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快速型心律失常是临床较为常见的心血管急症,病人病情变化快,长时间持续快速心室率可能会导致心力衰竭[1],需要及时接受诊断和治疗,但是因发作时间不规律,普通的心电图常常不易抓取,不能明确诊断。经食管心房调搏术(transesophageal atrial pacing,TEAP)是一种无创性心脏电生理诊断和治疗技术,其优势体现在安全性高且具备可操作性,广泛应用于快速型心律失常相关疾病的诊断和治疗[2]。本文以行TEAP的85例快速型心律失常病人为研究对象,探究TEAP在快速型心律失常诊断中的意义。
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在时限比较中发现,AVNRT(S-F)的病人均是R-P′E < P′E-R,且R-P′E < 70 ms;O-AVRT病人大多R-P′E < P′E-R,且R-P′E>70 ms(见表 1)。
分型 R-P′E < P′E-R R-P′E>P′E-R R-P′E≈P′E-R R-P′E及
P′E-R不固定R-P′E < 70 msR-P′E>70 ms O-AVRT 0 46 6 4 1 AVNRT(S-F) 19 0 0 0 0 AT 0 0 1 0 0 Af 0 0 0 0 0 AT+AF 0 0 1 0 0 AT+AVNRT(S-F) 1 0 0 0 0 ILVT 0 0 0 0 0 注:部分类型AF、Af、ILVT无P′E波,未测量。 表 1 不同类型快速心律失常病人食管导联R-P′E和P′E-R时限比较
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左侧旁道均为V1导联R-P′>食管导联R-P′E;右侧旁道多为V1导联R-P′ < 食管导联R-P′E(见表 2)。
分型 R-P′ < R-P′E R-P′≈R-P′E R-P′>R-P′E 左侧旁道 0(0.0) 0(0.0) 41(100.0) 右侧旁道 14(87.5) 2(12.5) 0(0.0) 表 3 O-AVRT病人V1导联R-P′和食管导联R-P′E时限的比较[n;百分率(%)]
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在快速型心律失常终止方面,TEAP的有效终止率88%。其中,AVNRT共19例,其中2例自行终止,17例调搏终止;AVRT共57例,其中48例调搏终止,6例自行终止,1例终止后出现Af,2例未能被终止;AT 1例,自行终止;Af 2例,均未能被终止;AF 1例,未能被终止;AT+AF 1例,未能被终止;AT+AVNRT(S-F)1例,调搏终止;VT 3例,其中1例自行终止,2例未能被终止。
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1例AVNRT(S-F),食管内心电图表现为窄QRS波心动过速,心律规则,R-P′E < P′E-R,R-P′E < 70 ms,可见假性r′波、假性S波(见图 1)。1例右侧旁道介导的O-AVRT,食管内心电图表现为窄QRS波心动过速,心律规则,V1导联的P′波较食管导联的P′E波提前,即食管导联的R-P′E>V1导联的R-P′(见图 2)。1例左侧旁道介导的O-AVRT,食管内心电图表现为窄QRS波心动过速,心律规则,可见QRS波电交替现象,R-P′E≈P′E-R,且食管导联的P′E波较V1导联的P′波提前,即食管导联的R-P′E < V1导联的R-P′(见图 3)。1例心脏电生理诊断为三尖瓣环相关性AF,食管内心电图示心室率124次/分,食管导联清晰可见AF呈2:1下传(见图 4)。
食管心房调搏在快速型心律失常诊断中的临床意义
Clinical significance of transesophageal atrial pacing in the diagnosis of tachyarrhythmia
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摘要:
目的探究食管心房调搏在快速型心律失常诊断中的临床意义。 方法选择85例快速型心律失常病人作为研究对象,实行食管心房调搏检查,测定食管导联的R-P'E、P'E-R时限,比较V1导联的R-P'时限与食管导联的R-P'E时限,并与心脏电生理检查的结果作比较。 结果经心脏电生理确诊后的分型:顺向型房室折返型心动过速(O-AVRT)57例,慢-快型房室结内折返性心动过速[AVNRT(S-F)]19例,房性心动过速1例,心房扑动1例,心房颤动2例,左心室特发性室速3例,冠状动脉窦无冠窦底起源的AT合并右房间隔部起源的心房扑动1例,左心房AT合并慢-快型房室结内折返性心动过速1例。经食管心房调搏检查发现AVNRT(S-F)型病人食管导联中R-P'E < P'E-R,且R-P'E < 70 ms;O-AVRT型病人大多R-P'E < P'E-R,且R-P'E>70 ms;右侧旁道型病人V1导联的R-P' < 食管导联R-P'E;左侧旁道型病人V1导联的R-P'>食管导联的R-P'E。经食管心房调搏终止,85例病人的快速型心律失常有效终止率为88%。 结论食管心房调搏可以鉴别快速型心律失常的类型,尤其是其中阵发性室上性心动过速的分型,对后续治疗方案的合理制定、心脏电生理检查以及射频消融术均提供了帮助,且对快速型心律失常有较高的终止率。 Abstract:ObjectiveTo investigate the clinical significance of transesophageal atrial pacing in the diagnosis of tachyarrhythmia. MethodsEighty-five patients with tachyarrhythmia were selected as the study subjects, and the transesophageal atrial pacing of the esophagus was carried out to determine the time limits of R-P'E and P'E-R of esophageal lead.The time limits between R-P' of V1 lead and R-P'E of esophageal lead were compared, and the results of which was compared with the results of the cardiac electrophysiological examination. ResultsThe tachycardia in all cases were typed after cardiac electrophysiology diagnosing, and the consequent type atrioventricular turn-back core tachycardia(O-AVRT)in 57 cases, slow-fast in atrioventricular node turn-back tachycardia[(AVNRT(S-F)] in 19 cases, room tachycardia in 1 case, atrial flutter in 1 case, atrial fibrillation in 2 cases, left ventricular idiopathic ventricular tachycardia(ILVT)in 3 cases, AT without coronary sinus origin combined with atrial flutter of right atrial septum origin in the coronary sinus in 1 case, and left atrial AT combined with slow - fast atrioventricular node reentrant tachycardia in 1 cases were found.The results of transesophageal atrial pacing showed that the R-P'E was less than P'E-R, and the R-P'E was less than 70 ms in esophageal lead of AVNRT(S-F)type patient.The R-P'E was less than P'E-R, and the R-P'E was more than 70 ms in most O-AVRT type patients.The R-P' of lead V1 in right side bypass patients was less than R-P'E of esophageal lead, and the R-P' of V1 lead in left side bypass patients was more than R-P'E of esophageal lead.The effective termination rate of tachyarrhythmia was 88% in 85 patients with transesophageal atrial pacing. ConclusionsThe transesophageal atrial pacing can distinguish the types of tachyarrhythmia, especially the classification of paroxysmal supraventricular tachycardia, which provides help for the rational formulation of follow-up treatment, cardiac electrophysiological examination and radiofrequency ablation.Moreover, the transesophageal atrial pacing has a higher termination rate for tachyarrhythmia. -
Key words:
- arrhythmia /
- transesophageal atrial pacing /
- electrocardiogram
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表 1 不同类型快速心律失常病人食管导联R-P′E和P′E-R时限比较
分型 R-P′E < P′E-R R-P′E>P′E-R R-P′E≈P′E-R R-P′E及
P′E-R不固定R-P′E < 70 msR-P′E>70 ms O-AVRT 0 46 6 4 1 AVNRT(S-F) 19 0 0 0 0 AT 0 0 1 0 0 Af 0 0 0 0 0 AT+AF 0 0 1 0 0 AT+AVNRT(S-F) 1 0 0 0 0 ILVT 0 0 0 0 0 注:部分类型AF、Af、ILVT无P′E波,未测量。 表 3 O-AVRT病人V1导联R-P′和食管导联R-P′E时限的比较[n;百分率(%)]
分型 R-P′ < R-P′E R-P′≈R-P′E R-P′>R-P′E 左侧旁道 0(0.0) 0(0.0) 41(100.0) 右侧旁道 14(87.5) 2(12.5) 0(0.0) -
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