非接触球囊标测系统指导下右室流出道室性期前收缩导管消融疗效及体表心电图应用价值

目的:探讨非接触球囊标测系统指导下右室流出道室性期前收缩（室早）导管消融疗效及体表心电图应用价值。方法:术前根据同步12导联体表心电图室早的形态特征初步判断室早起源部位,对58例药物治疗无效的顽固性室早患者进行导管射频消融治疗,其中26例采用传统标测法,32例采用非接触球囊标测法（Ensite三维标测法）。结果:①非接触球囊标测法与传统标测法相比较,成功率高（100% vs. 81%）、复发率低（3% vs. 19%）,X线曝光时间短［(3.6±1.4)min vs.(32±12)min］;②标测和消融结果显示30例患者室早起源于右室流出道间隔部,其中7例起源于前间隔,9例起源于中间隔,14例起源于后间隔。22例患者室早起源于右室流出道游离壁,其中7例起源于前游离壁,4例起源于中游离壁,11例起源于后游离壁。体表心电图特征对判断室早起源部位具有较高的灵敏度、特异度和准确度。结论:非接触球囊标测系统指导右室流出道室性心律失常射频消融安全有效,仔细分析心电图室早QRS波形态特征有助于判定室早起源部位,并缩短手术时间。     

起源于三尖瓣环的特发性室性心律失常体表心电图特点及射频导管消融治疗

目的 评估起源于三尖瓣环的室性心动过速(室速)和室性早搏(室早)的体表心电图特点及射频导管消融治疗效果.方法 共12例特发性室速/室早患者接受常规电生理检查及射频导管消融治疗,对所有病例的12导联体表心电图进行分析.结果 12例室速/室早均消融成功,并证实均起源于三尖瓣环附近,7例起源于三尖瓣环游离壁侧,5例起源于三尖瓣环间隔侧.三尖瓣环游离壁侧室速/室早QRS波平均时限长于三尖瓣环间隔侧室速/室早;游离壁侧室速/室早比间隔侧室速/室早QRS终末部更多见切迹.间隔侧室速/室早比游离壁侧室速/室早V1导联更多见QS型.结论 起源于三尖瓣环的室速/室早是特发性室速/室早的一个亚组,射频导管消融治疗可取得良好效果,掌握其体表心电图特点有助于消融术前判定室速/室早具体起源部位.     

流出道起源室性早搏心电图特征及其对射频消融靶点的判断价值

目的：研究室性早搏（室早）的心电图特征及对流出道室早的定位价值。方法回顾68例成功消融的右室流出道（RVOT）和左室流出道（LOVT）室早患者的图形,测量胸前导联 R／S值、R／S 转换部位、V2导联 QRS 波时限、V2导联 R 波振幅指数和 R 波时限指数,探讨其与射频消融靶点的关系。结果54例起源于 RVOT 与14例起源于 LVOT 的室早患者一般情况无显著差异。RVOT 室早比 LVOT 室早时限更短（P ＜0．05）,R／S 转换在 V1～V2导联的有12例,其中LVOT 11例,特异性91．67％,敏感性78．57％;转换在 V3导联的24例,其中 RVOT 21例,特异性87．50％,敏感性38．89％;转换在 V4～V6导联的为32例 RVOT 患者,特异性100％,敏感性59．26％;V2导联 R 波振幅指数和时限指数对 RVOT 室早的定位价值低于对 LVOT 室早的定位价值（P ＜0．05）。结论R／S 转换在 V2或 V2之前对 LVOT 的诊断价值大;转换在 V4或 V4之后对 ROVT 的诊断价值大;对于 R／S 转换在 V2～V3导联时,V2导联 QRS 波时限、R 波时限指数和 R 波振幅指数三个指标对确定室早的起源部位具有重要的价值。     

特发性左室流出道室性心律失常的心电图特点

探讨特发性左室流出道室性心律失常患者的心电图特点。对 7例特发性左室流出道室性早搏 (简称室早 )、室性心动过速 (简称室速 )患者进行心电图分析 ,并行心内电生理检查及射频消融治疗 ,同时对 10例预激综合征患者成功消融房室旁道后行主动脉瓣上及瓣下起搏 ,记录同步 12导联起搏心电图。对比分析两组病例体表心电图QRS波图形特点。结果 :7例左室流出道室早、室速患者经心内电生理检查证实 6例起源于冠状动脉窦内 ,1例起源于左室流出道主动脉瓣右瓣下方 ,所有患者经射频消融成功治疗室性心律失常。对照组 10例在主动脉瓣下起搏(其中 6例同时在主动脉瓣上起搏 )获得同步 12导联起搏心电图。两组病例体表心电图共同特点为 :QRS波额面电轴向下 ,Ⅱ、Ⅲ、aVF导联主波向上 ,QRS波在V2 或V3 前移行为Rs或R型。结论 :左室流出道为特发性室早、室速发生部位之一 ,体表心电图有其独特性 ,导管射频消融治疗安全有效。     

Sv_2/Rv_3指数（119）

近年来,起源于心室流出道的特发性室早或室速已成为心电学领域关注的热点,原因有二：①大量研究结果表明,右室流出道是特发性室早及特发性室速最多发生的部位;②起源于该部位的室早或室速一旦明确诊断,经射频消融治疗的成功率高达90%以上。因右室流出道与左室流出道及主动脉窦的解剖位置毗邻,使体表心电图有时很难确定室早或室速起源于哪侧心室。     

应用射频消融术治疗右室流出道频发室性早搏的疗效观察

目的评价经导管射频消融治疗频发单形性右室流出道室性早搏的方法和疗效。方法选择28例症状重、右室流出道室性早搏患者进行射频消融治疗。所有患者均无器质性心脏病,24h动态心电图（Holter）确定RVOT频发单形性室性早搏≥10000次／24h。采用起搏标测和激动顺序标测,前者以起搏标测诱发的QRS波与室性早搏QRS波形态完全相同为消融靶点,后者以早搏时最早心室激动点为消融靶点。其中26例起源于右室流出道间隔部,2例起源于右室流出道游离壁。结果消融即刻成功率92．9％（26／28）,其中右室流出道间隔部92.3％（24／26）,游离壁100％（2／2）。患者24h动态心电图记录消融前、后室性期前收缩分别为（16206±2030）次／24h和（100±110）次／24h,P〈0．01。随访6-20个月,1例复发,再次消融成功。结论经导管射频消融可有效治疗症状重、药物治疗无效或不能耐受的单形性右室流出道室性早搏。     

流出道室性早搏的体表心电图定位

<正>室性早搏(室早)是临床上最常见的心律失常,可以起源于心室的任何部位,以心室流出道好发,此处的室早导管消融术成功率可达90%~95%。流出道起源的室早体表心电图具有特征性,下壁导联(Ⅱ、Ⅲ、aVF导联)QRS波呈高大直立的R形。根据起源点不同又可以细分为右室流出道起源(前间隔、后间隔和游离壁)及其延伸部位(肺动脉瓣上)、左室     

右室流出道室性期前收缩的心电图特征及射频消融治疗

目的:探讨右室流出道室性期前收缩(室性早搏,室早)的心电图特征和评价单导管法消融单形性右室流出道室性早搏的有效性、安全性和实用性。方法:对52例心脏结构正常的右室流出道单形性室早的心电图特征进行分析并行单导管射频消融。采用起搏标测法,以起搏时与自发室性早搏形态波形态完全相同点为消融靶点。结果:右室流出道的室性早搏体表12导联心电图特征,呈完全性左束支阻滞形态,Ⅰ导联呈rs、m、QS及R型,aVR、aVL均呈QS型,Ⅱ、Ⅲ、aVF、V5~6导联均呈单向R波型,胸前导联R波移行区常在V3、V4导联之后。成功消融结果显示26例室早起源右室流出道间隔部:其中前间隔7例、中间隔5例、后间隔14例,游离壁21例:其中前游离壁6例、后游离壁15例,希氏束附近1例,肺动脉瓣下1例。消融即刻成功率94%(49/52),未成功的3例。手术操作时间30~150 min,X线曝光时间5~29 min。术后随访2~48个月无复发。结论:起源于右室流出道的室性早搏有其独特的心电图表现,单导管射频消融可有效、安全地消融心脏结构正常的右室流出道单形性室性早搏。     

右心室流出道室性早搏的定位与导管消融

目的本文旨在探索判断右心室流出道室性早搏（室早）起源的新流程,以便快速、准确地找到消融靶点。方法采用非接触三维标测系统对右心室流出道室早进行标测与导管消融,并分析右心室流出道室早体表心电图特征。根据三维标测与导管消融结果,并结合先前报道的室早起源判断流程,设计新的判断室早起源流程。结果标测与消融结果显示21例患者室早起源于右心室流出道间隔部,其中5例起源于前间隔,4例起源于中间隔,12例起源于后间隔;17例患者室早起源于右心室流出道游离壁,其中5例起源于前游离壁,2例起源于中游离壁,10例起源于后游离壁;1例患者室早起源于希氏束附近。判断室早起源新流程的总阳性预测值（77．3％）较Ito等报道的73．3％、Joshi等报道的73．3％、Dixit等报道的53．8％显著提高（P〈0．05）。新流程在判断室早具体起源部位较Ito等、Joshi等与Dixit等报道的室早起源部位判断流程有较大的优势,其敏感性、特异性与阳性预测值分别为78．1％,88．9％与84．2％,Joshi等报道的流程分别为32．9％,65．8％与48．1％,Dixit等报道的流程分别为50．7％,63．9％和55．2％（P均〈0．05）。结论非接触三维标测系统指导右心室流出道室早消融成功率高,判断室早起源新流程的敏感性、特异性与阳性预测值较先前报道的高,有良好的临床应用价值。     

左室乳头肌室早的V_1单导联定位法(196)

正左室乳头肌室早/室速是特发性室性心律失常的一种,其与起源于左室其他部位(例如分支、冠状窦口、流出道和二尖瓣环)室早/室速的形态相似,应用体表12导联心电图准确定位相对较困难。最近,Brice觡o等提出的V_1单导联定位法,有助于快速识别左室乳头肌室早。[定义]上述方法主要是指无器质性心脏病的患者,室早呈类右束支阻滞图形时,单用V1导联室早QRS波的形态及类本位曲折时限较短等特点,可以初步判定室早起源于左室乳头肌。[心电图表现及诊断标准]     

Evaluation of frontal plane QRS loop rotation in vectorcardiographic diagnosis

The diagnostic usefulness of frontal plane QRS loop rotation in the Frank vectorcardiogram (VCG) was evaluated in a series of 598 normal subjects, 301 patients with postero-diaphragmatic myocardial infarction (PDMI), 84 with lateral myocardial infarction (LMI), 844 with left ventricular hypertrophy (LVH), and 190 with right ventricular hypertrophy (RVH). In normals 62% showed clockwise (CW) rotation of the QRS loops; 28%, figure-of-eight; and 10%, counterclockwise (CCW). The respective distributions were 68%, 23%, and 9% in PDMI; and 23%, 40%, and 37% in LMI. In normals the superior and inferior limits (96% range) of the maximal QRS vector angles were +15° and +79° in VCGs with CW rotation, +12° and +62° in VCGs with figure-of-eight, and −4° and +58° in VCGs with CCW rotation. Based on these limits, approximately half of PDMI cases (with 2% false positives) and a little over two-thirds of LMI cases (with 4% false positives) could be separated from normal. In LVH and RVH groups without clinical evidence of ischemic heart disease, the superior and inferior limits (96% range) of the maximal QRS vector angles differed from those of normal. In LVH such limits were +1° and +86° in VCGs with CW rotation, +12° and +62° in VCGs with figure-of-eight, and −86° and +48° in VCGs with CCW rotation. The respective limits in RVH were +13° and −160°, −3° and +76°, and −30° and +65°. Thus, when LVH or RVH is present, the foregoing limits separating PDMI or LMI from normal need to be modified accordingly.Results of the study demonstrate the diagnostic significance of QRS rotation analysis in the frontal plane VCG. These findings should prove useful as the standard of reference for clinical interpretation of the Frank VCG.     

儿童病理性室性期前收缩心电学特点研究

为探讨心电检查对儿童病理性重性期前收缩的诊断意义,对比分析31例病理性室性期前收缩、28例非病理性室性期前收缩的心电图、心向量图及正交心电图.结果显示,病理性室性期前收缩;(1)起源于右心室流出道;(2)QRS环体的最大向量与0.06s瞬间向量额面之夹角<30°,各面振幅比<1.5,额面振幅差<0.7,横面<0.5;(3)正交电轴Y轴以R波为主,敏感性为48.39%～80 65%,特异性为75.00%～82.14%.提示以上标准可作为儿童病理性室性期前收缩的重要辅助诊断指标.     

Assessment of left ventricular hypertrophy by ECG and VCG in patients with inferior and posterior myocardial infarction. A comparison with echocardiographic data

Electrocardiographic (ECG) and vectorcardiographic (VCG) QRS voltage criteria have been analyzed in 26 patients with inferior and 17 with posterior myocardial infarction (MI) in comparison with left ventricular (LV) mass and global and regional wall motion as assessed by M-mode and two-dimensional (2D) echocardiography. Transverse plane QRS maximal vector correlated significantly with LV mass in patients with both inferior and posterior MI (r = 0.65 and 0.87, respectively, p less than 0.01). A transverse plane QRS maximal vector greater than 1.5 mV correctly recognized 12 of 15 (80%) and 9 of 12 (75%) patients with respectively inferior and posterior MI and LV mass greater than 221 gm. Of the ECG measurements, S V1-2 + R V5-6 correlated moderately with LV mass in patients with inferior MI (r = 0.47), and R V1-2 + R V5-6 correlated moderately with LV mass in those with posterior MI (r = 0.67). ECG and VCG QRS voltage data did not correlate with global and regional LV function as assessed by M-mode and 2D echocardiography. We conclude that: ECG and VCG QRS voltage parameters can be utilized for assessing non-invasively LV enlargement in patients with postero-inferior MI; ECG and VCG QRS voltage parameters should be utilized with caution for analyzing LV function or MI size in postero-inferior MI.     

主动固定螺旋电极在右室流出道间隔部起搏中的应用体会

目的探索采用主动固定螺旋电极行右室间隔部起搏的临床可行性。方法随机选择54例需要安装双腔起搏器的患者行右室流出道间隔部起搏,将心室起搏螺旋电极先后定位于右室心尖部及右室流出道间隔部并测试起搏参数。结果右室流出道间隔部电极定位成功率为98.15%,该部位起搏参数满足起搏要求,同时起搏的QRS波时限较心尖部变窄(130.45±18.24msvs153.11±20.10ms,P<0.001)。结论采用主动固定螺旋电极行右室流出道间隔部起搏安全性高、可行性好。     

A study on vectorcardiographic criteria for evaluating right ventricular hypertrophy in chronic obstructive pulmonary disease.

Vectorcardiographic analysis was mainly made on the basis of hemodynamic findings through right heart catheterization in COPD. From the results obtained in the present study, the authors proposed the following quantitative VCG criteria as a mean for clinical recognition of right ventricular overload in patients with COPD. (I) Individual parameters of the criteria are: i) The QRS loop; (a) P/A (posterior force/anterior force) greater than or equal to 2.8 (b) R/L (rightward force/leftward force) greater than or equal to 0.6 (c) P/6 (posterior force/leftward force) greater than or equal to 1.8 ii) The P loop; Ap/Pp (anterior force/posterior force) greater than or equal to 1.8 (II) Criteria i) "RVH (right ventricular hypertrophy)" should satisfy more than 3 of the above individual parameters. ii) "RVH suspected" should satisfy 1 or 2 of them. iii) "RVH negative" should not satisfy any of them. The recognition rate for RVH by the present VCG criteria was higher than the conventional ECG criteria and there was good correspondence with autopsy findings.     

Electro-vectorcardiographic study of ventricular extrasystole in arrhythmogenic dysplasia of the right ventricle]

The morphology of ventricular extrasystole (VES) in 46 cases of arrhythmogenic dysplasia of the right ventricle (ADRV) was correlated with the point of origin located by intracavitary mapping. The cases concerned 41 of left bundle-branch block (LBB) with various axes on the frontal plane (FP), 4 of right bundle-branch block (RBB), and 5 of atypical morphology (frontal plane shifted inferiorly and increased R from V1 to V6; on the horizontal plane, clockwise rotation of the loop oriented anteriorly and leftward). There is a good correlation with the site of origin: VESs which were LBB in appearance originated in the right ventricle (apex, septum, infundibulum); VESs which were RBB in appearance originated in the apex of the left ventricle, while the atypical VESs started in the upper posterior septum. A study of morphology may therefore also give an indication of the location of the disease.     

Prediction of right ventricular systolic pressure in pulmonary stenosis from combined vectorcardiographic data

In 38 patients with isolated unoperated pulmonary stenosis a systematic search was made for optimal VCG criteria for the prediction of peak systolic right ventricular pressure. Fifty VCG measurements, seven ECG measurements, and age of each patient were entered into a stepwise multiple regression computer program.The best individual predictors were found to be the QRS loop rotation in the horizontal plane and the closely related QRS dislocation along the 135 to 315 degree horizontal plane axis (r = 0.78). Five VCG criteria were better than the best ECG criterion (R V₁, r = 0.72). Thirty-three of the 58 variables showed significant correlations with the pressure (p < 0.01). Since the confidence intervals are large with this sample size and degree of correlation, conclusions regarding the superiority of one predictor vs. another should be drawn with great care.The multivariate equation selected by the computer involved four VCG variables and age; this improved the correlation coefficient to 0.93. This improvement from data combination is larger than in previous studies, probably because all variables were given equal opportunity to enter the equation.The results were tested on a secondary sample of 19 patients with pulmonary stenosis as their main cardiac lesion. Although this sample was less homogeneous, the formula-derived pressure estimates remained reasonably good (r = 0.88). The study suggests that the diagnostic power of ECG and VCG could be increased through the proper combination of easily obtainable measurements.     

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。     

Correlation between inducibility of sustained ventricular tachycardia and QRS duration

Some studies provide a link between the width of QRS complexesand late potentials occurring at the end of the QRS complexin signal-averaged recordings. The purpose of this study wasto compare three methods of QRS duration measurement: the conventional12 lead ECG. the Frank vectorcardiogram (VCG) and the signal-averagedelectrocardiogram. The recordings were made at a similar timein 121 consecutive patients with the Cardionics PC-based system(ECG and VCG) and the ardionics high resolution ECG, based onmethods described by Simson. Patients with bundle branch blockwere excluded. All patients had presented a myocardial infarctionand were studied either for spontaneous ventricular arrhythmiasor systematically 3 to 6 weeks after an acute myocardial infarction. The signal-averaged ECG and VCG QRS durations were similar in41 patients without inducible ventricular arrhythmias and withnormal signal-averaged ECG but were longer (P<0·001)than the conventional ECG QRS duration. In 36 patients withspontaneous and inducible ventricular tachyarrhythmias, theQRS duration was significantly longer on signal-averaged ECGthan on VCG (P<0·05) and longer on VCG than on conventionalECG (P<0·05). The QRS duration was also significantly(P<0·001) longer with the three techniques in patientswith spontaneous ventricular tachycardia (VT) than in patientswithout spontaneous and inducible VT. A QRS duration on VCG 110 ms and on conventional ECG 100 ms had a sensitivity of93% and 77% and a specificity of 83% and 85% respectively forpredicting an abnormal signal-averaged ECG. In conclusion, the measurement of QRS duration with the conventionalECG, VCG or the signal-averaged ECG could be a simple methodto detect the patients with myocardial infarction prone to VT.