多普勒组织成像加速度模式对显性旁道定位价值

目的探讨二维多普勒组织加速度图（2D-Doppler tissue acceleration，2D-DTA）技术对预激综合征（wolf-parkinson—white syndrome，WPW）旁道定位的可行性和准确性。方法选择60例体表心电图诊断为WPW的患者，在行导管射频消融（radiofrequency catheter ablation，RFCA）术前，采用2D-DTA初步确定旁道位置即最早心室激动点，并以心内膜靶点准确定位标测做对照。结果DTA技术所确定的心室最早激动亮点出现时限与同步记录的心电图δ波出现时限完全相同，DTA技术对旁道定化的准确性79％。结论DTA能比较直观地确定旁道位置，评价RFCA的效果，该技术无创、安全、重复性良好，为心内电生理标测技术有益的补充。     

预激综合征的房室旁道定位

根据国外旁道定位标准结合自己经验绘出心电图导联与房室环平面关系示意图对48例预激综合征房室旁道进行定位:左侧游离壁25例(52.1％),左后游离壁7例(14.6％),后间隔7例(14.6％),前间隔6例(12.5％),右游离壁0例,双旁道3例(6.3％)。手术治疗19例,其中单旁道17例,双旁道2例,共计21条旁道;除1条靠近希氏束的前间隔旁道未切断外,20条旁道均被切断,手术总成功率为95.2％,其中左游离壁旁道(15条)均被切断,成功率为100％。手术结果说明本方法定位简单、精确度较高。     

平面和断层核素时相分析对预激综合征旁道的定位诊断价值

用核素门控心血地显像对20例拟行射频消融术的预激综合征（WPW）患者进行平面时相分析，其中14例加做断层时相分析。用平面和断层时相分析对WPW旁道进行定位，并分别同射频消融术所证实的旁道定位和心电图的旁道定位对比。结果表明，核素时相分析对分道定位有较高的准确率，断层时相分析优于平面时相分析和心电图，核素时相分析还展示了“潜在性”旁道和多旁道定位的能力，能为射频消融术提供更多有价值的信息。     

房室旁道间歇性逆传阻滞的探讨ioven

为探讨房室旁道间歇性逆传阻滞的发生机制及临床意义 ,对房室旁道患者射频导管消融术中作腔内电生理检查 ,观察房室顺传和室房逆传功能及途径。结果显示261例中有7例 (4例为隐匿性预激综合征 )为旁道逆向 (或双向 )传导阻滞 (2.7% )。尽管旁道间歇性逆传阻滞是一种少见现象 ,但由于旁道传导阻滞 ,无法对旁道进行定位及射频导管消融 ,因此了解旁道有无间歇性逆传阻滞 ,对射频导管消融治疗有临床意义     

预激旁道合并房室结双径路所致的心动过速

分析１２例预激旁道合并房室结内双径路患者在食管电生理检验中诱发的心动过速，发现有３种不同表现形式。（１）房室结传导出现跳跃式延长后诱发出心动过速，并且符合ＡＶＲＴ；（２）心动过速中出现２种不同心动周期是由于２种Ｐ－Ｒ间期造成，Ｒ－Ｐ不变，心房除极顺序未发生改变；（３）心动过速中２种不同心动周期是由于２种Ｒ－Ｐ间期造成，并且心房除极顺序发生了改变。     

预激综合征间隔旁道的诊断与冶疗

本文报告14例WPW间隔旁道的诊治结果。EPS定位前间隔5例,后间隔前部4例。左后间隔与右后间隔各2例,双旁道1例(右后间隔十右游离壁)。左后、右后间隔各1例采用冠状窦口电灼治疗,未能阻断旁道,但右后间隔1例随访1年无持续室上速发作。左后间隔1例改为手术治疗,前间隔中4例亦手术治疗,均获成功。其余7例根据药物试验结果服用异搏定,室上速控制满意。文中讨论了EPS和术中间隔旁道详细定位及提高电灼与手术治疗成功率的问题。     

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。     

间隙性预激心房起搏显现旁路定位消融（附5例报告）

我们对５例间隙性预激合并房室折返性心动过速（ＡＶＲＴ）患者行射频消融术（ＲＦＣＡ），术中以适当频率高位右房起搏，出现旁路正向传导显现现象，并以此定位消融成功。认为间隙性预激旁路传导存在频率依赖性，右房起搏显现旁路可方便消融定位标测，避免遗留旁路。     

Novel Application of Tissue Doppler Imaging

Tissue Doppler imaging was used with transthoracic and transesophageal echocardiography to determine its clinical usefulness beyond visualization of ventricular wall motion. Thirteen novel applications were found: acoustically difficult transthoracic studies, thrombus, mitral chordal motion, shunt detection using saline contrast, spontaneous echo contrast, intra-aortic balloon pump position and function, endocarditis (prosthetic and native), valve strands (prosthetic and native), mobile aortic atheroma, prosthetic valve motion, aortic valve motion in the presence of a calcified aortic annulus, systolic anterior motion of the mitral valve, and cardiac tumors. Tissue Doppler imaging directly affected the ability to make difficult diagnostic decisions with increased confidence and reduced the need for additional studies.     

Septal Dyskinesia and Global Left Ventricular Dysfunction in Pediatric Wolff‐Parkinson‐White Syndrome with Septal Accessory Pathway

LV Dysfunction in WPW Syndrome. Introduction: Echocardiographic studies have shown that some patients with Wolff‐Parkinson‐White (WPW) syndrome have myocardial dyskinesia in the segments precociously activated by an accessory pathway (AP). The aim of the present study was to determine the extent to which the AP contributes to global left ventricular (LV) dysfunction. Methods: Electrophysiological and echocardiographic data from 62 children with WPW (age at diagnosis = 5.9 ± 4.2 years) were retrospectively analyzed. Results: The left ventricular ejection fraction (LVEF) of patients with septal APs (53 ± 11%) was significantly lower than that of patients with right (62 ± 5%) or left (61 ± 4%) APs (P = 0.001). Compared to patients with normal septal motion (n = 56), patients with septal dyskinesia (n = 6) had a reduced LVEF (61 ± 4% and 42 ± 5%, respectively) and an increased LV end diastolic dimension (P < 0.001 for both comparisons). Multivariate analysis identified septal dyskinesia as the only significant risk factor for reduced LVEF. All 6 patients with septal dyskinesia had right septal APs, and a preexcited QRS duration that was longer than that of patients with normal septal motion (140 ± 18 ms and 113 ± 32 ms, respectively; P = 0.045). After RFA there were improvements in both intraventricular dyssynchrony (septal‐to‐posterior wall motion delay, from 154 ± 91 ms to 33 ± 17 ms) and interventricular septal thinning (from 3.0 ± 0.5 mm to 5.3 ± 2.6 mm), and a significant increase in LVEF (from 42 ± 5% to 67 ± 8%; P = 0.001). Conclusion: The dyskinetic segment activated by a right septal AP in WPW syndrome may lead to ventricular dilation and dysfunction. RFA produced mechanical resynchronization, reverse remodeling, and improvements in LV function. (J Cardiovasc Electrophysiol, Vol. 21, pp. 290–295, March 2010)     

多普勒组织成像技术对心房颤动患者心房电-机械时间和心房收缩时间的测定

采用多普勒组织成像 (DTI)技术与同步心电图相结合观察阵发性心房颤动 (简称房颤 )患者心房各点电 -机械时间 (P A)和心房收缩时间 (A)及其离散度的变化。房颤组 4 2例、对照组 2 5例均行常规二维超声心动图 (2 DE)和脉冲DTI技术检查。取心尖四腔切面 ,将DTI取样容积分别置于室间隔房室环、二尖瓣环侧壁和三尖瓣环侧壁取样 ,测量心电图P波至 3个部位A波起始点的时间 (P A)、3点室壁DTI频谱A波起始点至终点的时间 (A)并计算不同部位之间P A、A的差值。与对照组相比 ,房颤组年龄、收缩压、左房内径明显增大 ;房颤组各点P A和A均显著延长 ,室间隔房室环与二尖瓣环侧壁之间P A、A的差值 (T1、TT1)显著增大 ,二尖瓣环侧壁与三尖瓣环侧壁之间P A、A的差值 (T3 、TT3 )显著增大 ;线性相关回归分析表明T1、T3 与年龄、左房内径呈正相关。结论 :阵发性房颤患者心房电 机械时间和心房收缩时间延长、离散度增大 ,年龄、左房扩大可能是主要影响因素。     

Right‐Sided Free Wall Accessory Pathway Refractory to Conventional Catheter Ablation: Lessons From 3‐Dimensional Electroanatomic Mapping

Right Free Wall Accessory Pathway Ablation . Introduction: The aim of this study was to delineate the electroanatomic substrates of right‐sided free wall (RFW) accessory pathways (APs) that were refractory to conventional catheter ablation utilizing 3‐dimensional (3‐D) mapping. Methods and Results: Eleven patients with RFW APs that failed initial conventional catheter ablation(s) by a mean of 1.9 ± 0.5 attempts were enrolled in the study. Electroanatomic mapping of the right atrium was performed during orthodromic reciprocating tachycardia in 3 patients and right ventricular pacing in 8 patients. The earliest atrial activation site, which represented the atrial insertion of the AP, was separated from the tricuspid annulus by an average of 14.3 ± 3.9 mm, and the local activation time was 27.8 ± 17.0 ms earlier than that of the corresponding annular point. One patient exhibited an AP with wide branching on the atrial side. RF ablation with an irrigated catheter successfully interrupted AP conduction in all patients without complications. Conclusions: RFW APs resistant to conventional catheter ablation might be due to unique anatomic AP features such as more epicardial course at the annulus level with atrial insertion distant from the tricuspid annulus. Electroanatomic mapping is helpful to accurately localize the atrial insertion sites of these APs and facilitates catheter ablation. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1317‐1324, December 2010)     

Site of Accessory Pathway Block After Radiofrequency Catheter Ablation in Patients with the Wolff-Parkinson-White Syndrome

Site of Accessory Pathway Block. Introduction: Recent studies have demonstrated that the most common site of accessory pathway conduction block following the introduction of a premature atrial stimulus during atrial pacing is between the accessory pathway potential and the ventricular electrogram. consistent with block at the ventricular insertion of the accessory pathway. However, no prior study has evaluated the site of conduction block during radiofrequency catheter ablation procedures. Therefore, the objective of this study was to determine the site of conduction block after catheter ablation of accessory pathways by analyzing and comparing the local electrograms recorded before and after radiofrequency energy delivery at successful ablation sites. Methods and Results: The electrograms evaluated in this study were obtained from 85 consecutive patients who underwent successful radiofrequency catheter ablation of a manifest accessory pathway. The 50 left free-wall accessory pathways were ablated using a ventricular approach and the 35 right free-wall or posteroseptal accessory pathways were ablated using an atrial approach. The characteristics of local electrograms recorded immediately before and immediately after successful ablation of the accessory pathway were determined in each patient. The site of accessory pathway block was determined by comparing the amplitude, timing, and morphology of the local eleclrograms at successful sites of radiofrequency catheter ablation before and after delivery of radiofrequency energy. A putative accessory pathway potential was present at the successful target site in 74 of the 85 patients (87%). Conduction block occurred between the atrial electrogram and the accessory pathway potential in 66 patients (78%) and between the accessory pathway potential and the ventricular electrogram in eight patients (9%). The site of block could not be determined in 11 patients (13%) in whom an accessory pathway potential was absent. Conduction block occurred most frequently between the atrial electrogram and the accessory pathway potential regardless of accessory pathway location. No electrogram parameter or accessory pathway characteristic was predictive of the site of conduction block. Conclusion: The results of this study demonstrate that conduction block occurs most frequently between the local atrial electrogram and the accessory pathway potential during radiofrequency catheter ablation of accessory pathways. This is true regardless of whether the accessory pathway is ablated from the atrial or ventricular aspect of the mitral or tricuspid annulus.     

Ventricular fibrillation as a primary manifestation of Wolff–Parkinson–White syndrome

Wolff–Parkinson–White syndrome (WPW) is defined as a condition involving an accessory pathway associated with symptoms. A typical ECG pattern of a pre-excitation shows a short PQ interval, presence of delta wave and a broad QRS complex on surface ECG. The underlying mechanism involves an accessory pathway, which enables conduction of a depolarization wave from atria to ventricles bypassing the AV node and predisposes to arrhythmias and sudden cardiac death. The most common arrhythmia in patients with WPW syndrome is atrioventricular reentrant tachycardia. However, it is not present in all patients with pre-excitation [1], [2], [3], [4]. Up to 1/3 of patients with AVRT experience atrial fibrillation, which may be conducted to ventricular myocardium via the accessory pathway and lead to a life-threatening ventricular fibrillation. The most effective treatment of the WPW syndrome is a radiofrequency catheter ablation [2], [5], [6], [7], [8]. This paper describes a case of a 40-year-old woman after a cardiopulmonary resuscitation for ventricular fibrillation, which was a primary manifestation of the WPW syndrome. It focuses on pathophysiology, clinical pattern and treatment possibilities of patients with WPW syndrome.