinctive electrogram patterns concerning anterograde conduction are associated with success of accessory pathway fulguration. The unfiltered unipolar recording mode (PQS pattern) contributes significantly to optimizing the accuracy of accessory pathway localization.