致心律失常性右心室心肌病一家系报告

目的 探讨家族性致心律失常性右心室心肌病的心电图特点。方法报道致心律失常性右心室心肌病患者一家系并结合文献分析其特点。结果本家系中右心室心肌病的发病率很高,男女患病比例相仿,疾病的表现度有较大的可变性,有时可无症状。先证者心电图发现Epsilon波且以V3R最为明显,所有患者V1～V3QRS波群终末部均有挫折,QRS时间均〉110ms,V3～V4均有T波倒置现象。结论致心律失常性右心室心肌病存在明显的遗传倾向,临床上以室性心律失常及猝死为主要表现,心电图具有相对特征性改变。     

致心律失常性右心室心肌病右胸导联QRS时间延长的临床意义

目的探讨致心律失常性右心室心肌病右胸导联QRS时间延长的临床意义。方法收集致心律失常性右心室心肌病25例,分析临床和常规体表心电图特征,测量QRS时间、Q-T间期等各项参数,计算右胸导联(V1～V3)和左胸导联(V4～V6)QRS时间的平均值及两者之比。结果25例致心律失常性右心室心肌病病例的年龄(37.1±15.0)岁,其中男性12例,女性13例。常规心电图中Epsilon波阳性(第1组)11例(44.0%),其中63.6%(7/11)见于V1～V3导联;Epsilon波阴性14例(第2组)。所有患者的平均QRS离散度为36.3±27.2ms,Q-T离散度为57.2±27.1ms。平均QRS时间右胸导联[QRS1=(V1+V2+V3)/3]为0.13±0.03s,而左胸导联[QRS2=(V4+V5+V6)/3]为0.11±0.02s,差异有非常显著性意义(P<0.01)。QRS1/QRS2值为1.0～1.9,其中16例(61.5%)≥1.2。发生晕厥第1组8例(72.7%),而第2组4例(28.6%)(P<0.05)。两组的QRS1分别为0.14±0.04s、0.13±0.02s,QRS2分别为0.12±0.03s和0.11±.017s,QRS1/QRS2值为1.22±0.26和1.21±0.13,差异均无显著性意义(P>0.05)。结论右胸导联平均QRS时间延长有助于诊断致心律失常性右心室心肌病,但能否作为致心律失常性右心室心肌病预后的不良因素尚须进一步研究。     

节制索上右束支起源的特发性室性心律失常的心电图特征及射频消融疗效

目的 研究右心室节制索（MB）上右束支（RBB）起源的特发性室性心律失常（VAs）的电生理特征及射频消融疗效。方法 回顾性分析2019年4月至2022年7月于首都医科大学附属北京安贞医院心律失常中心经电生理检查及射频消融证实起源于右心室MB上RBB的10例特发性VAs患者。通过在MB处行激动及起搏标测,分析其体表心电图特征、电生理特点、成功消融靶点处电位特征并观察分析射频消融的疗效。结果 起源于MB上RBB的特发性VAs体表心电图呈典型的左束支传导阻滞（LBBB）图形,电轴左偏,发作VAs时呈现较窄的QRS波,V1、V2导联为rS波,且S波无顿挫,VAs时R波均移行于V4～V6导联,晚于窦性心律,V6导联均有正向R波。在VAs时最早激动位点处均有领先的RBB电位,术中消融领先RBB电位均有效地消除了VAs,消融后6例出现右束支传导阻滞,随访过程中2例恢复。结论 MB上RBB的特发性VAs体表心电图表现为较窄的QRS波,典型LBBB,电轴左偏,胸前导联R波移行晚于窦性心律。消融最早激动位点前领先的RBB电位成功消除了VAs。     

36例致心律失常性右室心肌病的心电图特征和临床观察

目的探讨致心律失常性右室心肌病(ARVC)的心电图特征和临床表现。方法回顾分析符合欧洲心脏病协会ARVC诊断标准的36例患者的心电图参数、临床表现、超声心动图、腔内电生理检查等临床资料。结果36例中男26例、女10例,年龄37±13岁;33例表现为心悸、胸闷,11例同时伴有晕厥,2例有家族性猝死史。心电图研究发现10例(28%)出现Epsilon波,29例(81%)右胸(V1～V3)导联QRS波时限≥110ms;在29例无右束支传导阻滞的患者中,右胸导联分别有16例(55%)出现T波倒置、18例(62%)出现S波升支时间≥55ms;17例(47%)QRSd1/QRSd2(V1～V3导联与V4～V6导联QRS波时间平均值之比)≥1.2;24例(67%)出现室壁阻滞;27例(75%)记录到持续性或非持续性室性心动过速。29例超声心动图表现为严重的右室受累。25例行腔内电生理检查,20例诱发出右室起源的室性心动过速,即刻射频消融成功11例。结论ARVC好发于青年男性,是引起晕厥、室性心律失常和室壁运动异常的重要原因,Epsilon波、右胸导联QRS波时限≥110ms与T波倒置、右室起源的室性心律失常为其特征性的心电图改变,QRSd1/QRSd2≥1.2、室壁阻滞、右胸导联S波升支时间≥55ms有助于该病的诊断,经导管射频消融治疗室性心动过速成功率低。     

8例ARVC患者心电图表现及分析

目的 探讨心电图对致心律失常性右室心肌病（ARVC）的早期诊断价值.方法 选择8例于我院经心电图初诊为ARVC,其后根据2009年欧洲心律失常学会新修订诊断标准确诊的患者,对其心电图表现进行回顾性分析.结果 8例在无右心衰竭情况下,心电图均以起源于右心室的室性心律失常为主要表现,并有右胸导联T波倒置、Epsilon波、QRS时程≥120 ms等特征性表现.结论 心电图对ARVC早期筛查具有重要价值,且具有方便、快捷的优点.     

26例致心律失常右室心肌病的临床和心电图特点分析

目的:探讨致心律失常右室心肌病(ARVC)的临床和心电图特点。方法:收集、查阅1993～2003年 上海市中山医院心内科26例诊断为ARVC的入院病例资料,分析其窦性心律和(或)室性心动过速发作时的常 规体表心电图各项参数,并作统计分析。结果:26例ARVC病例中,入院年龄为13～70(37.7±15.1)岁,首发症 状年龄为8～55(33.2±13.9)岁;13例(50%)有晕厥发作史。25例常规心电图检查中有11例(44.0%)发现Ep silon波,多见于右侧胸导联(V1～3),部分病例可出现于Ⅱ、Ⅲ和aVF导联,其中1例在大多数导联上均可见Epsi lon波;8例(33.3%)右侧胸导联可见T波倒置。右侧胸导联的平均QRS间期(QRS1=V1+V2+V3间期的平 均值)为0.1～0.22(0.13±0.030)s,左侧胸导联的平均QRS时间(QRS2=V4+V5+V6间期的平均值)为0.08 ～0.18(0.11±0.02)s(P<0.01),QRS1/QRS2为1.2±0.2(1.0～1.9),其中16例(61.5%)两者之比≥1.2。4 例出现肢体导联低电压,3例出现完全性右束支传导阻滞,类右束支、左前分支、左后分支和室内传导阻滞各1 例,1例在aVF导联出现显著的T波电交替。结论:心电图中Epsilon波和右胸导联QRS间期延长,有助于诊断 ARVC。     

致心律失常性右室发育不良1例

患者男性,37岁。因突感心悸、心慌,急诊心电图（图1A）示：未见明显P波,心室率190次／分,QRS波群宽大畸形,呈完全性左束支传导阻滞形,R—R间距规整。aVL导联呈R形。心电图诊断：阵发性室性心动过速。彩超检查符合致心律失常性右室发育不良改变,经射频消融治疗后复查心电图（图1B）示：窦性心律,心率68次／分。右胸导联、下壁导联QRS波后可见一界限分明的低振幅小棘波（称Epsilon波）,导致QRS波群酷似右束支阻滞形。     

《思考心电图之132》答案

窦性P-P间期0.80~0.84s,频率71~75次/min, QRS波群呈典型完全性右束支传导阻滞图形（时间0.13s）,其前均有低小心室起搏脉冲出现,P-R（V）间期固定为0.16s,且不以P-P间期的长短而改变,呈现“窦性P波-心室起搏脉冲-完全性右束支传导阻滞型QRS波群”,强烈提示该起搏器为双腔起搏器（心室为双极起搏）,心房电极感知窦性P波后通过设置的P（A）-V间期触发心室发放脉冲,呈现VAT起搏模式。形成这种QRS波群有以下3种可能：（1）窦性心律、完全性右束支传导阻滞、伪室性融合波群：即该QRS波群由窦性P波顺传,存在完全性右束支传导阻滞,心室起搏脉冲与QRS波群无关,仅重叠在QRS波群起始部形成伪室性融合波群,此种可能性最大。（2）心室起搏脉冲引发心室起搏形成该QRS波群：一般情况下,双腔起搏器的心室电极大多植入在右心室的心尖部,引发心室除极所形成的起搏QRS忆波群呈类左束支传导阻滞图形;当其起搏电极穿过室间隔植入左心室心内膜或误入冠状静脉的侧静脉所引发心室除极时,可形成类右束支传导阻滞图形QRS波群,但V1绝不会出现典型的三相波（rsR忆型）,此种可能性极小。（3）窦性心律、完全性右束支传导阻滞、室性融合波群：即窦性激动与心室起搏激动共同除极心室形成真性室性融合波群,但以窦性激动控制心室为主;从P-R（V）间期固定,且不以P-P间期的长短而改变及QRS波群呈典型完全性右束支阻滞图形看,此种可能性较小。〈br〉 综上所述,本例心电图诊断为：（1）窦性心律;（2）完全性右束支传导阻滞;（3）双腔起搏器,以VAT模式工作,其心房感知功能正常,而心房和起搏功能及心室感知功能未能评价;（4）伪室性融合波群。     

致心律失常右心室心肌病心电图特征波新认识——附罕见粗大Epsilon波二例

致心律失常性右心室心肌病(ARVD)是主要累及右心室的非缺血性心肌病.90%的ARVD患者存在心电图异常,其中最常见的心电图改变为V1～V3导联T波倒置,大约25%～35%的患者存在特征性的Epsilon波.     

致心律失常右心室心肌病心电图特征波新认识——附罕见粗大Epsilon波二例

致心律失常性右心室心肌病(ARVD)是主要累及右心室的非缺血性心肌病.90%的ARVD患者存在心电图异常,其中最常见的心电图改变为V1～V3导联T波倒置,大约25%～35%的患者存在特征性的Epsilon波.     

心电图评价致心律失常性右心室心肌病病变程度的临床价值

目的 分析致心律失常性右心室心肌病(ARVC)患者的病变程度与心电图表现之间的关系.方法 分析61例已确诊的ARVC患者,根据心脏核磁共振成像(MRI)检查结果,将其按病变侵犯部位分为右心室局部病变组、右心室弥漫病变组、双心室病变组,分析比较三组的心电图特征.结果 心脏MRI结果显示右心室局部病变组19例(31%),右心室弥漫病变组28例(46%),双心室病变组14例(23%).心电图正常者3例,三组中各1例.伴有Epsilon波的患者24例(39%)、V1～V3导联的QRS波时限≥110 ms的患者21例(34%)、V1～V3导联S波升支≥55 ms的患者17例(28%)、完全右束支传导阻滞的患者10例(16%)、病理性Q波的患者9例(15%),这些指标的发生率均随病变程度的加重而增高(右心室局部病变组＜右心室弥漫病变组＜双心室病变组).Epsilon波、V1～V3导联的QRS波时限≥110 ms、完全性右束支传导阻滞(RBBB)、病理性Q波的发生率在双心室病变组中要高于右心室局部病变组,且两组间比较差异有统计学意义(P＜0.05).V1～V3导联S波升支≥55 ms的发生率在双心室病变组中要高于右心室局部病变组,且两组间比较差异有统计学意义(P＜0.05);在双心室病变组要高于右心室弥漫病变组,且两组间比较差异均有统计学意义(P均＜0.05).一度房室传导阻滞的发生率在双心室病变组中要高于右心室弥漫病变组,且两组间比较差异有统计学意义(P＜0.05).右心室局部病变组患者心电图T波倒置多局限于V1导联,右心室弥漫病变组和双心室病变组T波倒置多数表现于胸前导联V1～V3或超过V3导联的胸前导联、以及下壁导联.结论 心电图正常并不能排除ARVC.ARVC患者T波倒置在12导联心电图上具有很高的发生率,并且T波倒置在胸部导联的延伸与病变程度是相关的,T波倒置的范围可以提示ARVC病变累及的程度.

Abstract：

Objective To analyze the relationship between electrocardiographic (ECG) features and disease severity in patients with the arrhythmogenic right ventricular cardiomyopathy (ARVC). Method The study group consisted of 61 subjects with a definite diagnosis of ARVC on the basis of published guideline criteria and patients were divided into 3 subgroups according to the extent of diseased myocardium defined by cardiac magnetic resonance imaging (MRI): Group A: local involvement (n = 19, 31% ), Group B: diffuse involvement of whole right ventricle ( n = 28, 46% ) and Group C: involvement of both right and left ventricles ( n = 14, 23% ). Results Normal electrocardiogram was shown in 1 patient in each group.Epsilon wave was detected in 24 (39%) patients, QRS duration was prolonged [≥ 110 ms( V1 -V3 )] in 21 (34%) patients, S-wave upstroke was prolonged (≥55 ms) in 17 (28%) patients, complete right branch bundle block was evidenced in 10 ( 16% ) patients and pathologic Q waves was found in 9 ( 15% ) patients. The incidence of above abnormal ECG changes was increased in proportion to the degree of disease severity (group A ＜ group B ＜ group C). Incidence of Epsilon wave and prolonged QRS duration [≥ 110 ms (V1 - V3 )] were significantly higher in Group C than in Group A. Incidence of prolonged S-wave upstroke ( ≥55 ms) was significantly higher in Group C than in Group A and Group B. T-wave inversion in V1 leads was often found in Group A. T-wave inversion in inferior leads ( V1 - V3 leads or beyond V3 ) was often presented in Group B and Group C. Conclusions Normal ECG does not exclude the possibility of diagnosis of ARVC. The extent of T-wave inversion in the precordial leads and incidence of Epsilon wave, prolonged QRS duration [≥ 110 ms (Vt -V3 )] and prolonged S-wave upstroke ( ≥55 ms) were related to degree of disease severity in patients with ARVC.     

致心律失常性右室心肌病高危患者相关危险因素分析

目的探讨致心律失常性右室心肌病(ARVD/C)高危患者相关危险因素。方法根据1994年ARVD/C诊断标准,纳入43例ARVD/C先证者。分组标准:有晕厥病史并记录到室性心动过速(简称室速)为高危病人;记录到室性早搏(简称室早)、室速但无晕厥病史及其他临床情况定为低危病人。收集参数包括:①心电图V1～3QRS波时限≥110 ms、V1～3导联S波升支时限≥55 ms、Epsilon波、T波倒置、(V1+V2+V3)/(V4+V5+V6)QRS波时限≥1.2、QRS波离散度≥40 ms、QT离散度≥65 ms;②信号平均心电图记录晚电位参数;③Holter记录室早或室速;④超声记录双房、双室及右室流出道、流入道内径大小。Logistic回归分析高危患者ARVD/C病人的相关危险因素。结果心室晚电位阳性、右室射血分数<0.40与高危ARVD/C显著相关。结论晚电位阳性、右心功能不全是ARVD/C的高危因素。     

家族史在致心律失常性右心室心肌病危险分层中的地位

目的 探讨家族史在致心律失常性右心室心肌病(ARVC)危险分层中的地位.方法 根据1994年ARVC诊断标准,纳入34例ARVC先证者,男性26例,女性8例,平均年龄(38±15)岁.对其家族成员行临床筛查,项目包括:(1)心电图V1～V3导联QRS≥110 ms、V1～V3导联S波升支≥55 ms、Epsilon波、T波倒置(V1～V3导联倒置)、(V1+V2+V3)/(V4+V5+V6)QRS≥1.2、V1～V3导联与V6导联QRS差值≥25 ms,QRS离散度≥40 ms,QT离散度≥65 ms;(2)动态心电图记录室性早搏≥2000个/24 h或室性心动过速(VT);(3)超声心动图记录双心房、双心室及右心室流出道、流人道内径大小.比较ARVC家族史和上述各项临床参数的关系.分类变量用Fisher检验,连续变量使用t检验.P≤0.05为差异有统计学意义.结果 34例ARVC先证者中55个家族成员接受评估,男性28例(6例诊断ARVC)、女性27例(3例诊断ARVC),平均年龄(35±16)岁.8例先证者有家庭成员受累,其中5例有左束支阻滞形室性心动过速(LBBB-VT,63%);26例先证者家庭成员无受累,其中20例有LBBB-VT(77%),P=0.649.家族史和室性心动过速的发生筹异无统计学意义.结论 家族史并不能反映ARVC的危险程度.     

Special features of right bundle branch block in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia

We searched for special features in patients with complete and incomplete right bundle branch block diagnosed as having arrhythmogenic right ventricular cardiomyopathy/dysplasia. Whether right bundle branch block is a frequent finding in arrhythmogenic right ventricular cardiomyopathy should be studied. The question is whether special features exist such as T-wave inversions, localized right precordial QRS prolongation and r'/s ratio<1. RESULTS: ARVC could be diagnosed according to ISFC/ESC criteria in 374 patients. CRBBB was found in 22 cases (6%) and iCRBBB was present in 47 cases (12.5%). In CRBBB T wave inversions ≥ V4 was found in 10 cases (n.s.) and r'/s ratio<1 was present in 12 cases (p<0.001). In iCRBBB T wave inversions ≥ V4 was found in 10 cases (n.s.) and ST segment elevation in right precordial leads was present in 19 cases (p<0.005). In all patients with ARVC localized right precordial QRS prolongation was found. Patients with CRBBB have a bad prognosis: 17 of 22 patients developed biventricular heart failure requiring heart transplantation and diuretic therapy. CONCLUSIONS: CRBBB and iCRBBB are infrequent findings in arrhythmogenic right ventricular cardiomyopathy. Complete right bundle branch block is characterized by r'/s ratio<1. There are no significant T wave inversions ≥ V4. Incomplete right bundle branch block is characterized by ST segment elevation in right precordial leads but not by T wave inversions ≥ V4.     

心肌缺血少见的几种心电图变化

目的观察心肌缺血患者的少见心电图图形变化特征。方法回顾性分析215例心肌缺血患者的心电图资料,归纳几种少见的心电图特征。结果 215例患者的心电图资料中:①出现J波者16例,其中2例J波与T波融合且振幅逐波交替;②QTc间期改变者44例,其中延长者25例,缩短者19例;③出现(类)右束支阻滞者23例,其中14例持续存在,9例为一过性出现;④出现各种等位性Q波者106例,其中9例表现为新出现的s波。结论心肌缺血可表现为J波出现,QTc间期的改变、(类)右束支阻滞、s波型等位性Q波等。     

Conventional Electrocardiogram in Arrhythmogenic Right Ventricular Dysplasia-Cardiomyopathy and Idiopathic Right Ventricular Outflow Tract Tachycardia

Objective: Arrhythmogenic right ventricular dysplasia up to now is a rare cardiomyopathic entity with certain difficulties in clinical definition of diagnostic criteria. In 42 patients with major and minor criteria of arrhythmogenic right ventricular dysplasia and 25 patients with idiopathic ventricular arrhythmia, the role of conventional ECG in the diagnosis of arrhythmogenic right ventricular dysplasia was reevaluated. Methods: In standard 12-lead ECG, QRS duration was measured in limb lead D₁, and in V₁-V₆. A ratio of the sum of right (V₂+ V₃) and left (V₄+ V₅) was calculated. T wave inversions, Epsilon wave, and mechanisms of advancing right bundle branch block were analyzed. Results: In 39 out of 42 patients (93%) with the diagnosis of arrhythmogenic right ventricular dysplasia, a ratio of right and left precordial QRS duration of >1.2, a maximum right precordial QRS duration of > 100 ms in 10 cases (26%) and >110 ms in 29 cases (74%) could be found. Incomplete right bundle branch block with right precordial T inversions was found in one case. The ECG in two patients revealed a precordial R/S transition in V₁ or V₂; in all other cases, R/S transition was localized in V₃ or V₄. R peak time was normal (< 0.04 s) in all cases, a “notching” or “slurring” of the S wave was striking in 16 cases. T wave inversions were found in 27 cases and definite Epsilon wave in only one case. Although incomplete right bundle branch block and certain preforms could also be disclosed in four patients with idiopathic right ventricular outflow tract (RVOT) tachycardia, localized right precordial QRS prolongation could be excluded in all but one of these cases. Localized right precordial QRS duration prolongation in one case was probably due to a rotation of the heart with a precordial R/S transition between V₁ and V₂. Conclusion: Localized right precordial QRS prolongation in a normal precordial R/S transition: (a) seems to be the most important aspect of arrhythmogenic right ventricular dysplasia at conventional ECG, with a sensitivity of 93% and a specificity of 96% in order to distinguish idiopathic RVOT tachycardia; (b) can appear with (64%) or without (36%) secondary T wave inversions; and (c) is due to a “parietal” block sparing the specialized conducting system.     

V1检测电极在体表不同部位的起搏心电图形态研究

目的探讨V1检测电极的部位与起搏心电图形态的关系。方法选取植入永久性人工起搏器患者24例,将V1检测电极分别置于胸骨右缘第2、3、4、5肋间记录3导联同步心电图。分别测量V1QRS形态及时间。结果不同部位V1 QRS时间无明显差异（P〉0.05）。随着检测电极位置由胸骨右缘第5肋间移向第2肋间,V1R波电压逐渐增加,S波电压逐渐减小。电极位于胸骨右缘第5肋间者95.8％呈左束支传导阻滞型,位于胸骨右缘第3肋间者54.2％呈右束支传导阻滞型,位于胸骨右缘第2肋间者75．0％呈右束支传导阻滞型。胸骨右缘第4、5肋间以S型（QS、rS型）为主（95.8％）,胸骨右缘第2肋间R型（Rs型）为主（75．0％）,两者差异有统计学意义（P〈0．05）。结论调整V1检测电极的位置可快捷简便地判断心室起搏电极是否位于右心室,对判断有无心室电极穿孔有一定指导作用。     

致心律失常性右室心肌病患者Epsilon波的检出率

目的 探讨不同体表心电图记录方法对国人致心律失常性有室心肌病(arrhythmogenic right ventricular eardiomyopathy,ARVC)患者Epsilon波检出率的影响.方法 共人选ARVC患者32例,男性24例,女性8例,年龄18～70(42.3±13.3)岁.于安静仰卧位记录窦性心律情况下的标准12导联同步心电图(standard twelve leads electrocardiography,S-ECG)、右胸导联心电图(right precordial leads ECG,R-ECG)及Fontaine双极胸导联心电图(Fontaine bipolar precordial leads ECG,F-ECG)o Epsilon波判断标准为位于QRS波之后、sT段起始部的低波幅棘波、振荡波或平缓电位.结果 该组病例S-ECG、R-ECG及F-ECG对Epsilon波的检出率分别为37.5%、37.5%和50.0%,三种心电图记录方法之间Epsilon波检出率的比较差异无统计学意义(均为P＞0.05).其中1例Epsilon波仅见于S-ECG,3例仅见于R-ECG,5例仅见于F-ECG.S-ECG联合R-ECG的检出率为50.0%,S-ECG联合F-ECG的检出率为56.3%,三种记录方法的联合检出率为65.6%,S-ECG联合F-ECG的枪出率与S-ECG相比明显提高(P＜0.05),联合三种心电图记录方法的检出率与S-ECG相比有显著提高(P＜0.01).结论 联合使用S-ECG、R-ECG及F-ECG三种心电图记录方法,可以显著提高ARVC患者Epsilon波的检出率,且三种记录方法之间可以相互补充.