窦性心律时心电图对预激综合征旁道定位诊断的价值

关于心室预激的预激综合征(WPW 综合征)的既往研究表明,当 QRS 间期>140msec,心室预激程度可能最大,delta 波图形有助于旁道的定位.本文作者近期研究证实,窦性心律时即使心室预激未达最大程度,心电图对旁道定位诊断仍有重要价值。76例 WPW 综合征病人,均无多旁道和器质性心脏病,未服任何抗心律失常药物。全部病人作过电生理导管心内膜标测,其中45例手术治疗中进行计算机心外膜标测。将上述标测定位诊断结果与心电图对照,45例手术病人的心内膜与心外膜标测结果一致,仅30%病人的心电图 QRS 间期>140msec。     

多普勒组织成像对预激旁道的定位初探

目的 :评价多普勒组织成像 (DTI)探测显性预激旁道的准确性及其临床应用价值。方法 :9例临床明确诊断为预激综合征致阵发性房室折返性心动过速的患者 ,应用DTI寻找到与心电图δ波起始部同步出现的心室内异位兴奋点 ,与心内电生理检查和射频导管消融术的标测靶点相比较。结果 :DTI对 9例患者房室旁道的定位除 1例位置偏前外其余都与心内电生理检查相吻合 ,对 1例存在双侧旁道的患者更体现了DTI的指导意义。结论 :在DTI的帮助下 ,医患双方接受的射线量减小 ,手术操作时间缩短 ,消融彻底无复发。     

多普勒组织成像加速度模式对显性旁道定位价值

目的探讨二维多普勒组织加速度图（2D-Doppler tissue acceleration，2D-DTA）技术对预激综合征（wolf-parkinson—white syndrome，WPW）旁道定位的可行性和准确性。方法选择60例体表心电图诊断为WPW的患者，在行导管射频消融（radiofrequency catheter ablation，RFCA）术前，采用2D-DTA初步确定旁道位置即最早心室激动点，并以心内膜靶点准确定位标测做对照。结果DTA技术所确定的心室最早激动亮点出现时限与同步记录的心电图δ波出现时限完全相同，DTA技术对旁道定化的准确性79％。结论DTA能比较直观地确定旁道位置，评价RFCA的效果，该技术无创、安全、重复性良好，为心内电生理标测技术有益的补充。     

显性预激合并束支阻滞与P-J间期变化2例

例 1　男 ,68岁。 A型预激综合征 ,心内电生理标测旁道位于左后游离壁 ,消融前心电图 (图 1上 )示 :窦性心律 ,P- R间期 <0 .1 2 s,QRS时间 0 .1 2 s,QRS波群初始部有δ波 ,V1,3,5导联δ波与 QRS波群主波方向一致 ,均呈正相 ,V1导联呈 R型 ,P- J间期 0 .2 4 s(本文所测均在 导联 ) ;室上性心动过速发作时呈左束支阻滞 (图 1中 ) ;消融后心电图 (图 1下 )为 :窦性心律 ,P- R时间 0 .1 6s,QRS时间 0 .1 6s,P- J间期 0 .30 s,V1导联呈 QS型 ,V5导联 R型。图 1　例 1的心电图　　例 2　男 ,45岁。 A型预激综合征 ,心内电生理标测旁…     

经冠状静脉窦消融心外膜旁道一例

患者女性,58岁,阵发性心悸30年,心电图示A型预激,心内电生理检查为左后间隔显性旁道。经心内膜途径多次标测和消融均失败,改经冠状静脉窦内标测和消融成功。结论:冠状静脉窦消融可以成功的阻断心外膜侧旁道。     

体表标测q波对显性房室旁道定位的临床意义初探

为探讨房室旁道体表标测图ｑ波分布与旁道位置的关系，采用９１导联体表标测系统观察２６例显性预激综合征（单旁道）患者ｑ波分布图，并与射频消融成功靶点确定的旁道位置比较。发现旁道位置不同，ｑ波分布有别：左室游离壁旁道（１４例）ｑ波分布于左腋中线以后背部上方及右锁骨水平（１２例）；左后间隔旁道（３例）ｑ波局限于右胸背部（３例）。右侧游离壁旁道（７例）ｑ波分布于右胸背部及肋弓下缘（７例）；右前间隔旁道（１例）ｑ波位于右胸背上方（１例）；右后间隔旁道（１例）位于右胸背下方及左胸背第５肋以下（１例）。提示体表标测ｑ波分布有助于消融术前旁道定位。     

Ebstein心脏畸形伴预激综合征患者手术中的麻醉处理

2000-2003年，我院共收治12例Ebstein心脏畸形合并预激综合征的患者，均在低温体外循环下行Ebstein心脏畸形心内矫治术，并结合心外膜电生理标测确定预激点，行房室旁道切断终止预激发作，手术效果满意，无麻醉死亡。现将麻醉处理体会报告如下。     

心房扑动伴左侧旁道致伪完全性右束支阻滞1例

特快型心室率的心房扑动(简称房扑)或房颤伴预激综合征与其他宽QRS波群心动过速的鉴别诊断一直是心电图的诊断难点.降低心率使心房波和δ波显现有助于诊断,电生理检查是确诊的金标准.本文报告1例房扑、预激综合征、伪完全性右束支阻滞同时存在的病例.左侧旁道可致伪完全性右束支阻滞图形,阻断旁道后QRS波群恢复正常形态.左侧旁道伴...     

显性预激体表12导联心电图定位房室旁路诊断标准的临床研究

目的 研究体表１２导联心电图与显性预激到预激旁路定位的相关关系。方法 本研究采用心外膜标测（ＥＣＭ）手术切断旁路（ＡＰ）、心内膜标测电生理检查（ＥＰＳ）射频消融术（ＲＦＣＡ）离断旁路方法，成功根治１２３例显性预激病人１３３条ＡＰ，并对其体表１２导联主电图进行对比研究。结果 体表心电图（ＳＥＣＧ）的四个特征变化对旁路定位有重要价值。这四个特征是（１）Ｖ１导联ＱＲＳ综合波形态；（２）肢体导入△波极性变     

胸壁标测图与心外膜标测图相互关系的实验研究

使用心外膜和胸壁心电图同时标测的方法观察19只犬结扎冠状动脉后ΣQ,ΣR、ΣST在二种标测图上的相互关系。结果表明,8只犬的ΣQ、13只犬的ΣR及19只犬的ΣST变化在二种标测图上表现良好相关。提示体表心电图对反映心外膜面的Q波和R波变化尚有一定局限性。     

Accuracy and Limitations of Published Algorithms Using the Twelve-Lead Electrocardiogram to Localize Overt Atrioventricular Accessory Pathways

INTRODUCTION: The purpose of this study was to evaluate the accuracy and limitations of published algorithms using the 12-lead ECG to localize AV accessory pathways (APs). METHODS AND RESULTS: The 11 relevant algorithms found in the literature (MEDLINE database and major scientific sessions) were tested on a series of 266 consecutive patients who successfully underwent radiofrequency catheter ablation of a single overt AV AP. The positive predictive values (PPV) of the algorithms in applicable patients were significantly lower for algorithms with > 6 accessory location sites (40.6% +/- 10.9% vs 61.2% +/- 8.0%; P < 0.03) and show a tendency for algorithms not relying on delta wave polarity but on QRS polarity only (36.6% +/- 11.2% vs 52.3% +/- 13.1%; P = 0.09). The PPV in applicable patients is related to the AP location (P < 0.001) and ranked from the highest to the lowest as follows: left lateral (mean PPV = 86.3%), posteroseptal (mean PPV = 65.2%), right anteroseptal (mean PPV = 45.2%), and right posterolateral (mean PPV = 23.4%). CONCLUSION: Our study suggests that the accuracy of algorithms relying on the 12-lead ECG depends on AP locations as defined in the algorithms and on the number of AP sites. The accuracy tends to be lower when delta wave polarity is not included in the algorithm's architecture. This should be considered when using these algorithms or when building new ones.     

室上性心动过速时V_1导联rSr’波的诊断价值

目的　分析经射频消融术证实的 146例房室结双径路合并慢快型折返性心动过速和 12 0例隐匿性预激综合征病人的窦性心律和房室结折返性心动过速时的体表心电图 ,总结具有特异性改变的图形 ,提高体表心电图鉴别室上性心动过速的发生机制以及诊断房室结双径路的准确率。方法　用对比的方法分析窦律下和心动过速时 12导联体表心电图 ,找出心动过速时逆传P’波在不同导联的位置及与QRS波的关系。结果　房室结双径路的病人心动过速时 ,体表心电图 12导联均无逆传P’波 30例 ,发生率 2 0 5 % ;肢体导联无逆传P’波 ,而V1导联呈rSr’波 84例 ,发生率 5 7 5 % ;肢导有假s波 ,V1导联呈rSr’波 2 9例 ,发生率 19 9% ;12导联有假 q波 3例 ,发生率 2 1%。隐匿性预激的病人V1导联仅 1例出现rSr’图形。结论　体表心电图V1导联的rSr’波对房室结双径路合并室上速的诊断特异性强 ,准确性高 ,是快速、准确诊断房室结折返性心动过速的极为有价值的方法。     

后间隔旁道体表心电图及心内电图的特征

总结射频消融成功的后间隔旁道３７例体表及心内电图特征，结果显示：显性后间隔旁道体表心电图Ⅱ、Ⅲ、ａＶＦ导联δ波负向，ＱＲＳ波群在Ｖ２导联呈Ｒ或Ｒｓ形时，若Ｖ１导联为ｒＳＲ或Ｒｓ形诊断为左后间隔旁道，其敏感性７３．３％、特异性９１．７％；Ｖ１导联为ＱＳ形诊断为右后间隔旁道，其敏感性５８．３％、特异性１００％。冠状窦电极为间距１ｃｍ的４极标测电极，近端电极置于窦口。心动过速时，心内电图ΔＶＡＨ－ＣＳ（ＶＡＨ与最短ＶＡｃｓ的差值）≥２５ｍｓ提示左侧，敏感性６２．８％、特异性９３．７％；ΔＶＡｃｓ（冠状窦电极记录的最长与最短ＶＡ的差值）≤１５ｍｓ提示左侧，敏感性８７．５％，特异性９５．４％。此外，左后间隔旁道逆行Ａ波最早出现在冠状窦近端（ＣＳｐ）或冠状窦中端（ＣＳｍ），且冠状窦中端Ａ波（Ａｃｓｍ）均早于希氏束远端（Ｈｉｓｄ）Ａ波（ＡＨｉｓｄ）；右后间隔旁道逆行Ａ波最早出现在Ｈｉｓｄ或ＣＳｐ处，Ａｃｓｍ均晚于ＡＨｉｓｄ。通过体表心电图和心内电图特征，可简便准确地预测间隔旁道的消融靶点。     

A new algorithm for concealed accessory pathway localization using T-wave-subtracted retrograde P-wave polarity during orthodromic atrioventricular reentrant tachycardia

INTRODUCTION: AP localization can be predicted by analyzing the polarity of the delta wave, QRS polarity, and R/S ratio in patients with Wolff-Parkinson-White syndrome. However, the estimation of AP location is limited in patients with concealed pathways during atrioventricular reentrant tachycardias (AVRT). Thus, we analyzed retrograde P-wave polarity during orthodromic AVRT and developed an algorithm to predict the localization of concealed accessory pathways (AP). METHODS AND RESULTS: A total number of 131 patients with a single AP and inducible orthodromic AVRT were included. The initial 61 patients were analyzed retrospectively for algorithm development, whereas 70 patients were evaluated prospectively. The retrograde P-wave polarity was analyzed by subtracting the superimposing T-wave during orthodromic AVRT using custom-designed software. Four leads of the surface electrocardiogram (ECG) were identified to accurately distinguish AP locations assigned to four different regions around each AV annulus: I, aVR, aVL, and V(1). Lead V(1) was used to differentiate right (negative or isoelectric) from left (solely positive) APs. Retrograde P-wave in lead I was negative in left posterior APs exclusively and became more positive with an AP location shifting towards right anterior. P-wave polarity in lead aVR demonstrated a shift from a positive polarity from left APs to isoelectric in right APs. The opposite direction (shift from positive to isoelectric) was observed for lead aVL. The subsequently developed algorithm for concealed AP localization using these surface ECG leads demonstrated a high sensitivity, specificity, and positive predictive value particularly for common AP localizations (left posterior and inferior, and right septal) when applied in a prospective fashion. CONCLUSION: Concealed AP localization can be accurately predicted by the analysis of retrograde P-wave polarity during orthodromic AVRT using the algorithm derived from the presented study.     

Characteristics and radiofrequency ablation in posteroseptal and left free-wall subepicardial accessory pathways

Accessory pathways (APs) that can only be ablated from the coronary sinus are likely to be located subepicardially. The electrocardiographic (ECG) and electrophysiological characteristics as well as the immediate radiofrequency ablation success rate and the recurrence rate were compared in 15 patients (11 posteroseptal and 4 left free-wall) with subepicardial APs and in 31 control patients with posteroseptal (15) and left free-wall (16) APs matched with age, sex, and AP location during the same study period in whom APs were successfully ablated from the endocardial approach. Patients with posteroseptal subepicardial APs had a longer tachycardia cycle length (355 +/- 32 vs 286 +/- 49 milliseconds, P < .05), a lower success rate (9 /11 vs 15/15, P = .09), and a higher recurrence rate (3/9 vs 0/15, P < .05) as compared with control patients. A negative delta wave with QS or QR pattern in lead II was present in all 4 patients with a manifest posteroseptal subepicardial AP located in the middle cardiac vein as compared with none of the 5 control patients with posteroseptal APs located in the proximal coronary sinus and 1 of the 9 control patients (P < .01). A positive delta wave in lead I along with an R/S of less than 1 in lead V 1 , and a negative delta wave in lead II, was noted in 1 of the 2 patients with left free-wall subepicardial APs and none of the 7 controls (P = .047). The local activation time is significantly shorter in the 4 patients with left free-wall subepicardial AP than in the 16 control patients (31 +/- 9 vs 89 +/- milliseconds, P = .044). CONCLUSIONS: Some ECG characteristics are suggestive of APs located in the middle cardiac vein and left free-wall subepicardial site, while a longer local activation time is characteristic of left free-wall APs. The success rate is lower and the recurrence rate higher with radiofrequency ablation in patients with subepicardial AP.     

预激综合征射频消融术后心电图电张调整性T波及J-ST段特征分析

目的探讨预激综合征射频消融房室旁道后心电图出现电张调整性T波及J-ST段的特征及其发生机制。方法45例持续性预激综合征患者,对比射频消融术前后心电图,总结和分析术后电张调整性T波、J波以及ST段变化的发生规律和特征。结果45例中射频消融术后出现电张调整性T波改变有27例,间隔部和左前壁旁道消融后电张调整性T波出现率最高(达100%),电张调整性T波主要分布于下壁导联(Ⅱ、Ⅲ、aVF)和高侧壁导联(Ⅰ、aVL);下壁导联电张调整性T波倒置深度Ⅲ>aVF>Ⅱ(P<0.01),高侧壁导联aVL>Ⅰ。此外尚可出现J-ST改变,表现为J点抬高、J波和ST段水平或弓背向下型抬高,总发生率高于同期隐匿性旁道消融组(42.2%vs3.5%,P<0.01)。结论预激综合征射频消融术后电张调整性T波的出现取决于预激时QRS波形态;射频消融术后心电图可出现类似早期复极综合征的J-ST段改变。     

Determination of the preexcitation focus in the W-P-W picture by isopotential body-surface mapping

Experiences with the determination of the preexcitation focus in 13 patients with W-P-W syndrome aged 18-62 years are presented. The data of ECG mapping from the chest surface and the abdominal wall were processed by computer. For classification of the maps the criteria elaborated by Yamada et al., da Ambroggi et al., and Benson et al. were used. It was possible to determine on their basis the preexcitation focus in all examined subjects, although a reduced system of ECG leads was employed. Surface ECG mapping makes possible a more precise location of the preexcitation, which is of great clinical importance for the indication of surgical treatment, determination of prognosis and of working ability.     

Specific Electrocardiographic Features of Manifest Coronary Vein Posteroseptal Accessory Pathways

Coronary Vein Accessory Pathways. Introduction: Some posteroseptal accessory pathways (APs) can be successfully ablated by radiofrequency current only from inside the coronary sinus (CS) or its branches, because of an absolute or relatively epicardial location. The aim of this study was to identify ECG features of manifest posteroseptal APs requiring ablation in the CS or the middle cardiac veins (MCVs). Methods and Results: One hundred seventeen consecutive patients with manifest posteroseptal APs successfully ablated: (1) ≥ 1 cm deep inside the MCV (group MCV: n = 13); (2) inside the CS, including the area adjacent to the MCV ostium (group CS: n = 10); (3) at the right (group R: n = 60); or (4) the left posteroseptal endocardial region (group L: n = 34) were included. We reviewed delta wave polarity (initial 40 msec) and QRS morphology during sinus rhythm and atrial pacing as well as electrogram characteristics in these patients. The local target site electrogram in groups MCV and CS was characterized by a longer atrial to ventricular electrogram interval, suggesting a longer course of the pathway and more frequent recording of a presumptive AP potential compared to the group ablated at the right or left endocardium. The most sensitive ECG feature for group CS or group MCV was a negative delta wave in lead II in sinus rhythm (87%), but specificity (79%) and positive predictive value (50%) were relatively low. A steep positive delta wave in aVR during maximal preexcitation possessed the highest specificity and positive predictive value (98% and 88%, sensitivity 61%) which increased to 99% and 91%, respectively, when combined with a deep S wave in V₆ (R wave ≤ S wave). Conclusion: These data suggest that posteroseptal APs ablated inside the coronary venous system have highly specific features, including the combination of a steep positive delta wave in lead aVR and a deep S wave in lead V₆ (R wave ≤ S wave) during maximal preexcitation. The highest sensitivity is provided by a negative delta wave in lead II. These findings may be helpful for anticipating and planning an epicardial ablation strategy.     

显性房室旁道射频消融术后T波改变的临床意义

通过对房室旁道 (简称旁道 )消融术后T波改变的动态观察 ,探讨其临床意义。 12 4例消融成功的单旁道患者分为隐匿性旁道组 (n =5 6 )、轻度预激组 (n =2 4)和明显预激组 (n =44 )。记录消融术前、术后即刻、术后 1h、术后 1天及随访 1～ 3个月期间 12导联心电图 ,比较评价消融术前后T波改变。消融术后超声心动图检查及测定心肌酶。结果 :术后 2 4h明显预激组 2 7例 (6 1% )T波明显改变 ,轻度预激组 4例 (17% )T波明显改变 (P <0 .0 1)。隐匿性旁道组无 1例T波改变。室间隔 (87% )及左侧旁道 (77% )消融术后T波改变多于右侧旁道 (36 % )。T波改变与消融能量及心肌酶升高程度无关 ,与术前预激程度及旁道部位有关。术后 1～ 3个月T波改变者均完全恢复正常。结论 :提示显性旁道射频消融术后T波改变为电张调整性T波改变 ,非心肌损伤所致。     

Percutaneous epicardial mapping during ablation of difficult accessory pathways as an alternative to cardiac surgery

OBJECTIVES: The aim of this study was to define the role of percutaneous epicardial mapping for the ablation of previous failed ablation of accessory pathways. BACKGROUND: Cardiac surgery is the only curative option for failed radiofrequency (RF) catheter ablation of accessory pathway (AP)-mediated tachycardias. We investigated a combined percutaneous epicardial and endocardial approach for failed AP ablations. METHODS: We present our experience in a series of 6 cases (7 APs) with previous failed attempts at catheter ablation (median 2 attempts, range 1-4) and persistent symptomatic tachycardias. Endocardial mapping of the APs was performed using conventional techniques. Sites with local electrograms suggestive of AP location were selected. When initial endocardial mapping was not successful for ablation of the pathway, percutaneous transthoracic pericardial puncture was performed via a subxiphoid approach, and an ablation catheter was positioned at the epicardial aspect of the putative AP location for epicardial-endocardial electrogram comparison. Endocardial RF energy was applied to locations considered appropriate. Epicardial RF applications were delivered when endocardial applications failed. Coronary arteriography was performed to assess the proximity of coronary arteries to the ablation catheter. RESULTS: APs were located in the right free wall (4 patients, 5 APs) and the right (1 patient) and left (1 patient) posteroseptal regions. In all patients, epicardial mapping assisted in identifying successful ablation sites. In 3 patients, the earliest atrial activation during orthodromic tachycardia was present in an epicardial electrogram. Successful AP ablation was achieved with an epicardial RF application in 2 patients, either alone or with simultaneous endocardial-epicardial delivery. In the remaining 4 patients, APs were successfully ablated endocardially after epicardial mapping. These patients represent 18% of all cases referred to our institution for ablation of previously failed accessory pathways (6/32 patients). CONCLUSIONS: A combined endocardial-epicardial approach to mapping and RF ablation can facilitate successful endocardial ablation in most cases. In selected cases, APs can be ablated by epicardial delivery of RF. Epicardial mapping is an effective alternative to cardiac surgery for patients in whom prior attempts at AP ablation have failed.