心房颤动患者服用洋地黄后出现长RR间期复律前后的观察

有些学者观察了非洋地黄所致心房颤动（房颤）伴长ＲＲ间期患者,恢复窦性心律后的房室传导功能,阐明原来的长ＲＲ间期并非由于二度房室阻滞。本组观察了１５例服用洋地黄制剂的患者,其心电图呈房颤伴长ＲＲ间期转复为窦性心律后的房室传导功能,以评价这种心电图现象的...     

心房颤动伴二度房室阻滞的心电图诊断

临床心电学杂志心电快递专栏编辑 :心电图是否能够诊断心房颤动伴二度房室阻滞一直是令人十分感兴趣而又颇有争议的敏感问题。我最近遇到了三位病人的心电图均与这一问题有关。例 1(图 1)患者男 ,39岁 ,平素健康 ,有阵发性房颤史 ,伴较长的ＲＲ间期 ,最长的ＲＲ间期达 2 .5 9ｓ,经静脉注射胺碘酮治疗 ,第 2天转复为窦性心律 ,窦律时未见房室阻滞 ,ＰＲ间期正常。例 2 (图 2 )患者男 ,5 6岁 ,心房颤动持续 5年 ,1年前心电图已出现房颤伴长达 2 .2 8ｓ的ＲＲ间期 ,长ＲＲ间期还可连续发生 (图 2Ａ)。当时心电图就已符合有些作者提出的房颤伴二…     

心房颤动合并二度房室阻滞诊断的争议

房颤合并长R-R间期，是否属于二度房室阻滞，历来存在争议，90年代以前不少心电图学专著，多认为房颤合并长R-R间期，是房颤合并二度房室阻滞的表现。90年代以后，发现房颤合并长R-R间期相当常见，当房颤复律后，窦性心律时并无二度房室阻滞，因此，对房颤合并二度房室阻滞提出质疑。     

心房颤动伴心室长间歇的临床意义

目的 了解心房颤动伴心室长间歇的发生机制和临床意义.方法 对动态心电图记录到的86例心房颤动伴心室长间歇的患者进行分析,男性52例,女性34例,年龄25～85(54±8)岁.其中持续性房颤48例、阵发性房颤38例.结果 86例患者中房颤伴心室长间歇≥1.5 s的有(267.4±56.2)次,最长为2.1～4.0 s,其中60例心室长间歇发生在凌晨1-4时,26例昼夜均有发作且12例有晕厥发作.10例电复律转为窦性心率后,3例存在房室阻滞,其中Ⅰ度房室阻滞1例、Ⅱ度房室阻滞2例.结论 心房颤动伴心室长间歇多发生在凌晨睡眠时,如能及早做出房颤伴Ⅱ度房室阻滞诊断有重要的临床意义.其发生机制可能与房室传导障碍、隐匿性房室传导、迷走神经张力增高、间歇性房室结不应期延长或隐匿性交界性早搏有关.     

48例心房颤动伴长RR复律前后的心电观察

以往认为心房颤动 (房颤 )合并ＲＲ≥ 1 5ｓ或者出现交界区性或室性逸搏是诊断房颤伴二度房室阻滞的依据 ,为避免出现严重缓慢的心室率不予复律治疗 ,本文通过对 48例房颤伴长ＲＲ的患者复律治疗前后的心电变化观察 ,对此进行了分析探讨。　　资料和方法　 48例房颤患者 ,男性 32例 ,女性 16例 ,年龄 46～ 72 (5 6 40± 6 2 3)岁。其中冠心病 2 2例 ,风湿性心脏病 18例 ,高血压性心脏病 6例 ,扩张性心肌病 2例。持续房颤病史 3～ 6个月。左心房内径 38～ 45ｍｍ。均采用美国博利屋 770 0型动态心电图仪记录 2 4ｈ心电图。复律前清醒状态平…     

征解35:答案

征解35答案:一度房室阻滞、间歇性二度房室阻滞、双腔起搏器心电图伴心室保护性AAI起搏(即MVP功能)、起搏功能正常。诊断要点:本例心电图诊断难度较大,最终诊断为一度～二度房室阻滞,双腔起搏器功能正常。1.一度与间歇性二度房室阻滞:征解图中PR间期380m(sA),AAI起搏时pAV间期460ms,说明患者存在持续性一度房室阻滞。当PR间期>350ms时,常被诊断为PR间期过度延长,其能明显损害心脏舒张功能,使有效舒张期缩短。同时该患者还有间歇性二度房室阻滞,表现在部分心房起搏后伴QRS波的脱落(C、D)。     

心房颤动合并长R-R间期的动态心电图分析

目的观察心房颤动合并长R-R间期(≥2.0 s)的发作规律及变化,并分析房颤伴长R-R间期的意义。方法选取我院2013年3月~2014年8月收治的房颤病史患者96例进行动态心电图监测,检出持续性房颤41例。结果 41例持续性心房颤动患者中22例检出R-R间期≥2.0 s。结论房颤发作过程中出现长R-R间期是一个常见现象,是房室传导功能正常的房颤,为控制心室率,临床需用药物减慢房室传导而造成长R-R间期,不应绝对作出合并Ⅱ度房室传导阻滞诊断,要求由医生结合临床作出较为客观的诊断,在为患者提供诊断结果时考虑患者的病史。     

心房颤动合并Ⅱ°房室传导阻滞19例电复律后观察

近年有人经临床观察,对以往沿循的房颤合并二度房室传导阻滞(Ⅱ°AVB)的心电图诊断标准及临床意义提出质疑。为此,我们根据临床体会进行探讨。1.临床资料:本组19例均系电复律治疗前R～R间距≥1.5秒者,或有结性或室     

房室结双径路特殊表现一例

患者常规体表心电图PP间期基本规则,PR间期不典型逐搏延长,随后突然出现一长RR间期,酷似二度Ⅰ型房室阻滞.通过24 h动态心电图可观察到长RR间期前的QRS波终末部出现一个逆行P-波,PR间期跳跃性延长达到0.15 s,提示存在房室结双径路.考虑为快径路一度房室阻滞,房室结双径路伴慢径路文氏阻滞和慢-快径路蝉联现象.     

新发心房颤动自动复律后房室传导功能临床观察

<正>心房颤动(简称房颤)是临床上常见的心律失常,房颤时常有长R-R间期出现,如何评价该特定心律条件下的房室传导功能在学术界争论已久,主要原因在于目前尚无法检测房颤时患者房室传导的情况[1]。本文通过观察新发房颤患者自动复律后的房室传导功能,对房颤伴长R-R间期、逸搏及逸搏心律的临床意义作初步的探讨。     

心房颤动患者RR长间期的分布规律及其临床意义

目的观察心房颤动(简称房颤)时RR长间期的发作规律及射频消融术后的变化,探讨房颤RR长间期的临床意义。方法记录并分析持续性/永久性房颤患者动态心电图中RR长间期发生时间及次数,对因永久性房颤行环肺静脉电隔离(CPVA)术治疗者,观察其转复窦性心律后房室传导阻滞发生情况。结果205例患者中203例(99.02%)出现≥1.5s长间期,24:00时至凌晨04:00时出现次数最多,10:00时至12:00时次之。62例接受CPVA术的永久性房颤患者均伴长RR间期,全部成功终止房颤转复窦性心律,术后心电图示6例Ⅰ度房室传导阻滞(AVB)(9.7%),未发现Ⅱ度AVB,3例因窦房结功能障碍置入永久起搏器。结论持续性/永久性房颤患者常见≥1.5s的RR长间期,绝大多数并非病理性房室传导阻滞所致。     

The assessment of autonomic function in chronic atrial fibrillation: description of a non-invasive technique based on circadian rhythm of atrioventricular nodal functional refractory periods.

AIMS: Heart rate variability (HRV) parameters can be used to assess autonomic function and to predict outcome, but this has been done exclusively in patients with sinus rhythm. Atrial fibrillation (AF) is the commonest sustained arrhythmia and is particularly prevalent in heart failure. We have developed a simple index to assess autonomic function in patients with chronic AF. METHODS AND RESULTS: Forty patients with chronic AF (>1 month) and symptoms of heart failure underwent ambulatory 24 h electrocardiography recording as well as evaluation of symptoms, exercise capacity (6 min walk distance), ventricular function (echocardiography and radionuclide ventriculography), and neuroendocrine activation. A number of standard HRV parameters shown to have prognostic significance in sinus rhythm were also determined. A modified in-house HRV statistical programme was used to filter labelled QRS intervals and to compute the 5th percentile RR interval in each hour. This parameter has been shown to approximate the functional refractory period (FRP) of the atrioventricular node (AVN). A cosine curve was fitted to hourly 5th percentile RR intervals for each patient and from this was estimated the diurnal change in hourly 5th percentile RR interval (approximating DeltaFRP of the AVN) and, by inference, diurnal variation in sympathovagal input to the AVN. Digoxin was the sole agent permitted for control of ventricular rate. DeltaFRP of the AVN varied and revealed a significant correlation, on multivariate analysis, with mean RR interval (P<0.001), SDARR (SD of 5-min average RR intervals during 24 h, P<0.001), and NYHA class of heart failure (classes III and IV heart failure vs. classes I and II, P=0.02). SDARR has previously been shown independently to predict mortality in patients with chronic AF and heart failure. CONCLUSION: This analysis describes a novel non-invasive method for assessing autonomic function in chronic AF. Whether DeltaFRP in chronic AF patients can independently predict adverse prognosis or sudden death requires further study.     

自主神经节丛消融对窦房结及房室结功能的急性期影响

目的探讨神经节丛(GP)消融对窦房结(SAN)及房室结(AVN)功能的影响。方法 7条犬开胸并在左、右心房及肺静脉缝置多极电极导管以备记录及刺激,对左侧及右侧GP分别进行消融,消融前后分别测定静息心率、SAN及AVN功能,SAN功能包括测定6个不同水平起搏周长(380,350,330,300,280及250 ms)时SAN恢复时间(SNRT)以及校正的SNRT(cSNRT);AVN功能包括AH间期(H is束电图记录的房室结传导时间)、递增起搏时出现文氏房室传导阻滞时起搏周长、出现2∶1房室传导阻滞时起搏周长、右房短阵超速起搏诱发心房颤动(简称房颤)时的平均心室率。结果 GP消融后窦性心率无显著改变,长起搏周长时SNRT及cSNRT无显著变化,而短起搏周长时则显著减少(P0.05)。各起搏周长下AH间期、出现文氏房室传导阻滞及2∶1房室传导阻滞时的起搏周长、房颤时平均心室率在GP消融前后均无显著变化。结论 GP消融在较短起搏周长情况下增强了SAN功能,但对AVN功能无明显影响,可能与GP消融时同时破坏了副交感及交感神经成分有关。     

心房颤动伴长R-R间期的临床意义

目的 探讨心房颤动伴长R-R间期的临床意义.方法 记录204例心房颤动患者环肺静脉隔离术（CPVA）前后的动态心电图,根据患者术后恢复窦性心律后的动态心电图有无二度房室传导阻滞分为：无二度房室传导阻滞组（A组）及二度房室传导阻滞组（B组）,分析两组平均心率、长R-R间期及逸搏心律的平均次数及R-R间期、逸搏心律的分布规律.结果 204例（A组193例,B组11例）心房颤动患者CPVA术后均成功转为窦性心律,两组R-R间期＞2.0s、R-R间期＞2.7s及逸搏心律平均次数比较,差异均有统计学意义（均P＜0.05）.A组中R-R间期＞2.0s及逸搏心律的分布与睡眠或休息有关,而B组中则日夜均可见.结论 不能单纯根据长R-R间期诊断心房颤动伴二度房室传导阻滞,只有R-R间期＞2.0s明显增多并出现R-R间期＞2.7s且心室率＜35 次 / min的逸搏心律（与睡眠或休息无关或伴有器质性心脏病）时,心房颤动伴二度房室传导阻滞的诊断才可能成立.     

心房颤动时高度或Ⅲ度房室阻滞的诊断

为探讨心房颤动（简称房颤）时高度或Ⅲ度房室阻滞（ＡＶＢ）的诊断。分析房颤伴高度或Ⅲ度ＡＶＢ患者的２４ｈ动态心电图,测定持续性房颤者的平均心率（ＨＲ）、最大ＨＲ（ＨＲｍａｘ）、最小ＨＲ（ＨＲｍｉｎ）、最大ＲＲ间期（ＲＲｍａｘ）及阵发性房颤发作时的ＨＲｍａｘ、ＨＲｍｉｎ、ＲＲｍａｘ,并分析阵发性房颤转为窦性心律时有无ＡＶＢ发生及其程度。持续性房颤伴高度ＡＶＢ者（ｎ＝６４）平均ＨＲ７４．３±１０．３ｂｐｍ,日间ＨＲｍａｘ１３８．６±２７．２ｂｐｍ、ＨＲｍｉｎ４２．９±１０．６ｂｐｍ,夜间ＨＲｍａｘ１１８．８±２７．９ｂｐｍ、ＨＲｍｉｎ３６．３±６．０ｂｐｍ,ＲＲｍａｘ２．５８９±０．５２９ｓ。持续性房颤伴Ⅲ度ＡＶＢ者（ｎ＝１５）平均ＨＲ６５．５±１３．９ｂｐｍ,日间ＨＲｍａｘ１２１．９±３９．２ｂｐｍ、ＨＲｍｉｎ４０．１±８．４ｂｐｍ,夜间ＨＲｍａｘ９９．０±３２．３ｂｐｍ、ＨＲｍｉｎ３３．１±５．０ｂｐｍ,ＲＲｍａｘ２．４９２±０．６６１ｓ。阵发性房颤者（ｎ＝１０）房颤时ＨＲｍａｘ１５４．７±２３．５ｂｐｍ、ＨＲｍｉｎ４３．２±４．８ｂｐｍ、ＲＲｍａｘ１．９２３±０．５９７ｓ,在转为窦性心律时,仅４例伴有Ⅰ度Ａ?     

Achieving regular slow rhythm during atrial fibrillation without atrioventricular nodal ablation: selective vagal stimulation plus ventricular pacing.

OBJECTIVES: The aim of this study was to achieve regular slow ventricular rhythm during atrial fibrillation (AF) without destroying the AV node (AVN). BACKGROUND: Recent experimental and clinical studies have demonstrated that selective AVN vagal stimulation (AVN-VS) can be used to slow ventricular rate during AF; however, an irregular rhythm remains. Alternatively, ventricular on-demand (VVI) pacing achieves rate regularization but at rates faster than the already fast intrinsic rate during AF. We hypothesized that AVN-VS combined with VVI pacing would achieve slow, regular rhythm during AF without requiring AVN ablation. METHODS: AF was induced in eight dogs. AVN-VS was applied to the epicardial fat pad that projects vagal nerve fibers to the AVN. A computer-controlled algorithm adjusted AVN-VS intensity to achieve three levels of mean ventricular RR interval: 75%, 100%, or 125% of the spontaneous sinus cycle length. At each of the three levels, concomitant VVI pacing was delivered at a constant cycle length equal to the corresponding target. Hemodynamic measurements were performed during the study to elucidate the advantages of the proposed method. RESULTS: AF resulted in rapid, irregular ventricular rates (RR = 287 +/- 36 ms, or 56% of sinus cycle length). AVN-VS achieved average ventricular rate slowing to the three target levels in all dogs (RR increased to 381 +/- 41, 508 +/- 54, and 632 +/- 68 ms, respectively). At each of the three target rate levels, AVN-VS combined with VVI pacing fully eliminated rate irregularities. The regular slow ventricular rhythms during AF were associated with significant hemodynamic improvement. CONCLUSIONS: A novel approach combining AVN-VS with VVI pacing results in a regular, slow ventricular rhythm during AF that does not necessitate AVN ablation. Rate regularization achieved by this approach was associated with pronounced hemodynamic benefits during AF.     

Effects of Atrioventricular Nodal Ablation on Permanent Atrial Fibrillation Patients With Cardiac Resynchronization Therapy: A Systematic Review and Meta‐analysis

Cardiac resynchronization therapy (CRT) is a well‐established therapy for patients with heart failure (HF) and wide QRS configuration, especially for those in sinus rhythm. However, for those with permanent AF, atrioventricular nodal (AVN) ablation use remains under debate. Our objective was to evaluate clinical outcomes and mortality of AVN ablation in HF patients with permanent AF receiving CRT. Electronic publication database and reference lists through October 1, 2013 were searched. Observational cohort studies comparing CRT patients with AF who received either AVN ablation or medical therapy were selected. Outcomes included mortality, CRT nonresponse, changes in left ventricular remodeling, and functional outcomes, such as New York Heart Association (NYHA) functional class, quality of life, and 6‐minute hall walk distance. Of 1641 reports identified, 13 studies with 1256 patients were included. Among patients with permanent AF and insufficient biventricular pacing (<90%), those who had undergone AVN ablation compared to those who did not had numerically lower all‐cause mortality (risk ratio [RR]: 0.63, 95% confidence interval [CI]: 0.42 to 0.96, P = 0.03) and significantly lower nonresponse to CRT (RR: 0.41, 95% CI: 0.31 to 0.54, P < 0.00001). Furthermore, AVN ablation was not associated with additional improvements on left ventricular ejection fraction, NYHA functional class, 6‐minute hall walking distance, and quality of life. In patients with permanent AF undergoing CRT, AVN ablation tended to reduce mortality potentially and improved clinical response when it was applied to patients with inadequate biventricular pacing (<90%). Randomized controlled trials are needed to further address the efficacy of AVN ablation among this population.     

Infranodal chronic auriculo-ventricular block in subjects under 50 years of age

The aetiology and evolution of chronic infranodal atrioventricular block (AVB) of young patients are not well known: are they the first sign of subclinical myocardial disease which can only be diagnosed by long term follow-up or do they represent isolated degenerative disease of the conduction tissue (Lenegre's disease)? Eighteen patients (15 men, 3 women) aged 25 to 49 years (average 41.5 years) were followed up for periods of 2 to 20 years (average 7.33 years) after pacemaker implantation for syncopal AVB. Follow-up was focused on the evolution of the conduction defects and the cardiovascular status. The patients were divided into two groups at the initial assessment: Group I: 15 patients with documented AVB; Group II: 3 patients in whom all basal recordings showed sinus rhythm (SR). Apart from one patient with an early non-ischaemic dilated cardiomyopathy, there was no previous cardiovascular disease. There was no history of ischaemic heart disease, drug effects, infection or inflammation in favour of an acute AVB. Three patients had permanent AVB, either 2nd degree with bundle branch block (N = 2) or 3rd degree block (N = 1). The other 15 patients were in sinus rhythm with bundle branch block: left bundle branch block (LBBB) in 5 cases, right bundle branch block (RBBB) in 3 cases; RBBB with left anterior hemiblock in 5 cases, RBBB and left posterior hemiblock in 2 cases. Paroxysmal AVB was recorded in 12 of these 15 patients on at least one occasion.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clustering of RR intervals predicts effective electrical cardioversion for atrial fibrillation

INTRODUCTION: Atrial fibrillation (AF) is characterized by an irregularly irregular ("random") heart beat. However, controversy exists whether the ventricular rhythm in AF is truly random. We investigated randomness by constructing three-dimensional RR interval plots (3D plots), allowing identification of "clustering" of RR intervals. It was hypothesized that electrical cardioversion (ECV) would be more effective in AF patients with clustering, because clustering might reflect a higher degree of organization of atrial fibrillatory activity. METHODS AND RESULTS: The study group consisted of 66 patients (44 men and 22 women; mean age 68 +/- 11 years), who were referred for ECV because of persistent AF. Twenty-four-hour Holter recordings were used to construct 3D plots by plotting each RR interval (x axis) against the previous RR interval (y axis) and the number of occurrences of each of these x,y combinations (z axis). A clustering index was calculated as the percentage of beats within the peaks in the 3D plot. Based on the 3D plots, clustering of RR intervals was present in 31 (47%) of the 66 patients. ECV was effective in restoring sinus rhythm in 29 (94%) of these 31 patients, whereas sinus rhythm was restored in only 25 (71%) of the remaining 35 patients without clustering (P = 0.020). The clustering index ranged from <2% in the 12 patients with failed ECV to >8% in the 32 patients with sinus rhythm at the end of the study (4 weeks after the ECV); the clustering index in the 22 patients with a relapse of AF after effective ECV was intermediate (P = 0.034 and P = 0.042, respectively). CONCLUSION: This study indicates that ECV is more effective in restoring sinus rhythm in AF patients with clustering compared to patients in whom no clustering is apparent on 3D plots. In addition, the degree of clustering appears to be predictive of the overall outcome of ECV; the higher the degree of clustering, the higher the likelihood of sinus rhythm at follow-up.     

植入型心电事件记录仪在不明原因晕厥中的应用价值:单中心经验

目的探讨植入型心电事件记录仪(ILR)在不明原因晕厥患者中的应用价值,并筛选可能的心律失常源性晕厥预测因素。方法连续入选2013年1月至2018年10月在大连医科大学附属第一医院诊断为不明原因晕厥,且植入ILR的患者37例,年龄(59±19)岁,男24例。植入后进行常规随访,每3~6个月进行1次随访,主要随访内容:症状、程控事件、是否发生晕厥。如患者发生晕厥,通知回院就诊,接受程控和心电学检查,分析晕厥病因及心律失常类型和相关危险因素。结果共22例(59.46%,22/37)患者记录到晕厥事件,其中9例为窦性心动过缓或窦性停搏,6例为三度或高度房室传导阻滞,1例为室性心动过速,2例为室上性心动过速,4例为心房颤动(房颤)伴RR长间歇(>2 s),在植入后(187.73±177.12)d发生晕厥事件。1例患者记录到房颤伴RR长间歇,但未发生晕厥。16例患者植入永久起搏器,1例患者植入心律转复除颤器,2例患者行导管消融治疗。对性别、年龄、合并基础疾病、植入前晕厥次数、心电信息等进行分析发现,动态心电图中存在RR长间歇(>2 s)是预测晕厥发作的影响因素。结论植入ILR可使不明原因晕厥患者获得明确诊断并接受相应治疗,ILR是明确晕厥病因的有效手段之一。动态心电图中存在RR长间歇(>2 s)是心律失常原因晕厥的重要预测因素。