经食管心房刺激同步记录诊断心律失常

多年来食管法心脏电生理检查在无创性窦房结功能检测,揭示预激旁道与房室结双径路电生理特性,诱发、终止阵发陛室上性心动过速等方面应用广泛,为普及电生理知识发挥了较大的作用。但长期以来,在检查时只能通过体表单导联或多导联同步记录来分析诱发的心律失常,有时在心房刺激后诱发的心律失常瞬间出现,因不易捕捉或宽QRS波群心动过速时体表导联P波不清而丢失许多心电信息,从而无法明确诊断。     

食管心脏电生理在心律失常诊治中的应用

体表心电图是诊断心律失常的重要手段,百余年来为临床诊治提供了及时、简便、可靠的诊断依据.但体表心电图须在患者心律失常发作时才能捕捉到,且记录点局限在体表,难以进一步了解心脏具体起源点及激动顺序,对于某些复杂心律失常仍不能明确诊断.心腔内电生理检查借助心导管技术将多根电极导管分别放置在右心房、希氏束、冠状静脉窦以及右心室心尖部等部位标测,可了解到各部位的起源点及激动顺序.结合体表心电图,采用程控电刺激还可了解心脏传导系统的电生理特性,诱发及终止心律失常,明确心律失常的发生机制等,但因其属创伤性检查且费用昂贵,无法普及.食管心脏电生理检查则利用食管与心脏解剖关系密切的特点,将电极导管经鼻腔送入食管,采用心内电生理检查的程控刺激技术起搏心房,同时记录体表导联与食管导联心电图以获得心脏各部位的电生理参数并复制心律失常.因其属无创性、设备简单、方便易行、价格低廉,在我国得到广泛应用,也在诊治心律失常方面发挥重要作用的同时,为心电图医师提供了学习心脏电生理知识的良好平台.     

食管心脏电生理检查诊治心律失常

<正>食管心脏电生理检查是一种无创心脏电生理检查技术,既可复制心律失常,又能在心律失常发作时通过食管导联心电图及程序心脏刺激终止心动过速时,并进一步了解证实心律失常的发生机制,具有无创、简而易行的优势。     

双极食管心电图对间隔部隐匿性旁路的诊断价值

目的比较单极食管心电图和双极食管心电图对间隔部隐匿性旁路的诊断价值。方法选择经心内电生理检查和射频消融术证实的19例间隔部隐匿性旁路患者。消融术前经食管心房调搏诱发阵发性室上性心动过速发作,记录发作前后体表12导联心电图、单极食管心电图、双极食管心电图。分别观察P波形态、极性、P波与QRS波群关系,测量P波振幅、时限,以心内电生理检查结果为标准分析单极食管心电图和双极食管心电图对间隔部隐匿性旁路的诊断率差异。结果单极食管心电图P波无极性变化,双极食管心电图P波可根据需要调整极性。双极食管心电图和单极食管心电图的P波振幅分别为（0.58±0.12）mV和（0.36±0.11）mV（P<0.05）,P波时限分别为（96±11）ms和（99±14）ms。单极食管心电图和双极食管心电图对间隔部隐匿性旁路的诊断符合率分别为58%和89%（P<0.05）。结论双极食管心电图记录的P波振幅大于单极食管心电图,并能更清晰的显示P波、P波和QRS之间的关系,对间隔部隐匿性旁路的诊断优于单极食管心电图。     

双极食管心电图对P波的形态特征及右侧隐匿性旁道的诊断

目的探讨双极食管心电图P波的形态特征以及其对右侧隐匿性旁道的诊断价值。方法选择经心内电生理检查和射频消融术证实的32例右侧隐匿性旁道患者。消融术前经食管心房调搏诱发阵发性室上性心动过速发作,以相同的走纸速度和振幅记录发作前后体表12导联、单极食管、双极食管心电图。分别观察P波形态、极性、P波与QRS波关系,测量P波振幅、时限,以心内电生理检查结果为标准分析单极与双极心电图对右侧隐匿性旁道的诊断灵敏度。结果单极食管心电图P波无极性变化,双极食管心电图P波可根据需要调整极性。双极食管心电图和单极食管心电图的P波振幅分别为0.55±0.10mV和0.34±0.10mV(P<0.05),P波时限分别为98.4±11.2ms和101.2±12.5ms(P>0.05)。单极食管心电图和双极食管心电图对右侧隐匿性旁道的诊断灵敏度分别为68.8%和93.8%(P<0.05)。结论双极食管心电图记录的P波振幅大于单极食管心电图,并能更清晰的显示P波以及P波与QRS波之间的关系,对右侧隐匿性旁道的诊断优于单极食管心电图。     

双极食管导联记录右心房电位探讨

目的　探讨双极食管导联记录右心房电位的方法及其临床意义。　方法　心内电生理检查时同步记录高位右心房、希氏束、冠状静脉窦和双极食管导联心电图 ,分析食管导联中右心房电位和左心房电位的关系。　结果　双极食管导联记录到的窦性 P波由圆钝直立的右心房电位和尖锐高大的左心房电位组成。 2 8例右心房、左心房传导时间分别为 (4 2 .86± 8.81) ms和 (6 4.2 8± 6 .78) ms,右心房/左心房 =0 .10± 0 .0 3。在窦性心律 ,右心房、左心房和右心室起搏时 ,食管导联的右心房电位和心腔内高位右心房导联的 A波一致 ,左心房电位与冠状静脉窦导联的 A波基本一致。　结论　双极食管导联记录方法能够可靠记录到右心房电位 ,并且分别反映出右心房和左心房激动顺序 ,对了解心房间传导功能 ,分析房性心律失常 ,初步判断隐匿性房室旁路部位等方面 ,有一定的实用价值     

食管心脏电生理技术与临床应用(5)——食管心脏电生理分析方法与报告内容

<正>食管心脏电生理检查需要发放多种方式的刺激脉冲及同步记录体表与食管导联心电图,连贯地仔细分析电生理检查全过程的体表和食管导联心电图改变,从而获得心脏各部位电生理参数。与分析体表心电图一样,可根据刺激波与心电图各间期及波形变化这些特点,仔细分析记录结果并做出心脏电生理诊断。1分析方法电脉冲在心电图上表现出高尖的钉状刺激波     

食管法心脏电生理检查中S-P间期临床意义探讨

目的　为探讨食管法心脏电生理检查中存在S P间期的临床意义。方法　回顾性分析双极食管导联刺激同步记录时 ,能在刺激脉冲波后稳定录得清晰P2 波且资料完整者 5 0例。分别测量食管导联和V1导联中P2 波脱漏前最短S1S2 间期时的S2 波至P2 波间期 ,食管导联中P2 波至V1导联P2 波期间。结果　发现随着S1S2间期的逐渐缩短 ,食管导联和V1导联中均存在S2 ～P2 间期逐渐延长的特征。P2 波脱漏前的S2 P2 EB和S2 P2 V1间期分别为 (76 33± 11 89)ms和 (14 9± 2 6 83)ms,P2 EB P2 V1间期 (72 0 0± 10 31)ms。结论　提示 :①食管导联电极至左心房外膜间存在递减性传导 ,使该区域容易形成裂隙现象 ,亦造成心房不应期缩短和房间传导阻滞的假象 ;②采用单导联记录时不宜将刺激脉冲波作为左心房激动的标志 ,V1导联刺激波至P2 波顶峰时距不能反映左房后壁至右房前壁的房间传导时间 ;③心脏外组织存在传导延缓是食管法心脏电生理检查的一大特点     

食管心房调搏和标测专用导管电极应用研究

应用作者研制的9F8极食管心房调搏和标测专用导管电极对60例患者进行电生理研究,目的是探索降低食管心房调搏阈值,提高检查成功率和提高无创性电生理诊断准确率的途径.通过食管电生理对照研究,结果证明,应用此种新型导管电极,心房起搏和电生理检查阈值可降低25%—30%,检查成功率为100%.由于这种导管电极可同时进行心房调搏、同步记录2道食管双极导联滤波心电图,提高了无创性电生理检查诊断心律失常的水平.     

食管心脏电生理技术与临床应用（3）--常用刺激方法与应用技巧

食管心房调搏是利用食管与心脏解剖关系密切的特点,将电极导管经鼻腔送入食管。除了在心律失常时记录食管导联心电图外,主要应用心脏刺激仪发放直流电脉冲,通过贴近心脏的食管电极对心房进行调搏。同步记录体表及食管内心电图以获得心脏各部位的电生理参数,揭示心律失常的发生机制,诊断和治疗某些心律失常。     

食管心房调搏对阵发性室上性心律失常的诊断意义

目的探讨食管心房调搏对阵发性室上性心律失常的诊断意义。方法应用食管导联心电图对82例各类阵发性室上性心律失常的检出率对照分析。结果房室结双径路在双极食管导联的检出率为82.57%,单极食管导联的检出率为57.3%（P〈0.01）;预激综合征（WPW）合并房室折返性心动过速在双极食管导联的检出率为11.46%,单极食管导联的检出率为10.98%（P〈0.05）。室性心动过速伴房室分离在双极食管导联的检出率为2.75%,单极食管导联心电图的检出率为1.22%（P〈0.05）;室性心动过速与心房扑动并存在双极食管导联的检出率为2.29%,单极食管导联心电图的检出率为1.22%（P〈0.05）;室性心动过速伴1：1室房逆传在双极食管导联的检出率为1.83%,单极食管导联心电图的检出率为1.22%（P〈0.05）。结论双极食管导联对阵发性室上性心律失常的检出率比单极食管导联的检出率高,安全、可靠、实用、能定位、对射频消融术前病例的筛选具有重要作用。     

Esophageal electrocardiography: a new technology revives an old technique

This study evaluates the clinical use of an easily swallowed bipolar electrode for recording an esophageal electrocardiogram (ECG). Fourteen patients were selected for bedside diagnosis (ECG group) because of arrhythmias difficult to evaluate using a standard 12-lead ECG. A second group of 27 non-selected patients scheduled for routine 24-hour ambulatory electrocardiographic recordings (ambulatory ECG group) had an esophageal ECG recorded as the "third channel." All 14 patients (100%) in the ECG group had excellent-quality tracings, and the esophageal ECG was diagnostic in 12 cases (86%). Of 27 patients in the ambulatory ECG group, 19 (70%) had fairly good to excellent-quality 24-hour esophageal pill tracings, with the esophageal ECG contributing to correct arrhythmia diagnosis in 11 patients (41%). It is concluded that this easily swallowed esophageal electrode provides an excellent-quality short-term ECG and often permits proper arrhythmia diagnosis in selected patients with arrhythmias. Good-quality 24-hour esophageal ambulatory electrocardiographic recordings can also be obtained that contribute to arrhythmia diagnosis in a limited number of unselected patients, and should be even more clinically useful in carefully selected patients.     

体表与食管心电图在隐匿性房室旁路诊断及定位中的价值

目的探讨诊断隐匿性房室旁路的简易方法。方法110例经心内电生理确诊并成功消融的隐匿性房室旁路患者。术前行食管心房调搏检查,观察S2R2有无跳跃性延长;记录心动过速时的体表心电图,观察逆传P波的方向及形态;同步记录食管与V1导联心电图,观察P波在V1(P-V1)及食管导联(P-E)的先后顺序。结果110例中106例S2R2呈逐渐延长。67例左侧旁路房室折返性心动过速时P-E先于P-V1,39例右侧旁路P-V1先于P-E,4例中间隔旁路P-E与P-V1几乎同时出现。且不同部位的房室旁路在不同导联上逆传P波形态不同,并有显著差别。结论隐匿性房室旁路可根据心动过速时的体表心电图P波的方向及形态作出初步诊断,结合食管与V1导联同步心电图以及食管调搏结果可基本确定诊断。     

Prospective evaluation of 4-mm diameter endoscopes for esophagoscopy in sedated and unsedated patients

BACKGROUND: Unsedated esophagoscopy with small-diameter endoscopes is generally well tolerated but of limited sensitivity for the diagnosis of esophageal mucosal disease. This study evaluated the sensitivity of esophagoscopy performed with new 4-mm diameter prototype battery-powered and video endoscopes. Patient tolerance for an unsedated examination with the 4-mm endoscopes was assessed and the performance characteristics of the battery-powered and video 4-mm endoscopes were compared. METHODS: Patients referred for EGD were recruited to undergo an additional examination with a 4-mm endoscope. A prototype 60-cm long, 4-mm diameter battery-powered fiberoptic esophagoscope was used in the first 24 patients and a prototype 60-cm long, 4-mm diameter video esophagoscope in the next 27 patients. Examiners who were unaware of patient history and procedure indications recorded esophageal findings, ease of intubation, optical quality (5-point visual scale), and time for examination of the esophagus and then recorded esophageal findings after the standard EGD. RESULTS: The sensitivity, specificity, and accuracy for identification of Barrett's esophagus was 100%; overall sensitivity, accuracy, and specificity for detecting esophageal lesions were, respectively, 91%, 98%, and 99%. Patient tolerance (assessed by symptom scores for choking, pain, and discomfort) and acceptability of unsedated esophagoscopy with the 4-mm diameter instruments were significantly better than in a historical group of patients examined with a 3-mm diameter endoscope. The optical quality of video endoscope was rated as superior to that of battery-powered endoscope, and esophageal examination was performed significantly quicker with the video versus the battery-powered endoscope (68 vs. 137 seconds; p = 0.001). CONCLUSIONS: Unsedated esophagoscopy with 4-mm diameter endoscopes may be an alternative to EGD for screening for Barrett's esophagus. Given the current state of endoscopic technology, a minimum diameter of 4 mm is required for satisfactory esophageal imaging.     

比较远程心电监测与心电图、动态心电图在心律失常及心肌缺血中的诊断价值

目的探讨远程心电监测诊断心律失常、心肌缺血的临床价值。方法采用远程心电监测检查78例明确诊断为心脏病或存在心脏不适的患者,所有患者同时行常规12导联心电图检查,其中42例患者行24h动态心电图检查。比较远程心电监测与常规心电图及24h动态心电图在心律失常及缺血性ST-T改变检出率方面的差异。结果 78例患者中,远程心电监测及常规心电图分别检出62例、46例心律失常患者(P<0.05),同时分别检出14例、6例患者心电图存在缺血性ST-T改变(P<0.05);在完善24h动态心电图检查的42例患者中,远程心电监测与24h动态心电图分别检出34例、30例心律失常患者(P>0.05),同时分别检出10例、7例心电图有缺血性ST-T改变的患者(P>0.05)。结论远程监测无论在心律失常还是缺血性ST-T改变的检出率均高于常规心电图组;远程监测对心律失常及缺血性ST-T改变的检出率与24h动态心电图无显著差异。     

经食管信号平均心电图记录窦房结电图的临床研究

探讨无创性经食管信号叠加直接记录窦房结电位 (SNP)的技术 ,对 2 5 6例食管电生理检查窦房结传导时间(SACT)和窦房结恢复时间 (SNRT)均在正常范围的患者 ,其中男 14 2例、女 114例 ,年龄 4 4 .2± 12 .4 (10～ 74 )岁进行检测。采用自制三导心电微电位检测仪将食管导联的信号放大 (增益达到 10 0 μV/cm)、滤波 (0 .1～ 5 0Hz) ,16位模 /数 (A/D)转换 ,系统采样频率 2kHz,对信号进行叠加 ,189例 (74 % )记录到食管SNP。所测信号叠加食管SNP为P波前的低幅、低频波 ,可见有两种形态 :园顶型 (6 0 % )和上斜型 (4 0 % )。所测窦房传导时间为 83.3± 2 6 .7ms ,分布范围为 2 3～ 118ms;波幅为 3.5～ 2 7.7μV ;dv/dt为 0 .4 3～ 1.93mV/s。笔者认为在适当的滤波、高增益和抗基线漂移技术条件下 ,利用经食管信号叠加技术 ,大多数窦房结功能正常的患者可直接记录到食管SNP。     

Esophageal squamous cell carcinoma co-existing with achalasia: report of two cases

Esophageal achalasia is a primary motility disorder of the esophagus. Although various treatments can relieve the symptoms, esophageal cancer arising in patients with achalasia is the most important problem for long-term survivors. We encountered 2 cases of esophageal squamous cell carcinoma co-existing with achalasia that had been diagnosed 27 and 30 years earlier, respectively. Neither patient had been aware of dysphagia due to dilatation of the esophagus. Both patients underwent esophagectomy via right thoracotomy. Although esophagectomy with radical lymphadenectomy was performed successfully in one case of submucosal cancer, the primary tumor in the other case was more invasive and aggressive than indicated by the preoperative clinical diagnosis, and could not be completely resected. Regular endoscopic examination should be scheduled for long-term survivors of achalasia in order to detect esophageal cancer early and evaluate any changes in the esophagus carefully.     

Cerebral responses evoked by electrical stimulation of the esophagus in normal subjects

Cerebral responses to electrical stimulation of the esophagus were investigated in 11 healthy male volunteers, 20-40 yr old. The stimulus was applied via a probe equipped with bipolar ring electrodes. It was positioned in the middle and distal esophagus at 20 and 37 cm from the incisors, respectively, and sucked to the mucosa. Electrical stimuli (0.1-ms duration, different stimulus voltages) were applied at frequencies of 0.1-1.0 Hz or in randomized order. Cerebral responses to electrical stimulation were recorded after 20-40 stimulations and averaged on a time base of 1000 ms. Evoked potentials consisted of successive peaks and troughs in the averaged electroencephalogram with good reproducibility within and between subjects. Amplitudes of evoked potentials showed a significant reduction with electrical stimulation at 37 cm compared with 20 cm, and with stimulation frequencies of 0.5 and 1.0 Hz compared with 0.2 and 0.1 Hz. Evoked potentials from 37 cm showed longer latencies compared with those from 20 cm. Irregular stimulation and stimulation during mental distraction did not alter these responses. It is concluded that reproducible evoked potentials can be recorded from the scalp after electrical stimulation of the esophagus and that these are transferred centrally via vagal afferents. The technique may become a useful tool in the study of visceral nervous connections to the brain in health and disease.     

Short segment Barrett's esophagus and distal gastric intestinal metaplasia

BACKGROUND: Short segment Barrett's esophagus is defined by the presence of <3 cm of columnar-appearing mucosa in the distal esophagus with intestinal metaplasia on histophatological examination. Barrett's esophagus is a risk factor to develop adenocarcinoma of the esophagus. While Barrett's esophagus develops as a result of chronic gastroesophageal reflux disease, intestinal metaplasia in the gastric cardia is a consequence of chronic Helicobacter pylori infection and is associated with distal gastric intestinal metaplasia. It can be difficult to determine whether short-segment columnar epithelium with intestinal metaplasia are lining the esophagus (a condition called short segment Barrett's esophagus) or the proximal stomach (a condition called intestinal metaplasia of the gastric cardia). AIMS: To study the association of short segment Barrett's esophagus (length <3 cm) with gastric intestinal metaplasia (antrum or body) and infection by H. pylori. PATIENTS AND METHODS: Eight-nine patients with short segment columnar-appearing mucosa in the esophagus, length <3 cm, were studied. Symptoms of gastroesophageal reflux disease were recorded. Biopsies were obtained immediately below the squamous-columnar lining, from gastric antrum and gastric corpus for investigation of intestinal metaplasia and H. pylori. RESULTS: Forty-two from 89 (47.2%) patients were diagnosed with esophageal intestinal metaplasia by histopathology. The mean-age was significantly higher in the group with esophageal intestinal metaplasia. The two groups were similar in terms of gender (male: female), gastroesophageal reflux disease symptoms and H. pylori infection. Gastric intestinal metaplasia (antrum or body) was diagnosed in 21 from 42 (50.0%) patients in the group with esophageal intestinal metaplasia and 7 from 47 (14.9%) patients in the group with esophageal columnar appearing mucosa but without intestinal metaplasia. CONCLUSION: Intestinal metaplasia is a frequent finding in patients with <3 cm of columnar-appearing mucosa in the distal esophagus. In the present study, short segment intestinal metaplasia in the esophagus is associated with distal gastric intestinal metaplasia. Gastroesophageal reflux disease symptoms and H. pylori infection did not differ among the two groups studied.     

Accuracy of a narrow-diameter battery-powered endoscope in sedated and unsedated patients

BACKGROUND: Esophagoscopy with a portable battery-powered endoscope could provide a safe, inexpensive, and minimally invasive way to screen for Barrett's esophagus or esophageal varices. The use of such an instrument in an unsedated fashion has not been previously evaluated. METHODS: Patients referred for an EGD were recruited to undergo an additional examination with the battery-powered endoscope before EGD. In phase 1, (n = 42) patients received conscious sedation before the battery-powered endoscopic examination. In phase 2, (n = 56) patients were not sedated and were given the option of a peroral (n = 43) or transnasal (n = 13) endoscopy. Examiners were blinded to patient history and procedure indications. Esophageal findings, ease of intubation, optical quality, and patient comfort for the battery-powered endoscope and standard EGD were recorded by the endoscopist. RESULTS: Ninety-eight patients (60 men, 38 women, mean age 53 years) were recruited. The sensitivity for detecting Barrett's esophagus, esophageal tumors, and esophageal varices was 54.5%, 66.7%, and 80%, respectively. Ease of intubation and patient comfort as perceived by the endoscopist were not significantly different between the battery-powered endoscope and EGD. Optical quality was ranked as less than 4 (on a 5-point scale with 5 = standard EGD and 1 = poor) in 42% of battery-powered endoscopic examinations. There were no complications. CONCLUSION: The accuracy of esophageal examination with a 3.1-mm endoscope is substantially inferior to standard EGD. Thus, the battery-powered endoscope would not be useful for screening patients for Barrett's esophagus or varices unless improvements in optical quality and visualization are made.