His束逆传不应期心室早搏刺激鉴别间隔隐匿性旁道与房室结折返性心动过速

探讨His束逆传不应期心室早搏刺激法临床应用时的注意事项。 37例慢 快型房室结折返性心动过速(AVNRT)和 2 0例间隔部隐匿性快旁道引起的房室折返性心动过速 (AVRT)患者 ,成功消融前在常规行腔内电生理检查的同时均行His束逆传不应期心室早搏刺激法。结果 :心动过速时His束逆传不应期内心室早搏刺激 ,37例AVNRT患者心房激动无明显提前 ,2 0例AVRT心房被提前激动超过 2 0 (30～ 5 0 )ms ,其中 9例终止心动过速 ,此方法鉴别AVRT和AVNRT特异度、灵敏度较高。结论 :心动过速时His束逆传不应期行心室早搏刺激法鉴别诊断AVRT和AVNRT操作简单、准确性高。但行此法检查时要求有持续发作的心动过速 ;能够标测出清晰的His束电位 ;心室早搏刺激最好与His束电位同步发放 ;反复多次重复检测以进一步提高诊断的正确性     

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。     

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-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-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-快型房室结折返性心动过速,敏感性75%,特异性可达100%.结论希氏束旁刺激法对鉴别诊断AVRT与AVNRT有较高的特异性.     

希氏束旁起搏鉴别间隔部隐匿性房室快旁道的临床价值

目的:探讨希氏束旁起搏鉴别间隔部隐匿性房室快旁道的临床价值。方法:采用希氏束逆传不应期心室期前收缩刺激法,将142例患者诊断为慢-快型房室结折返性心动过速(AVNRT)74例和间隔部隐匿性房室折返性心动过速(AVRT)68例。对142例患者采用希氏束旁起搏方法进一步检测。结果:希氏束旁刺激法检测结果显示,74例AVNRT患者中8例未检测成功,其余66例均为逆传房室结图形;68例AVRT患者中6例未检测成功,其余62例患者中48例均呈逆传旁道/旁道图形,14例呈非逆传旁道/旁道图形。如果以逆传旁道/旁道图形为标准鉴别间隔部快旁道引起的AVRT与慢-快型AVNRT,敏感性为77%,特异性为100%。结论:希氏束旁刺激法对间隔部隐匿性房室快旁道的鉴别诊断有很高的特异性。     

不典型房室结折返性心动过速与房室折返性心动过速的电生理鉴别

房室结折返性心动过速(AVNRT)与房室折返性心动过速(AVRT)的鉴别有时较困难,尤其是不典型AVNRT与间隔旁道参与的AVRT鉴别,不典型AVNRT在心动过速发生时最早心房激动位于后间隔区域,与后间隔旁道引起的AVRT相似。通常检测房室结双径路的电生理方法仅能鉴别63%的不典型AVNRT。该文介绍了两者的主要电生理鉴别方法,包括希氏束旁起搏、在希氏束不应期给予心室期前程序刺激、心室或希氏束旁起搏后间期与心动过速周长之差(PPI-TCL)和刺激信号至心房波减去室房(SA-VA)间期的区别、校正的心室PPI-TCL和VA间期、心动过速时VA分离现象及TCL行心室起搏时的VA间期与心动过速时的VA间期之差等9种方法。     

同频率心尖部、心底部右中间隔区刺激鉴别间隔部隐匿性旁路和房室结双径路的作用

在诊断间隔隐匿性房室旁路时，希氏束逆传不应期心室早搏刺激法是目前诊断房室折返性心动过速(AVRT)重要的标准。但行此法检查时要求有持续发作的心动过速、心动过速时的周长保持恒定、心动过速时能够标测出清晰的希氏束电位，因此有时影响了其在临床上的广泛应用。国外学者Martinez—Aiday曾提出窦性心律时分别于心尖部和心底部起搏刺激，测起搏的V波与逆传的心房A波即VA间期的方法，以诊断间隔隐匿性旁路。现就我们采用此方法诊断鉴别的体会汇报如下。     

心室拖带中的室性融合波逆传心房对隐匿性间隔旁诊断价值的研究

目的探讨能够快速、准确鉴别室房传导途径的简便方法。方法选择射频消融(RFCA)的阵发性室上性心动过速(PSVT)患者共55例,55例患者在心动过速发作时,心内膜标测心房逆传激动顺序均为向心性分布,诱发心动过速后,以快于心动过速10～20次/min的频率起搏心室(RV)、观察心室被起搏刺激完全夺获之前的心室融合波是否伴有心房激动的提前或延迟,若有可诊断为间隔旁道逆传参与的房性折返性心动过速(AVRT),若无即可排除AVRT。结果心室拖带中室性融合波发生心房逆传,诊断间隔旁道参与的AVRT的敏感性为85.71%,特异性为91.89%,阳性预测值为100%,阴性预测值为91.89%,临床准确性为94.55%。结论心室拖带中室性融合波逆传心房是一种诊断间隔旁道参与的AVRT的重要方法,而且简便快捷、准确性高,值得临床推广应用。     

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。     

希氏束逆传不应期心室早搏刺激鉴别间隔隐匿性旁道与房室结折返性心动过速

目的探讨采用希氏束逆传不应期心室早搏刺激法临床应用时的注意事项.     

心室起搏拖带对房室结折返性和间隔旁路参与的房室折返性心动过速的鉴别作用

目的　研究心动过速时心室起搏拖带对房室结折返性心动过速 (AVNRT )和间隔旁路参与的顺向型房室折返性心动过速 (间隔旁路ORT)的鉴别意义。方法　 30例AVNRT和 2 5例间隔旁路ORT病人在心动过速发生后 ,采用较心动过速的周长 (TCL)短 10～ 4 0ms的周长行右心室起搏拖带心动过速。测量右心室起搏之前的心室 心房 (VA)间期和TCL。停止起搏后 ,测量最后一次刺激信号至最后起搏拖带的心房激动 (SA)间期 ,以及起搏后间期 (PPI)。结果　所有 30例AVNRT病人的SA -VA间期 >85ms、PPI-TCL >115ms,而 2 5例ORT病人的SA -VA间期 <85ms、PPI-TCL <115ms。结论　PPI TCL和SA VA间期是鉴别AVNRT和间隔旁路ORT的非常可靠的指标 ,具有较高的特异性。     

Changes in right ventricular ejection fraction in right coronary angioplasty

In order to analyse the response of the right ventricule (RV) to transient myocardial ischaemia, the RV ejection fraction was measured using a new rapid response thermodilution catheter in 15 patients (14 men and 1 woman: average age 58 +/- 7 years) referred for percutaneous transluminal coronary angioplasty of a dominant right coronary artery. Only patients with single vessel disease with a proximal stenosis of the right coronary without a visible collateral circulation who had no previous history of myocardial infarction were included. Right heart catheterisation was performed with a rapid-response thermodilution catheter which enabled measurement of heart rate, cardiac index, RV end-diastolic and end-systolic volumes and RV ejection fraction. Angioplasty was carried out with the usual steerable balloon catheters. During balloon inflation, there was a slight increase in RV end-diastolic volume (from 78 +/- 11 ml/m2 to 85 +/- 13 ml/m2 at 60 seconds; p less than 0.01) and a large increase in RV end-systolic volume (from 29 +/- 8 ml/m2 to 35 +/- 8 ml/m2 at 30 seconds and 43 +/- 11 ml/m2 at 60 seconds, p less than 0.001) leading to a significant decrease in RV ejection fraction (from 62 +/- 8% to 56 +/- 6% at 30 seconds and 51 +/- 7% at 60 seconds; p less than 0.001). All parameters returned to basal values two minutes after the dilatation. Acute occlusion of the proximal segment of the right coronary artery is therefore associated with a marked change in right ventricular function which rapidly returns to normal after the coronary circulation is restored.     

Synovial sarcoma in the right atrium and right ventricle

A metastatic synovial sarcoma in the right atrium and ventricle is described. A 36-year-old man was admitted to our hospital with generalized fatigue, dyspnoea, and precordial pain. Transthoracic echocardiography demonstrated a metastatic tumour in both the right atrium and right ventricle and revealed obstruction of the inflow tract of the right ventricle caused by a metastatic right atrial tumour. Thoracic computed tomography revealed a pleural-based paravertebral mass in the left intrathoracic cavity and multiple pulmonary nodules in both lungs. Cardiac surgery was performed for palliative treatment due to right cardiac failure and a risk of fatal embolization. The patient died 12 months after the cardiac surgery.     

Usefulness of echocardiographic right ventricular measurements in estimating right ventricular hypertrophy and right ventricular systolic pressure

Right ventricular wall thickness (T) measurements were made in 111 patients by echocardiography to evaluate their usefulness in diagnossing right ventricular hypertrophy (RVH) and in predicting right ventricular peak systolic pressure (P). Anatomic and echocardiographic findings of RVH were compared in 36 of 111 subjects: diastolic T (dT) and systolic T (sT) had a sensitivity of 90 and 34% and a specificity of 94 and 100%, respectively, in the diagnosis of RVH. Echocardiographic and hemodynamic findings were compared in the remaining 75 of 111 patients undergoing cardiac catheterization: dt was 6.5 +/- 2.7 mm in 46 patients with elevated P (58.2 +/- 30.2 mm Hg) versus 3.8 +/- 0.9 in 29 patients with normal P (26.3 +/- 2.7 mm Hg) (p less than 0.01). The dT and P had a linear correlation (r = 0.92) in 40 patients with right ventricular end-diastolic dimension less than 13 mm/m2. Estimates of P in 22 patients with atrial septal defect and right ventricular end-diastolic dimension greater than 13 mm/m2 were fairly good (r = 0.83). It is concluded that echocardiographic measurements of T are useful in diagnosing RVH and in estimating P.     

Diagnostic accuracy of right ventriculography in arrhythmogenic right ventricular cardiomyopathy

Diagnostic sensitivity and specificity of cineangiography were evaluated by multivariate logistic discriminant analysis in 32 patients with arrhythmogenic right ventricular (RV) cardiomyopathy, 27 patients with biventricular dilated cardiomyopathy, 28 patients with atrial septal defect and 18 normal subjects. In patients with arrhythmogenic RV cardiomyopathy and biventricular dilated cardiomyopathy, the diagnosis was confirmed by endomyocardial biopsy. All RV values overlapped for the diagnosis of atrial septal defect and arrhythmogenic RV cardiomyopathy; overlapping extended to dilated cardiomyopathy for end-diastolic volume and infundibular dimensions. RV ejection fraction appeared reduced in all the diseases; in particular, mean values in dilated cardiomyopathy and arrhythmogenic RV cardiomyopathy were 38 and 53%, respectively (p less than 0.05). Left ventricular quantitative studies showed a significant difference between dilated and arrhythmogenic RV cardiomyopathy, both in terms of pumping indexes (mean end-diastolic volumes 180 vs 91 ml/m2 and mean ejection fraction 33 vs 60%), and indexes of contractility (stress/end-diastolic volume 3.7 vs 6.7). Multivariate analysis disclosed that transversally arranged hypertrophic trabeculae, separated by deep fissures, were associated with the highest probability of arrhythmogenic RV cardiomyopathy (p less than 0.001). Posterior subtricuspid and anterior infundibular wall bulgings were the only other independently significant variables. Coexistence of these signs was associated with 96% specificity and 87.5% sensitivity. Thus, arrhythmogenic RV cardiomyopathy presents quantitative volumetric and hemodynamic as well as qualitative features that clearly distinguish it from dilated cardiomyopathy and confirm its nosographic autonomy among the primary diseases of the myocardium.     

Predominant right ventricular dysfunction after right ventricular destruction in the dog

Right and left ventricular function was assessed by observing the response to rapid blood volume expansion before and after extensive cauterization of the right ventricle in open chest dogs. In the control period, left ventricular end-diastolic pressure surpassed right ventricular end-diastolic pressure by an average of 11.5 mm Hg after volume expansion whereas, after destruction of the right ventricle, pressure in this chamber surpassed pressure in the left ventricle by an average of 4 mm Hg. In contrast, after left ventricular damage, left ventricular end-diastolic pressure averaged 25 mm Hg more than right ventricular end-diastolic pressure. Despite extensive damage to the right ventricular free wall, the right ventricle continued to generate a near normal pressure and aortic flow could be increased above control levels by volume expansion. We conclude that, in contrast to previous evidence, damage to the right ventricle produces a syndrome of predominant right ventricular dysfunction. However, cauterization of the entire free wall of the right ventricle does not reproduce the more profound right ventricular dysfunction noted in infarction of the right ventricle in man.     

双支右冠状动脉并右房瘘一例

患男,43岁。因“活动后胸闷、乏力、气急5年,加重1年”入院。患5年前无明显诱因下开始出现恬动后胸闷、乏力、气急,休息后缓解。近1年来症状较以前明显加重,以“冠状动脉粥样硬化性心脏病,高血压病2级”收入院。体格检查：血压165／96mmHg（1mmHg=0．133kPa）．心率76次／min,心界稍向左扩大,心律齐,心尖区可闻及2／6级收缩期杂音,不传导,无震颤。     

Angiographic right and left ventricular function in arrhythmogenic right ventricular dysplasia

We prospectively documented right ventricular (RV) and left ventricular (LV) volumes and ejection fractions in a large series of patients with arrhythmogenic RV dysplasia/cardiomyopathy (ARVD/C). Eighty-five patients with ARVD/C and 11 controls underwent 2 successive orthogonal right and left monoplane x-ray-digitized cineangiographies. Volumes were calculated using the hemielliptical RV and ellipsoidal LV models. All controls and 58 of 85 patients (ARVD/C-I) had a RV ejection fraction > or =35% and 27 patients had a RV ejection fraction <35% (ARVD/C-II). Tricuspid annulus plane systolic excursion (TAPSE) was lower in ARVD/C-II than in ARVD/C-I patients (6 +/- 3 vs 14 +/- 3 mm) and controls (16 +/- 2 mm) (each p <0.001). In patients with ARVD/C, TAPSE was positively related to RV ejection fraction (r = 0.79) and to crista supraventricularis shortening (r = 0.81) (each p <0.001). Sensitivity and specificity of TAPSE <12 mm in identifying patients with RV ejection fraction <35% were 96% and 78%, respectively. LV ejection fraction was > or =50% in 68 patients, 40% to 49% in 10, and <40% in 7. Diffuse RV outflow tract aneurysm was observed in 9 patients, all belonging to ARVD/C-II, and this sign identified patients with LV ejection fraction <40% with 86% sensitivity and 96% specificity. In conclusion, 68% of ARVD/C patients had normal RV ejection fraction and RV volumes, and 80% of ARVD/C patients had normal LV ejection fraction. Decreased TAPSE <12 mm and a diffuse RV outflow tract aneurysm were sensitive and specific indicators of RV ejection fraction <35% and LV ejection fraction <40%, respectively.     

Significance of right precordial ST elevation in experimental right ventricular infarction

We produced experimental isolated right ventricular infarction (RVI) with closed chest method, and examined ECG changes of right precordial leads and changes of cardiac output (C. O) in 19 dogs. As a result, ECG showed ST depressions in leads, II, III, aVF and V2-V6 and ST elevations in a VR lead in all 15 cases of the proximal occlusion of right coronary artery (RCA). In 10 of 15 dogs ST elevations in some right precordial leads occurred, and the sensitivity of ST elevation in single right precordial lead was 60% (V5R), 53% (V4R) and 47% (V3R and V1), respectively for the detection of RVI. When left circumflex artery (LCX) was occluded, ST elevation in V4R lead after RCA occlusion was blocked. Therefore, it is thought that the sensitivity of ST elevation in right precordial lead may be lower than expectation in identifying RVI. Concerning anterior chest leads, none of 15 dogs with RVI showed ST elevations in leads V2-V6 in this study. If ST elevations in right precordial leads did not appear, variation of C.O was small and C.O reduced in proportion to the extension of ST elevations in right precordial leads.