特发性室性心动过速伴室房传导一例

临床资料 患者女性,４６岁。阵发性心动过速反复发作３年,每次发作均自行终止。曾多次检查心电图、超声心动图和Ｘ线胸片,均未发现异常。２０００年 ８月 ２８日,因心动过速发作 ２ ｈ就诊,心电图（图１Ａ）示宽ＱＲＳ心动过速。ＲＲ间期０．５２ｓ,ＱＲＳ时限 ０．１２ ｓ,粗看 ＱＲＳ波呈右束支阻滞伴心电轴显著左偏;除 Ｖ４导联最后 １个 ＱＲＳ波外,在每 １个 ＱＲＳ波后均可见 Ｐ’波,ＲＰ’间期 ０．２０ｓ。似可考虑为房室折返性心动过速伴室内差异性传导。图１Ｂ示ＲＲ间期、ＲＰ’间期均无明显变化,多次出现连续２个 Ｑ…     

三磷酸腺苷对宽或窄QRS波心动过速的鉴别

对７６例心动过速施行了三磷酸腺苷（ＡＴＰ）分级递增快速静脉注射试验，旨在评价ＡＴＰ对宽或窄ＱＲＳ波心动过速的鉴别诊断价值。ＡＴＰ静脉注射后，５９／６４例有房室结参与折返的宽或窄ＱＲＳ波折返性室上性心动过速被终止，８／８例窄ＱＲＳ波房性心律失常（房速３例、房扑４例、房颤１例）出现２°房室阻滞，３／３例预激合并房颤短时内预激波更明显，１例室速未被终止。结果表明，ＡＴＰ静脉注射对宽或窄ＱＲＳ波心动过速具有鉴别诊断价值     

食管心房调搏对儿童室上性心动过速的诊断

３４例阵发性室上性心动过速（室上速）患儿经食管心房调搏检查，诊断为房室结折返１３例。快慢径有效不应期分别为３３７±５９．４６ｍｓ和２７８±７１．２４ｍｓ（Ｐ＜０．０５）；传导时间分别为２２０±５０ｍｓ和３０８±５８．０９ｍｓ（Ｐ＜０．０５）。旁室旁道折返１９例，其中６例为隐性，旁道前向有效不应期２００～３２０ｍｓ，与年龄呈正相关，但无显著性。自律性房住心动过速２例。儿童ＳＶＴ以房室折返为主，测定ＰＶ１－ＰＥ时距及ＲＰＥ间期有助于鉴别折返性室上速的类型及旁道位置。房室结折返ＰＶ１－ＰＥ时距近于零，房室折返为３４．２９±８．５ｍｓ．左侧旁道为正值，右侧为负值。但ＰＶ１有时辨认不满意，有局限性。房室结折返ＲＰＥ间期＜７０ｍｓ．而旁路折返则＞７０ｍｓ。     

短R－P＇性室上性心动过速的体表心电图和食管电生理特征及意义

为了能较准确地无创性诊断阵发性室上性心动过速（ＰＳＶＴ）的类型，对经心内电生理明确ＰＳＶＴ类型的１０６例短Ｒ－Ｐ＇性ＰＳＶＴ患者的ＰＳＶＴ频率、ＲＰＥ间距、ＰＶ１－ＰＥ时距、有无Ｓ２Ｒ间期跳跃式延长现象、频率依赖性束支阻滞、ＱＲＳ波电交替、体表心电图（ＥＣＧ）ｐ＇波形态方向、房室传导阻滞等体表ＥＣＧ及食管电生理八个方面特征进行了研究，认为绝大多数短Ｒ－Ｐ＇性ＰＳＶＴ可通过分析体表ＥＣＧ及食管电生理的特征变化确定其ＰＳＶＴ类型，特别是观察ＰＶ１－ＰＥ时距、ＲＰＥ间距、体表ＥＣＧＰ＇形态和有无Ｓ２Ｒ间期跳跃式延长现象等四个方面变化在ＰＳＶＴ分型诊断中具有重要意义．     

短PR综合征合并室上性心动过速的电生理特性研究

目的探讨短ＰＲ综合征ＰＲ缩短的原因以及合并的室上性心动过速的电生理机制。方法对既往射频消融病例中具有短ＰＲ（ＰＲ＜０．１２秒）和ＱＲＳ波正常的２６例患者的电生理特性进行了研究，并与同期ＰＲ间期正常的２８例室上性心动过速患者的电生理特性进行了对比观察。结果Ⅰ组（短ＰＲ组）的ＡＨ间期和ＡＶ间期明显短于Ⅱ组（ＰＲ间期正常组）的ＡＨ间期和Ａ－Ｖ间期，差异有显著性，Ｐ＜０．０１；Ⅰ组室上性心动过速的电生理机制是２０例为房室结折返性心动过速，６例为房室折返性心动过速。结论ＰＲ缩短的原因是由房室结的解剖或电生理特性所决定的，大多数短Ｐ－Ｒ综合征合并室上速的电生理机制是房室结双径路，少部分病例为隐匿性房室旁路     

二度房室传导阻滞伴T波电交替1例

患者男性 ,４７岁。因心悸、乏力１０余天入院。心电图示 :窦性Ｐ波规则 ,Ｐ＿Ｐ间期为０．６６ｓ,Ｐ＿Ｒ间期固定 ,为０．１８ｓ,ＱＲＳ波群增宽为０．１５ｓ ,Ｖ３ 呈ＲＳ型 ,Ｓ波增宽有切迹 ,每两个Ｐ波后脱漏一个ＱＲＳ＿Ｔ波群 ,Ｔ波直立。心电图诊断 :窦性心律 ,二度房室传导阻滞 (房室传导为２∶１) ,完全性右束支传导阻滞 (图略 )。临床血生化检查正常。超声心动描记术提示轻度扩张型心肌病。２天后复查心电图 (图１)示 :窦性心律 ,二度房室传导阻滞 (房室传导２∶１～３∶２) ,完全性右束支传导阻滞 ,Ｔ波电交替现象。本例Ｔ波电交…     

房室结折返性心动过速性2：1房室阻滞中的传导改善现象二例

例1　患者女性,35岁。因反复胸闷、心悸3年,再发1天就诊。食管电生理检查诱发出慢快型房室结折返性心动过速(ＡＶＮＲＴ)。入院后成功消融房室结慢径路,静脉点滴异丙肾上腺素后未能再诱发心动过速。图1为置入冠状窦电极导管时诱发出心动过速,ＱＲＳ波群形态正常,ＲＲ间期680ｍｓ。在两次ＱＲＳ波群之间可见到倒置的逆行Ｐ(Ｐ-)波,Ｐ-Ｐ-间期680ｍｓ。在冠状窦近端电极中清楚显示出ＱＲＳ波群中埋有Ａ-波,Ａ-Ａ-间期340ｍｓ,频率176ｂｐｍ,与其后ＡＶＮＲＴ频率完全一致。表明心动过速实为ＡＶＮＲＴ存在下部共同径路2∶1传导阻滞,ＱＲＳ波群…     

房室折返性心动过速合并房室结双径现象

目的 分析射频消融术证实的房室帝道（ＡＰ）合并房室结双径（ＤＡＶＮＰ），以了解其电生理特点。方法 以食管心房调博及心内电生理检查，确诊室上速合并房室结双径１２例，并行射频消融枚。结果 ＡＰ合并ＤＡＶＮＰ占ＡＰ的１６．４％（１２／７３），多为陷匿性ＡＰ（１０／１２），其折返途径多为ＡＰ逆传（１０／１２），房室结单一径路前传，房室结快径道不应期及心动过速时ＲＰ’（ＶＡ）与ＲＰ意期，在食道电生理与心内电     

隐匿性旁道合并房室结双径路致不典型文氏现象1例

患者女性 ,６２岁。因“内痔”来院手术 ,术后感心悸１２ｈ。１９９７年曾因“预激综合征”在外院行射频消融术。２４ｈ动态心电图 (图１Ａ、Ｂ)示 :窦性心律 ,心率７９次／ｍｉｎ ,Ｐ＿Ｐ间期０．７６ｓ,Ｐ＿Ｒ间期由０．１８、０．１８、０．２０、０．５８ｓ或０．１８、０．５２ｓ下传心室 ,以Ｐ-波结束文氏周期或引起房室折返性心动过速。心动过速发作时 (图１Ｃ)心率９４次／ｍｉｎ ,ＱＲＳ时间正常。Ｐ-波均位于ＱＲＳ波群后 ,Ｒ＿Ｐ-间期０．１０ｓ,Ｒ＿Ｐ-间期＜Ｐ-＿Ｒ间期 ,Ｐ-波极性在体表心电图 (图１Ｄ箭头处 )表现为Ｐ-Ⅰ倒…     

窄QRS波群心动过速ST—T改变的临床意义

为了解窄ＯＲＳ波群心动过速ＳＴ－Ｔ改变的临床意义,观察６０例窄ＱＲＳ波群室上性心动过速发作时心电图Ｒ－Ｒ间期、ＳＴ－Ｔ改变和心腔内心电图房间传导时间、逆向心房激动顺序。结果显示：房室折返性心动过速的ＳＴ段压低〉２ｍｍ和／或Ｔ波倒置（％）、ＳＴ波压低幅度、房间传导时间均非常显著大于房室结折返性心动过速（Ｐ均〈０．０１）;发作时ＳＴ－Ｔ改变左侧旁道多见于Ｖ１～Ｖ６导联、右侧旁道多见于Ⅱ、Ⅲ、ａＶＦ导联     

The differential diagnosis on the electrocardiogram between ventricular tachycardia and preexcited tachycardia

The 12-lead surface electrocardiogram is a simple and useful tool for the differential diagnosis of regular wide QRS complex tachycardia. However, criteria do not as yet exist to discriminate between ventricular tachycardia and supraventricular tachycardia with anterograde conduction over an accessory pathway (preexcited tachycardia). Therefore, we designed a new stepwise approach with three criteria for the electrocardiographic differential diagnosis between ventricular tachycardia and preexcited tachycardia and prospectively studied 267 regular tachycardias with electrophysiologically proven mechanism and a wide QRS complex (≥ 0.12 s): 149 consecutive ventricular tachycardias and 118 consecutive preexcited regular tachycardias. Underlying heart disease was old myocardial infarction in 133 of 149 (89%) ventricular tachycardias. The patients presenting with preexcited tachycardia had no additional structural heart disease. Atrial fibrillation with preexcited QRS complex was not included. The criteria favoring ventricular tachycardia were: (1) presence of predominantly negative QRS complexes in the precordial leads V₄ to V₆, (2) presence of a QR complex in one or more of the precordial leads V₂ to V₆, and (3) AV relation different from 1:1 (more QRS complexes than P waves). The final sensitivity and specificity of these three consecutive steps to diagnose ventricular tachycardia were 0.75 and 1.00, respectively. This new stepwise approach is sensitive and highly specific for the differential diagnosis between ventricular tachycardia in coronary artery disease and preexcited regular tachycardia.     

New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia.

BACKGROUND: We recently reported an ECG algorithm for differential diagnosis of regular wide QRS complex tachycardias that was superior to the Brugada algorithm. OBJECTIVE: The purpose of this study was to further simplify the algorithm by omitting the complicated morphologic criteria and restricting the analysis to lead aVR. METHODS: In this study, 483 wide QRS complex tachycardias [351 ventricular tachycardias (VTs), 112 supraventricular tachycardias (SVTs), 20 preexcited tachycardias] from 313 patients with proven diagnoses were prospectively analyzed by two of the authors blinded to the diagnosis. Lead aVR was analyzed for (1) presence of an initial R wave, (2) width of an initial r or q wave >40 ms, (3) notching on the initial downstroke of a predominantly negative QRS complex, and (4) ventricular activation-velocity ratio (v(i)/v(t)), the vertical excursion (in millivolts) recorded during the initial (v(i)) and terminal (v(t)) 40 ms of the QRS complex. When any of criteria 1 to 3 was present, VT was diagnosed; when absent, the next criterion was analyzed. In step 4, v(i)/v(t) >1 suggested SVT, and v(i)/v(t) < or =1 suggested VT. RESULTS: The accuracy of the new aVR algorithm and our previous algorithm was superior to that of the Brugada algorithm (P = .002 and P = .007, respectively). The aVR algorithm and our previous algorithm had greater sensitivity (P <.001 and P = .001, respectively) and negative predictive value for diagnosing VT and greater specificity (P <.001 and P = .001, respectively) and positive predictive value for diagnosing SVT compared with the Brugada criteria. CONCLUSION: The simplified aVR algorithm classified wide QRS complex tachycardias with the same accuracy as standard criteria and our previous algorithm and was superior to the Brugada algorithm.     

ECG in the diagnosis of supraventricular tachyarrhythmias

The development of catheter ablation techniques during the last decade provided new data about the mechanism of supraventricular tachyarrhythmias and at the same time, set new requirements for their classification. An accurate diagnosis of individual SVT can usually be made during an electrophysiologic study that precedes catheter ablation. Nevertheless, clinically acceptable differential diagnosis of SVT can be based on analysis of a standard 12-lead electrocardiogram. This may prove useful especially when selecting optimum antiarrhythmic drug according to a suspected mechanism of arrhythmia. At the same time, electrocardiogram during SVT serves as a recording of clinical arrhythmia for catheter ablation. At present, SVTs are divided into 3 main categories: 1. atrial tachyarrhythmias confined solely to atrial tissue, 2. tachycardias involving the AV junction, and 3. AV reentrant tachycardias involving one or more accessory connections with an electric impulse travelling between atria and ventricles. The first category can be further subdivided into: a) macroreentrant atrial tachycardias related to the presence of macroscopic anatomical or functional barriers; b) focal atrial tachycardias arising from a focus of abnormal automaticity or microreentry in the atrium; c) the syndrome of inappropriate sinus tachycardia resulting most probably from hypersensitivity to adrenergic stimulation; d) atrial fibrillation based on the existence of multiple wandering wavelets in the atria. Electrocardiographic differential diagnosis is predominantly based on an analysis of the standard 12-lead ECG. Principal diagnostic features include the presence and timing of the P waves in relation to the QRS complex. Additional criteria comprise the presence or absence of AV block during the tachycardia, an axis orientation of the P waves and their morphology, the appearance of QRS alternans or frequency of tachycardia.     

Computer detection of atrioventricular dissociation from surface electrocardiograms during wide QRS complex tachycardias

Differentiation of wide QRS complex tachycardias on surface electrocardiograms is difficult for physicians and computers due in part to their inability to identify atrial activity, specifically atrioventricular (AV) dissociation. We studied 20 examples of AV associated rhythms and 17 examples of AV dissociated ventricular tachycardia. We applied an algorithm consisting of subtraction of a mean beat from each individual beat in leads II and V1 to generate remainder electrocardiograms. The remainder electrocardiograms were visually inspected for the presence of P wave candidates and then autocorrelated. AV dissociated P wave candidates were evident on visual inspection of remainder electrocardiograms in none of 20 AV associated and 15 of 17 AV dissociated rhythms. Atrial cycle length and the presence of AV dissociation were automatically detected by applying a peak selection algorithm to the autocorrelation function. AV association was detected in all 20 AV associated rhythms and AV dissociation was detected for 11 of 17 AV dissociated rhythms (sensitivity 65%, specificity 100%, positive and negative predictive accuracy 100%, 77%). The correlation coefficient of detected vs true atrial cycle length for the 11 correctly detected AV dissociated rhythms was r = .98. Visual inspection of the remainder electrocardiograms along with the original electrocardiogram may increase the ease with which human readers can identify the presence of AV dissociation and thus diagnose ventricular tachycardia. Computer diagnosis of wide QRS complex tachycardias should be significantly improved by use of this algorithm.     

Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia.

AIMS: The Brugada criteria proposed to distinguish between regular, monomorphic wide QRS complex tachycardias (WCT) caused by supraventricular (SVT) and ventricular tachycardia (VT) have been reported to have a better sensitivity and specificity than the traditional criteria. By incorporating two new criteria, a new, simplified algorithm was devised and compared with the Brugada criteria. METHODS AND RESULTS: A total of 453 WCTs (331 VTs, 105 SVTs, 17 pre-excited tachycardias) from 287 consecutive patients with a proven electrophysiological (EP) diagnosis were prospectively analysed by two of the authors blinded to the EP diagnosis. The following criteria were analysed: (i) presence of AV dissociation; (ii) presence of an initial R wave in lead aVR; (iii) whether the morphology of the WCT correspond to bundle branch or fascicular block; (iv) estimation of initial (v(i)) and terminal (v(t)) ventricular activation velocity ratio (v(i)/v(t)) by measuring the voltage change on the ECG tracing during the initial 40 ms (v(i)) and the terminal 40 ms (v(t)) of the same bi- or multiphasic QRS complex. A v(i)/v(t) >1 was suggestive of SVT and a v(i)/v(t) 相似文献   

Taquicardia de QRS largos – importância eletrocardiográfica no diagnóstico diferencial

Correct diagnosis in wide QRS complex tachycardia remains a challenge. Differential diagnosis between ventricular and supraventricular tachycardia has important therapeutic and prognostic implications, and although data from clinical history and physical examination may suggest a particular origin, it is the 12‐lead surface electrocardiogram that usually enables this differentiation.Since 1978, various electrocardiographic criteria have been proposed for the differential diagnosis of wide complex tachycardias, particularly the presence of atrioventricular dissociation, and the axis, duration and morphology of QRS complexes. Despite the wide variety of criteria, diagnosis is still often difficult, and errors can have serious consequences. To reduce such errors, several differential diagnosis algorithms have been proposed since 1991. However, in a small percentage of wide QRS tachycardias the diagnosis remains uncertain and in these the wisest decision is to treat them as ventricular tachycardias.The authors’ objective was to review the main electrocardiographic criteria and differential diagnosis algorithms of wide QRS tachycardia.     

Narrow complex tachycardias. Differential diagnosis and management.

Narrow complex tachycardias are a common clinical problem and can be divided into those in which the arrhythmic circuit is located exclusively in the atrium (pharmacologic treatment is oriented toward altering atrial electrophysiologic properties) and those that involve the AV node or an accessory pathway (pharmacologic therapy is directed toward slowing conduction or increasing refractoriness in these structures). The electrocardiographic diagnosis of the mechanism responsible for SVT includes the regularity of the RR interval; the AV conduction ratio; the presence of P waves, P wave morphology, and the relationship of the P waves to the QRS complexes; and the response of the arrhythmia and atrial activity to vagal maneuvers. Acute therapy includes cardioversion in hemodynamically unstable patients and vagal maneuvers and specific pharmacologic therapy for SVT based on the electrocardiographic diagnosis. There have been recent exciting advances in the nonpharmacologic treatments of SVT, most notably surgery and radiofrequency percutaneous catheter ablation for AV nodal reentry, AV reciprocating tachycardia, atrial flutter, and atrial tachycardias.     

Value of the 12-lead electrocardiogram in discriminating atrioventricular nodal reciprocating tachycardia from circus movement atrioventricular tachycardia utilizing a retrograde accessory pathway

The value of the 12-lead electrocardiogram for distinguishing atrioventricular (AV) nodal reciprocating tachycardia from circus movement AV tachycardia utilizing a retrograde accessory pathway was studied in 100 patients with narrow QRS complex tachycardia. Intracardiac electrograms showed AV nodal reciprocating tachycardia in 40 patients and circus movement AV tachycardia in 60. The 12-lead electrocardiograms recorded during tachycardia were randomly sorted and reviewed by 4 experienced cardiac electrophysiologists who were blinded to the diagnosis associated with each tracing, the relative proportion of each arrhythmia and the hypotheses to be tested. Each reviewer was asked to indicate the location of the P wave relative to the QRS complex, electrical axis of the P wave in the frontal and horizontal planes and presence or absence of QRS alternation, and to interpret the most likely mechanism. The performance of published electrocardiographic criteria to differentiate AV nodal reciprocating tachycardia from circus movement AV tachycardia was evaluated. The overall accuracy of the reviewers' interpretations was 75%, similar to the accuracy of the predefined criteria when applied by these observers (71% correct, difference not significant). Interobserver agreement of reviewer interpretations was 76% and the intraobserver agreement was 78%. Features associated with circus movement AV tachycardia by univariable analysis were P waves after the QRS complex, faster tachycardia rates and QRS alternation. Multivariable analysis showed that only the location of the P wave relative to the QRS complex was independently associated with the mechanism of tachycardia (p = 0.002). QRS alternation was found by multivariate analysis to be associated with the rate but not the mechanism of the tachycardia.     

12-Kanal-Elektrokardiogramm

The surface electrocardiogram (ECG) is an important diagnostic tool for the diagnosis of arrhythmias and acute coronary syndrome. Supraventricular tachycardias (SVT) are paroxysmal tachycardias as are sinus tachycardia, atrial tachycardia, AV nodal reentry tachycardia, and tachycardia due to accessory pathways. All SVT are characterized by a ventricular heart rate >100/min and small QRS complexes (QRS width <0.12 s) during tachycardia. It is important to analyze the relation between P wave and QRS complex to look for an electrical alternans as a leading finding for an accessory pathway. Wide QRS complex tachycardias (QRS width ≥ 0.12 s) occur in SVT with aberrant conduction and SVT with bundle branch block or ventricular tachycardia (VT). In broad complex tachycardias, AV dissociation, negative or positive concordant pattern in V₁–V₆, a notch in V₁ and QR complexes in V₆ in tachycardias with left bundle branch block morphologies are findings indicating VT. In addition, an R/S relation <1 in V₆ favors VT when right bundle branch block tachycardia morphologies are present. By analyzing the surface ECG in the right way with a systematic approach, the specificity and sensitivity of correctly identifying a SVT or VT can be raised by >95%. The 12-lead surface ECG allows the coronary culprit lesion to be located in 97% due to determination of the 12-lead ST segment deviation score.     

Regular Wide QRS Complex Tachycardia During Atrial Fibrillation in a Patient with Preexcitation Syndrome: A Case Report

AV Conduction in WPW. We report an unusual case of a relatively regular wide QRS complex tachycardia alternating with periods of an irregular narrow QRS complex tachycardia during atrial fibrillation in a patient with Wolff-Parkinson-White syndrome. Both tachycardias resulted from atrial fibrillation, the wide QRS complex tachycardia being due to 2:1 AV conduction of a type I atrial fibrillation across a posteroseptal accessory AV connection.