房室旁路并房室结双径路的心电图1例

房室旁路或房室结双径路均可引起折返性心动过速,而两者并存且引起折返性心动过速的典型心电图表现较少见到。现报道1例,其动态心电图显示:显性预激综合征,由房性早搏诱发和终止的顺向型房室折返性心动过速以及在其发生过程中分别经房室结快慢径路下传造成两种明显的频率变化。这是房室旁路合并房室结双径路的典型心电图表现。     

隐匿性房室旁道心电图定位的临床研究

目的 探讨通过心电图进行隐匿性房室旁道定位. 方法回顾性分析36例经射频导管消融证实为隐匿性房室旁道患者术前的顺向性房室折返性心动过速心电图. 结果通过分析P-波形态与R-Pˉ间期改变,可将旁道初步分为右前、右后、左前、左后4个部位.①V1的Pˉ波倒置时旁道位于右侧,Pˉ波直立时旁道位于左侧,V,的R-Pˉ间期≥P^-R间期时提示旁道位于左前区域.②ⅡⅢ、aVF的Pˉ波直立时旁道位置靠前,倒置时旁道位置靠后;左侧旁道的Ⅲ Pˉ波电压高于aVF时旁道位于左前区域,右侧旁道的Ⅱ Pˉ波电压高于Ⅲ时旁道位于右前区域;Pˉ波深倒置为后间隔旁道特征性表现.⑧Ⅰ、aVL的Pˉ波直立时旁道位于右侧或间隔部,Pˉ波倒置时旁道位于左前区域,Pˉ波倒置越深旁道越靠前.结论 隐匿性旁道逆传形成的Pˉ波形态及V1 R-Pˉ间期改变可对房室旁道定位,不同导联的特征性Pˉ波越多.旁道定位越准确.     

手术治疗隐匿性房室旁路并房室结双径路的电生理、心外膜和房室结周定位标测

介绍自１９９２年８～１０月对２例房室旁路并房室结双径路的患者运用手术直视切割房室旁路及房室结周最早心房逆传点的方法治疗药物难治性室上速获满意疗效。术后随访２２～２４个月无复发，房室传导正常。作者对本症的电生理、房室结周定位特点和手术治疗的适应证进行了分析讨论。     

体表心电图对AVRT及AVNRT的诊断价值和方法

通过对６６例房室折返性心动过速及房室结折返性心动过速及体表心电图与心内电生理检查结果对比分析,总心动过速时体表心电图逆传Ｐ波使波形改变的规律,从而利于用体表心电图对ＡＶＮＲＴ及ＡＶＲＴ鉴别诊断。     

体表心电图对阵发性窄QRS波心动过速鉴别诊断及定位的价值

目的:通过分析152例阵发性窄QRS波心动过速（NQRST）患者体表心电图（ECG）的6种指标,探讨ECG对NQRST鉴别诊断及定位的价值。方法:选取152例NQRST患者,其中94例为房室结折返性心动过速(AVNRT),42例为房室折返性心动过速（AVRT),16例为房性心动过速(AT)。上述患者电生理机制均经腔内电生理检查所证实,对比分析每位患者窦性心律及心动过速发作时体表心电图在心率、ST-T改变、QRS波电交替、R-P′/P′-R相似文献   

食管电生理在隐匿性房室旁道定位诊断中的作用

目的探讨食管电生理对隐匿性房室旁道定位的诊断价值。方法回顾性分析69例经心内电生理确诊并成功消融的隐匿性房室旁道患者术前食管电生理指标,观察心动过速诱发时体表心电图逆行P波形态、P波在V1及食管导联的先后顺序。结果不同部位的房室旁路在不同导联上逆行P波形态不同;69例中左侧游离壁旁路48例,P′E领先P′V1,右测游离壁旁道12例,P′V1领先P′E,间隔旁路9例,P′V1与P′E几乎同时出现。结论食管电生理检查对隐匿性房室旁道能进行初步定位,为射频消融手术提供有力帮助。     

体表心电图对房室结折返性与房室折返性心动过速的鉴别诊断

为探讨体表心电图对房室结折返性和房室折返性心动过速的鉴别诊断价值,对以射频导管消融、心脏电生理检查、心外膜标测的方法确诊房室结折返性心动过速(AVNRT)和房室折返性心动过速(AVRT)的88例患者的室上性心动过速发作时心电图作对照研究。结果显示:(1)P'波出现率在AVNRT占33％,在AVRT占100％(P<0.01)。(2)R-P'间期<80ms时常见于AVNRT,而≥80ms多见于AVRT(P<0.01)。(3)AVNRT在下壁导联(Ⅱ、Ⅲ、aVF)常见假性S波,而V_1导联常合并假性r波。(4)AVRT无文氏现象,但常出现束支传导阻滞改变且符合Coumel-Slama定律。认为以上特点对两者鉴别诊断有重要价值。     

房室结／隐匿性旁道折返性心动过速食管调搏诊断指标的评价

为提高食管调搏对折返性心动过速的诊断准确率,对30例房室结折返性心动过速和35例隐匿性旁道折返性心动过速作食管调搏(该65例诊断结果与射频消蚀诊断一致率为98.5%).结果显示:电刺激重复诱发和终止以及心动过速时R-P/P-R<1诊断两型的必备指标;室上速第1个P-R间期<240ms、房室结双径路、R-P间期<70ms或>95ms、P_(v_1)-P_E时距≥25ms、P与QRS重叠、QRS后逆行P等是鉴别两型的综合指标.认为食管调搏多指标综合分析对诊断两型折返性心动过速及指导治疗有重要意义.     

体表心电图特征对典型的房室结折返性心动过速和房室折返性心动过速的鉴别作用

对150例射频消融明确诊断的窄QRS心动过速患者的窦性心律和发作室上性心动过速时的心电图进行分析,从而归纳出典型的房室结折返性心动过速(AVNRT)和房室折返性心动过速(AVRT)心电图特征的差异.结果 5项心电图指标对区分这两种心动过速类型有意义.认为对于AVNRT有预测作用的为伪r′波(V1导联)和伪S波(Ⅱ、Ⅲ、aVF导联).对于AVRT有预测作用的为逆传P波,RP′间期≥70 ms及ST段改变.     

预激综合征房室旁路无创性定位诊断

房室折返性心动过速时,心房激动的顺序对预激综合征患者房室旁道的定位非常重要。本文通过比较经右胸壁记录的右房电位和经食管记录的左房电位,大致能将游离壁旁路和间隔旁路区分开来。本组无创性房室旁路定位诊断均经心内电生理检查加以证实。     

希氏束旁起搏鉴别间隔部隐匿性AVRT与AVNRT的临床价值

目的：探讨希氏束旁起搏鉴别间隔部隐匿性房室旁道与慢一快型房室结折返性心动过速（AVNRT）的临床价值。方法：采用希氏束逆传不应期心室早搏刺激法将61例患者分别诊断为37例慢一快AVNRT和24例间隔部房室折返性心动过速（AVRT）；再对61例患者采用希氏束旁起搏方法进一步检测。结果：采用希氏束旁起搏法检测37例AVNRT患者中有6例未检测成功，其余31例均为逆传房室结图形；24例AVRT患者中4例未检测成功，15例呈逆传旁道／旁道图形，5例呈非逆传旁道／旁道图形。如以逆传旁道／旁道图形为标准，鉴别间隔快旁路引起的AVRT与慢一快型房室结折返性心动过速，敏感性75％，特异性可达1009／6。结论：希氏束旁刺激法对鉴别诊断AVRT与AVNRT有较高的特异性。     

Successful elimination of concealed accessory pathway-mediated tachycardia by ablation of AV nodal slow pathway

We report a case of atrioventricular reentrant tachycardia (AVRT) using a concealed para-Hisian accessory pathway for retrograde conduction, which also required anterograde conduction over the AV nodal slow pathway to maintain the tachycardia. The shortest VA interval during AVRT (70 ms) was noted at a site with His bundle electrogram amplitude of 0.25 mV. The AVRT was cured by radiofrequency ablation of the AV nodal slow pathway without affecting accessory pathway conduction. The patient has not reported any sustained palpitations at 2 years after ablation while receiving no medications. The case presented in this report illustrates a para-Hisian AVRT that was successfully eliminated by an unconventional approach of ablation of the atrial inputs to the AV nodal slow pathway.     

Concealed conduction and dual pathway physiology of the atrioventricular node

INTRODUCTION: Both concealed conduction and dual pathway physiology are important electrophysiologic characteristics of the AV node. The interaction of AV nodal concealment and duality, however, is not clearly understood. METHODS AND RESULTS: The properties of AV conduction curves in the presence and absence of a conditioning blocked impulse were prospectively studied during premature atrial stimulation in 20 patients with AV nodal reentrant tachycardia before and after slow pathway ablation and in 14 control patients. AV nodal duality in the control conduction curve in the absence of a conditioning impulse was observed in 19 (95%) of 20 patients with AV nodal reentrant tachycardia. However, AV nodal duality in the modulated conduction curve in the presence of a blocked impulse was only identified in 2 (10%) of 20 patients (2/20 vs 19/20, P < 0.0001). The modulated curve was characterized by a significantly longer AV nodal effective and functional refractory periods compared to the control curve (P < 0.0001) in both patients with and without AV nodal reentry and in AV nodal reentry patients after successful slow pathway ablation. The maximum AH interval (AH(max)) of the modulated curve was significantly shorter than the control curve in both patients with (217 +/- 74 ms vs 347 +/- 55 ms, P < 0.0001) and without AV nodal reentry (178 +/- 50 ms vs 214 +/- 54 ms, P = 0.02). AH(max) of the control curve was significantly longer in AV nodal reentry patients than in controls (P < 0.0001). AH(max) of the modulated curve, however, was not significantly different between the two groups. After slow pathway ablation, AH(max) of the control curve was significantly reduced (347 +/- 55 ms vs 191 +/- 40 ms, P < 0.0001). Significant reduction in AH(max) of the modulated curve was not observed. CONCLUSION: An interaction of AV nodal concealed conduction and dual pathway physiology was demonstrated by our data. Slow pathway conduction of the AV node was prevented by the concealed beat in both patients with and without AV nodal reentry.     

Typical atrioventricular nodal reentrant tachycardia in a patient with fasciculoventricular pathway

We report a 34-year-old female patient with preexcitation electrocardiogram and recurrent paroxysmal palpitations. Standard 12-lead electrocardiogram showed minimal preexcitation with normal PR interval and normal frontal QRS axis. The electrophysiologic study showed normal AH intervals, short HV intervals, and no change in the degree of preexcitation by rapid atrial pacing. These findings were compatible with the fasciculoventricular pathway. Typical atrioventricular nodal reentrant tachycardia with narrow QRS complex and normal HV interval was induced reproducibly by programmed electrical stimulation. Slow pathway was ablated successfully with radiofrequency catheter ablation, and then the patient remained asymptomatic during a follow-up of 12 months. Although the fasciculoventricular pathway is rare and supraventricular tachycardia in a patient with fasciculoventricular pathway may mimic Wolff-Parkinson-White syndrome, possibility of typical atrioventricular nodal reentrant tachycardia with fasciculoventricular pathway should be considered as a mechanism of supraventricular tachycardia in a patient showing preexcitation electrocardiogram.     

逆行瓣上法射频消蚀左侧房室旁路

３０例左侧房室旁路并房室折返性心动过速（ＡＶＲＴ）病人，用逆行主动脉左房瓣上法行射频消蚀术。均为逆行左室侧瓣下法未成功的病例。每例瓣上放电３．１±２．０次，放电能量为２５～３０Ｗ，旁路距冠状窦口０．５～５．５ｃｍ，消蚀靶部位Ａ／Ｖ比例为０．８３±０．２８，３０例消蚀均成功。本文就逆行左房瓣上法消蚀左侧房室旁路的适应证、方法学等进行了讨论。     

Local slow potential preceding the surface QRS complex detected at the subvalvular mitral annulus in patients with a left-sided concealed accessory pathway. Incidence, electrophysiological characteristics and the possible mechanism, with demonstration of anterograde concealed conduction through the pathway.

AIM: We sought to evaluate the incidence and electrophysiological features of the local slow potential preceding the surface QRS complex (pre-QRS potential) which was detected more frequently at successful sites of catheter ablation of left parietal concealed accessory pathways, than at unsuccessful sites. METHODS AND RESULTS: Thirty eight consecutive patients with a single left sided concealed accessory pathway underwent radiofrequency catheter ablation exclusively from the subvalvular mitral annulus. The local bipolar electrograms during sinus rhythm from the target sites were carefully analysed and the incidence of pre-QRS potentials was compared between successful and unsuccessful ablation sites. All ablation sessions attained a successful outcome with a total of 84 radiofrequency current applications (38 at successful sites, 46 at unsuccessful sites). The incidence of pre-QRS potentials (preceding by 10 ms or more) was 12/38 at successful sites (32%) and 1/46 at unsuccessful sites (2%) (P<0.001). The QV interval, defined as the interval between the upstroke of the QRS complex and the ventricular electrogram, including the pre-QRS potential, was -5.6+/-9.1 ms at successful sites, while it was 1.2+/-6.1 ms at unsuccessful sites (P<0.001). The pre-QRS potential disappeared during atrioventricular reciprocating tachycardia and right ventricular pacing, and was eliminated by successful ablation. CONCLUSIONS: Detection of the pre-QRS potential was clinically relevant and could be distinguished from artifact. This potential may be caused by anterograde concealed conduction through the accessory pathways.     

Accessory atrioventricular node with properties of a typical accessory pathway: anatomic-electrophysiologic correlation

We report an accessory AV node producing ventricular preexcitation and comprising the retrograde limb of AV reentrant tachycardia (AVRT). A 66-year-old man presented with an anteroseptal myocardial infarction and thereafter developed recurrent, drug-refractory AVRT requiring multiple cardioversions. Electrophysiologic findings were typical for a concealed anteroseptal accessory pathway 0.5 cm anterior to the His bundle. The patient died of intractable heart failure after endocardial resection for a left ventricular aneurysm and coronary bypass grafting. Pathologic examination revealed a para-Hisian accessory AV node connecting the right atrium to ventricular myocardium immediately anterior to the His bundle at a depth of 4 mm from the endocardium. No typical AV accessory pathway was found. This is the first report of an accessory AV node that participated in AVRT. It was deeper than typical radiofrequency catheter ablation lesions.     

常规心电图对典型的房室结折返性心动过速和顺传型房室折返性心动过速的鉴别作用

目的探讨12导联心电图对阵发性窄QRS心动过速中最常见两种类型--典型的房室结折返性心动过速（AVNRT）和顺传型房室折返性心动过速（AVRT）的鉴别作用.方法对206例阵发性窄QRS心动过速（QRS〈0.11 s,心室率〉120次/min）患者的心电图进行了分析.第一部分分析139例患者的心电图,从中归纳出1个12导联心电图算法（algorithm）.第二部分前瞻性分析了67例患者的心电图,以检测这一算法的准确性.心动过速的机制和旁路位置均由成功的射频导管消融术确定.结果 5项心电图指标对区分这两种心动过速类型有意义.对于AVNRT有预测作用的为伪r′波（V1导联,敏感性53%、特异性96%）,伪S波（Ⅱ、Ⅲ、aVF导联,敏感性21%、特异性100%）.对于AVRT有预测作用的为逆传P波（敏感性89%、特异性68%）,RP间期〉70 ms（敏感性90%、特异性91%）,及ST段改变.ST段改变归纳出3个联合指标,分别为：V4、V5导联ST段同时下降≥2 mm（敏感性24%、特异性94%）;V5、V6导联ST段同时下降≥1 mm（敏感性41%、特异性81%）;V6导联ST段同时下降≥1 mm和aVR导联ST段抬高≥1 mm同时出现（敏感性30%、特异性85%）.V1导联逆传P波极性对于旁路的初步定位有帮助,左侧旁路大多为直立、双向或平坦的逆传P波,右侧旁路大多为倒置的逆传P波.12导联心电图算法对心动过速机制的正确诊断率分别为85%和82%.对于AVRT旁路位置的正确判断率为75%～86%.在3个联合指标中,V5、V6导联ST段同时下降≥1 mm的鉴别作用最佳.结论心电图算法有助于更加准确地鉴别阵发性窄QRS心动过速的机制,并且可以对旁路初步定位.     

隐匿性慢旁束心动过速的诊断和消融

２例隐匿性慢旁束折返性心动过速的诊断依据：１、心房和心室电刺激易诱发和终止心动过速；２、心动过速时体表心电图呈窄ＱＲＳ波，递行Ｐ波及ＰＲ〈ＰＲ；３、心动过速与右心室起搏均呈同样的偏心性心房激动顺序；４、心动过速时于希司速不应期刺激心室可提前夺获心房；５、经旁速室房传导呈递减性，未发现旁束有前传能力；６、射频消融心动过速的逆传支后表现为室房分离。射频消融需在心运过速或心起搏时仔细标测三尖瓣环，寻找最     

心室融合波伴心房激动提前对间隔旁路逆传的房室折返性心动过速的诊断作用

目的 观察心室融合波伴心房激动提前对间隔旁路逆传的顺向型房室折返性心动过速(OAVRT)的诊断作用。方法 按心内电生理检查标准和射频消融结果，将47例符合人选条件的患者分为两组：房室结折返性心动过速(AVNRT)组和间隔旁路逆传的0AVRT组，分别为24例和23例。心动过速时行心室期前程序刺激(RS2刺激)和心室快速刺激，测量体表心电图上心室融合波之后的心房激动时间是否提前。结果 RS2刺激和心室快速刺激均能形成多个心室融合波。AVNRT组无l例伴有心房激动提前(特异性100％)，而OAVRT组在心室刺激成分明显的心室融合波时，心房激动均被提前(敏感性100％)。两组间的差异十分显著(P＜0．001)。结论 心室融合波伴心房激动时间提前是诊断间隔旁路逆传OAVRT的可靠指标，具有敏感性和特异性高的特点，而且也可用于未能记录到希氏束电图的患者。