起源于上腔静脉房性心动过速的心电图特征及导管射频消融治疗

目的 探讨起源于上腔静脉房性心动过速(AT)的12导联体表心电图特征及导管射频消融(RFCA)治疗.方法 对3例上腔静脉起源AT患者行RFCA治疗,并分析其12导联体表心电图的特征.结果 3例患者经RFCA治疗均即刻成功,AT的最早起源位于上腔静脉内,消融有效靶点距其口部分别为0.5、1.0、2.0 cm,双极心内电图A-P1间期分别为54、35、40 ms.P1波形态在Ⅰ、Ⅱ、Ⅲ、avF、Ⅴ,导联为正向,avR、avL导联为负向.结论 RFCA治疗上腔静脉起源的局灶性AT安全有效.掌握其体表心电图特点有助于RFCA术前初步判定其起源部位,缩短手术时间、提高成功率.     

起源于肌袖的房性心律失常的心电图与动态心电图特征

在临床工作中 ,心房早搏 (房早 )、房性心动过速(房速 )、心房扑动 (房扑 )、心房颤动 (房颤 )是常见的心律失常。然而 ,随着对房性心律失常解剖机制与电生理机制研究的进展 ,以及对其各种心电现象更加细致的分析 ,发现一些起源于心脏大静脉肌袖的房性心律失常有其独特的心电图特点、相似的临床特征、一致的电生理和解剖机制以及共同的转归———心房颤动 ,尤其可以通过导管射频消融肌袖电隔离技术得到根治 ,因此我们对这种房性心律失常提出了一个新的命名———肌袖性房性心律失常。现将这一类心律失常的心电图和动态心电图的特点总结如下 …     

心房颤动射频消融术中转为规则房速的机制

肺静脉消融对于药物治疗无效的房颤患者是一种有效的治疗方法[1],由于导管射频消融治疗房颤效果显著,安全可靠,已经被广泛推荐为房颤治疗的首选方案,然而射频消融术的过程中常伴有较多的并发症,如左房食管瘘、心包填塞、房性心动过速等[2],已有报道术中发生规则房速的概率为10%~75%[3-6].     

右室流出道室性早搏及特发性室性心动过速的导管射频消融治疗

目的 探讨导管射频消融治疗右室流出道室性早搏及特发性室性心动过速(室速)的方法及有效性. 方法 对9例右室流出道频发室性早搏和(或)室速采用激动标测与起搏标测相结合的方法,1例左室间隔面室速采用激动标测普肯耶(P)电位方法进行导管射频消融治疗.术前根据体表心电图初步判断起源部位. 结果 10例患者全部消融成功,随访1～27个月,平均(11.9±10.3)个月,无一例复发,亦无手术相关并发症发生.起源部位:7例位于右室流出道间隔,2例位于右室流出道游离壁,1例位于左室中间隔. 结论 采用激动标测结合起搏标测消融右室流出道室性早搏、特发性室速有效且成功率高;对部分术中未能诱发出心动过速的左室间隔面室速,仅在窦性心律下标测最早P电位,亦可能成功.     

射频消融治疗顽固性室性早搏疗效评价

目的探讨单导管射频消融治疗顽固性室性早搏（室早）的安全性、有效性和方法学。方法对16例药物治疗无效的顽固性室性早搏患者进行单导管射频消融治疗,术前根据同步12导联体表心电图VPC的形态初步判断室早起源部位,术中依据初步判断的结果采用起搏标测与心室激动顺序标测相结合的方法对室早进行标测定位,消融电极起搏心电图QRS波图形与室早图形11／12以上一致时或消融电极标测到室早最早激动点较体表心电图QRS波提前30ms以上及单极腔内图记录到完全负向波时放电消融。结果14例患者导管射频消融成功,消融成功率为88％,术前室早数量（23586±643）个／24h,术后5d室早数（530±95）个／24h（P〈0．01）,无手术相关并发症。1个月后随访,复发2例,其余患者自觉症状明显改善。结论单导管射频消融治疗室性早搏安全、有效并节省费用,体表心电图和单极腔内心电图对VPC的定位和消融具有较高的实用价值,值得临床推广应用。     

三尖瓣环近希氏束起源室性期前收缩心电图特点及射频消融

目的研究起源于三尖瓣环近希氏束室性期前收缩的临床心电图特点及电解剖标测(Carto)指导下射频消融结果。方法选择2009年5月～2012年2月起源于三尖瓣环近希氏束的频发室性期前收缩患者7例,在Carto指导下非冷盐水灌注导管行射频消融,分析其体表心电图特点、心内电图及消融结果。结果 7例患者Ⅱ导联均为正向;Ⅲ导联4例正向,2例负正双向,1例负向;aVF导联均为正向,振幅较低;I导联均为正向;aVL导联为正向或正负双向。胸前导联3例移行于V2-V3导联,4例移行于V3-V4。成功射频消融靶点V波提前于体表心电图QRS波22～58ms,平均(37.3±13.2)ms,消融靶点距离希氏束6.7～10.7mm,平均(8.9±1.4)mm,1例消融过程中出现交界区心律,所有患者射频消融成功,术中、术后无并发症发生。结论三尖瓣环近希氏束起源的室性期前收缩具有一定的心电图特点,在Carto三维标测指导下可以成功射频消融。     

心房重构及P波离散度与房性心律失常相关性探讨

本文探讨心房重构对房性心律失常的影响及P波离散度变化的意义。作者根据超声心动图结果将128例患者分成左房扩大组、右房扩大组及心房内径正常组。用24h动态心电图记录所有患者房性心律失常发生情况并根据Kleigar分级标准分为轻度及复杂心律失常组；同时记录窦性心律时十二导联心电图P波离散度（Pd）。结果显示，心房增大尤左房扩大是引起心房电生理紊乱、产生房性心律失常的重要因素之一。     

心电图辅助下中心静脉导管定位的临床应用

目的探讨根据右心房内心电图的变化辅助中心静脉导管尖端定位的可行性。方法选取38例择期行心脏手术的患者,常规进行右侧颈内静脉穿刺,依据右心房内心电图的P波变化确定中心静脉导管置管深度,术后拍胸部正位x线片。对置管深度与患者身高进行相关性分析。结果38例患者中,2例因心房颤动导致无特征性P波出现而放弃观察,2例因心电图受到不明原因干扰而放弃观察。置管成功率为91．2％（31／34）。置管深度与患者身高之间无相关性（t=-0．580,P〉0．05）。结论心电图辅助下中心静脉导管定位,方法简便易行,置管成功率高,有一定的临床意义。     

下壁导联“钩形R波”对继发孔型房间隔缺损的诊断价值评价

目的 评价心电图下壁导联中出现＂钩形R波＂对继发孔型房间隔缺损的诊断价值.方法 回顾性分析60例经心脏彩超证实患有继发孔型房间隔缺损并已行心导管封堵或手术修补患者的术前及术后心电图,取48例心脏彩超检查未发现房缺的其他心脏病住院患者的心电图为对照组,分别记录两组心电图下壁导联＂钩形R波＂的数目,进行统计分析.结果 （1）房缺组和对照组在下壁导联出现＂钩形R波＂的数目之间差异有统计学意义（P〈0.01）.（2）依据下壁导联中出现＂钩形R波＂来诊断继发孔型房缺,其灵敏度、特异性、诊断符合率、阳性预测值和阴性预测值分别为75%、88%、81%、88%和74%.（3）术后＂钩形R波＂的消失率为45%.结论 下壁导联＂钩形R波＂的出现有助于诊断继发孔型房间隔缺损.     

具有Mahaim纤维特性的左侧旁道电生理特征和射频消融

目的 探讨具有Mahaim纤维特性的左侧旁道电生理特征和射频消融.方法 28例经射频消融治疗具有Mahaim纤维特性的旁道,其中3例是具有Mahaim纤维特性的左侧旁道,均为男性,年龄分别为34、20、38岁,心动过速发作史1～5年.通过10极冠状窦电极导管、高位右房电极导管、房室束电极导管和消融导管记录其电生理检查结果、靶点位置,并观察体表心电图.结果 窦性心律时心电图1例有轻微预激,2例正常;心房刺激出现与心动过速一致的宽QRS波(右束支阻滞或类似右束支阻滞),可见旁道前传文氏现象,室房逆传呈向心性递减传导,心动过速时房室束电图呈V-H-A顺序,逆传A波以房室束处最早,三磷酸腺苷可阻断旁道前传.窦性心律下,3例患者分别在左中后间隔、左后间隔、左前游离壁处放电消融阻断旁道.其中1例诊断为结室旁道,2例诊断为房束旁道.结论 Mahaim纤维特性的左侧旁道极少见,有特殊的电生理特征,射频消融能治疗成功.     

Electroanatomical mapping and radiofrequency ablation of tachycardia originating in pulmonary vein in an adult patient

A 29-year-old male was admitted to our outpatient clinic because of palpitation and documented narrow QRS arrhythmia. Based on the ECG, supraventricular tachycardia was diagnosed, electrophysiological examination was indicated and ablation therapy was recommended. During positioning of the catheter the patient developed arrhythmia. On the coronary sinus catheter the activation spread from distal to proximal electrodes, suggesting left atrial origin. During atrial entrainment pacing long return cycle was observed and distal coronary sinus pacing resulted in a 15 ms longer cycle length than the arrhythmia. Therefore, the left atrial origin of the arrhythmia was confirmed and double transseptal puncture was performed. Lasso and irrigated tip catheter were introduced into the left atrium and electroanatomical mapping was performed with CARTO3 system. After electroanatomical mapping the origin of tachycardia was located proximally in the left superior pulmonary vein. Ablation was started at the earliest activation point, where acceleration was observed and the arrhythmia stopped after the first ablation. Pulmonary vein isolation was completed, and bidirectional block could be confirmed. After 30 minutes the arrhythmia was not inducible. During follow-up, Holter-examination was negative and the patient remained asymptomatic. The pulmonary vein tachycardia is a supraventricular arrhythmia that can occur at any age, but the diagnosis based on the ECG is not always simple. Detailed electroanatomical mapping is very important in the diagnosis of this type of arrhythmia, although it can be verified with conventional electrophysiological methods as well. Focal ablation may be a therapeutic option; however, total isolation of pulmonary veins can be more effective.     

上腔静脉综合征的诊断与外科治疗

目的：探讨上腔静脉综合征（superior vena cana syndrome,SVCS）的外科诊疗经验,提高手术成功率。方法：上腔静脉综合征病例7例,手术切口采用右胸后外侧切口4例,胸骨正中切口3例。行根治性右全肺切除加上腔静脉（SVC）置换术3例,姑息性右肺上叶切除加左无名静脉与存b耳旁路搭桥术1例,纵隔肿瘤部分切除加左无名静脉与右心耳旁路搭桥术2例,纵隔炎性病变行左无名静脉与右心耳旁路搭桥术1例。5例采用绦纶人造血管,2例采用螺旋形的自体大隐静脉。结果：本组无手术死亡及严重手术并发症。通过采取SVC置换术、左无名静脉与右心耳旁路搭桥术,平均压由术前28．4cm H2O降至术后的9．5cm H2O。患者SVCS症状一般在3d内消失。凡良性疾病引起的上腔静脉阻塞均得到根治,恶性肿瘤所致上腔静脉阻塞手术后改善了患者生存质量。结论：任何疾病所致上腔静脉阻塞,选择性采取手术治疗是必要的。尽量缩短上腔静脉阻断时间,以减轻对脑组织的损害。在人工血管置换时,可采用先吻合近心端的方法,即将肿瘤游离后不切断上腔静脉,先完成人工血管与右心耳的吻合后,再阻断SVC,切除肿瘤,最后行人工血管与SVC远端的端端吻合,这样可显著缩短上腔静脉阻断时间,可有效预防脑组织损害。     

Superior vena caval obstruction in patients with gut failure receiving home parenteral nutrition

Clinical suspicion and venographic conformation were used to diagnose 15 cases of superior vena caval obstruction (SVCO) in 107 home parenteral nutrition (HPN) patients over 379 cumulative years of HPN (3.9 cases/100 patient-years). Patients with SVCO had been on HPN a mean of 51.5 months and had used 6.2 (range 1-50) central catheters, including short- and long-term, before SVCO was diagnosed. The frequency of inflammatory bowel disease (IBD) with SVCO was approximately the same as that in our general HPN population. Positive blood cultures were present immediately preceding the diagnosis of SVCO in 40% (six of 15) of cases. Atypical line placements were noted in two cases. The most common management strategies employed were conversion to enteral feedings in five patients and placement of a new catheter directly into the right atrium by thoracotomy in another five patients. Two of the five with right atrial catheters experienced a postpericardiotomy syndrome (fever, pericardial rub, and pulmonary infiltrates) that responded promptly to indomethacin. The most significant long-term sequela of SVCO was the need for a left jugular vein to right atrial appendage bypass in one patient with chronic venous congestion from her SVCO. Once the SVCO is confirmed, systemic heparinization provides immediate antithrombotic effect and minimizes the risk of pulmonary embolism. The use of streptokinase may result in rapid thrombolysis.     

中心静脉置管在危重病人抢救中的应用

目的报告该院自1992年以来,在危重病人抢救时采用中心静脉穿刺置管,快速建立输液的静脉通道216例的体会。     

Histopathology of the heart conducting system in experimental Chagas disease in mice

Although mice infected with Trypanosoma cruzi develop a wide variety of electrocardiographic (ECG) alterations, the typical isolated right bundle branch block or its association with the left anterior hemiblock patterns are not found in this model. This has been explained as related to topographic differences in the anatomy of the murine conducting system. However, there is no conclusive evidence that the murine conducting system differs from the human system. In this study, the anatomy of the murine conducting system is described, as well as its involvement in the chronic stages of experimental infection. 24 three-month-old C3H mice were infected with 50 bloodstream forms of T. cruzi, Tulahuén strain. Animals were killed after 3, 8 and 12 months. Whole frontal sections of the heart, including the conducting system, were serially studied. The sinoatrial node was located in the right atrial appendage, or in the junction between the superior vena cava and the right atrium, or "riding" on the interatrial septum. The atrioventricular (A-V) node and the His bundle showed a similar anatomic course to that in man. Therefore, there was no important anatomical difference that might have explained the lack of the ECG patterns observed in human chagasic myocardiopathy. The inflammatory involvement and the lesions of the conducting system were diverse and rarely severe. No significant difference was observed in animals killed at different times. The lesions in the working myocardium were similar to those observed in humans (chronic inflammatory infiltrates). Nevertheless, the topography of lesions was different: there was a selective involvement in the neighbourhood of the A-V groove.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pulmonary vein isolation by circumferential radiofrequency lesions in atrial fibrillation. From substrate to clinical outcome

Circumferential ablation around pulmonary vein ostia by CARTO system was performed in 98 patients with paroxysmal and 29 with permanent atrial fibrillation (AF). Preablation and postablation activation, propagation and voltage maps were obtained. A total of 135 +/- 18 radiofrequency pulses were delivered. After a follow-up of 14.7 +/- 3.3 months, 84 patients with paroxysmal and 22 with chronic AF are in sinus rhythm and 75 of them without antiarrhythmics. Only the area extent of low voltage potentials within and just around the lesions distinguished patients with and without successful ablation. Pulmonary vein isolation is an effective procedure to cure resistant AF; the extent of lesion area around pulmonary vein ostia may be crucial in predicting the outcome.     

环肺静脉电隔离消融与药物治疗心房颤动对患者生活质量影响的研究

目的评价环肺静脉电隔离消融与药物治疗心房颤动对患者生活质量的影响。方法113例心房颤动患者,分别采用环肺静脉电隔离消融与抗心律失常药物治疗,其中消融组58例,药物组55例,进行随访,6个月后采用SF-36量表问卷调查方式对两组患者生活质量进行评价。结果平均随访（14．7±5．3）月,消融组维持窦性心律者33例,成功率56．9％,药物组维持窦性心律者14例,成功率25．5％。两组患者治疗6个月后SF-36量表中除肌体疼痛差异无统计学意义外,躯体功能、躯体角色、总的健康状况、活力、社会功能、情感角色和心理健康,消融组较药物组均有明显改善（P〈0．05）。结论环肺静脉电隔离消融较抗心律失常药物治疗房颤能明显提高患者的生活质量。     

组织多普勒成像评价室间隔缺损合并肺动脉高压手术前后右室功能的研究

目的探讨应用组织多普勒成像定量评价室间隔缺损合并肺动脉高压手术前后右室功能的临床价值。方法 56例VSD患者分为PH(+)组(n=33)和PH(-)组(n=23)。应用组织多普勒成像技术于手术前及手术后1个月、6个月分别测量两组的三尖瓣环Sa、Ea与Aa、右室IVCT、IVRT、ET、Tei指数。结果两组手术后1个月及6个月的左室舒张末期内径、左房内径及肺动脉收缩压均小于术前,差异有统计学意义(p<0.05)。在PH(-)组,术后6个月肺动脉收缩压低于术后1个月,差异有统计学意义(p<0.05),术后6个月三尖瓣环Sa高于术前,差异有统计学意义(p<0.05)。在PH(+)组,术后6个月的IVRT、Tei小于术前,术后6个月的ET大于术前,差异有统计学意义(p<0.05)。结论组织多普勒成像技术能定量评价室间隔缺损合并肺动脉高压患者手术前后右室功能的变化,判定肺动脉高压对预后的影响。     

An Incidentally Discovered Left Atrial Appendage Membrane: Case Report and Literature Review

The left atrial appendage (LAA) is an extension of the left wall of the atrium and its close anatomic relationship to the free wall of the left ventricle gives it anatomic characteristics distinct from the left atrium. To date, only seven cases involving a LAA membrane have been described. A patient with an incidentally discovered, partially obstructive membrane at the orifice of the LAA, causing functional stenosis is presented, and our case is compared to those in the existing literature.The clinical significance of LAA membranes remains unknown. These rare membranes are usually an incidental finding on transesophageal echocardiogram during evaluation of an atrial dysrhythmia. It is not clear if these membranes could be promoting atrial fibrillation or if the association is merely a result of sampling bias. These membranes may also affect cardioembolic risk. Finally, the increasing use of percutaneous catheter-based therapies such as radiofrequency ablation and occlusion of the left atrial appendage, will likely result in the increasingly frequent identification of these membranes, and when present may increase the technical difficulty associated with these catheter-based therapies.     

阵发性心房颤动患者血清炎性因子水平及其来源

目的 探讨阵发性心房颤动患者肿瘤坏死因子（TNF）-α、白细胞介素（IL）-6和可溶性肿瘤坏死因子受体1 （sTNFR1）的变化及其可能来源.方法 连续采集30例行射频消融术治疗的阵发性心房颤动患者（阵发性心房颤动组）股静脉、高位右房、冠状窦及左房血液样本,酶联免疫吸附法检测血清TNF-α、sTNFR1和IL-6水平,与相同部位采血的20例阵发性室上性心动过速患者（阵发性室上性心动过速组,左侧旁路）进行比较.结果 阵发性心房颤动组股静脉、高位右房、冠状窦及左房血清TNF-α和IL-6水平较阵发性室上性心动过速组增高[TNF-α：（4.45±1.76） ng/L比（0.59±0.36） ng/L、（6.67±1.43） ng/L比（0.51±0.30） ng/L、（8.35±2.03） ng/L比（0.85±0.50） ng/L、（9.97±2.70） ng/L比（0.28±0.29） ng/L;IL-6：（2.02±0.87） ng/L比（1.04±0.63） ng/L、（1.51±0.68） ng/L比（0.74±0.26） ng/L、（2.00±0.51）ng/L比（0.88±0.35） ng/L、（1.32±0.47） ng/L比（0.48±0.28） ng/L],差异有统计学意义（P=0.000）.阵发性心房颤动组高敏C反应蛋白（hs-CRP）水平高于阵发性室上性心动过速组[（2.41±1.35） mg/L比（1.10±0.53） mg/L,P=0.002].阵发性心房颤动组左房TNF-α水平较其他三个部位增高,差异有统计学意义（P=0.000）;IL-6水平在股静脉和冠状窦增高,与高位右房和左房比较差异有统计学意义（P＜ 0.05）; sTNFR1水平在股静脉、高位右房、冠状窦比较差异无统计学意义（P＞0.05）,但均高于左房,差异有统计学意义（P＜0.05）.各部位血清TNF-α、IL-6水平及肘静脉hs-CRP水平与左房内径（LAD）存在相关性（P＜ 0.01或＜0.05）;左房sTNFR1水平与LAD呈正相关,而右房sTNFR1水平与LAD呈负相关（P＜0.01）.结论 阵发性心房颤动患者血清hs-CRP、TNF-α及IL-6水平增高,心房颤动患者TNF-α、IL-6水平增高可能来源于心肌分泌,并与左房增大有关.