隐匿性旁路与房室结折返性心动过速鉴别诊断的临床研究
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摘要
目的:
观察经校正的心室起搏拖带的起搏后间期(PPI)与心动过速周长(TCL)差值和希氏束旁起搏刺激方法在隐匿性旁路介导的顺向房室折返性心动过速(O-AVRT)与房室结双径路所致房室结折返性心动过速(AVNRT)鉴别诊断中的价值。
方法:
2006年9月～2007年12月间中南大学湘雅二医院心导管室经过心内电生理检查和射频消融的65例室上速心动过速患者,窦律时无预激波出现。其中AVNRT 37例,O-AVRT 28例,以快于心动过速频率5～15次/min的刺激频率进行心动过速拖带,比较校正的心室起搏拖带的起搏后间期(PPI)与心动过速周长(TCL)差值[校正PPI—TCL=PPI—TCL—(起搏后AH间期—心动过速时AH间期)]等参数在这两组中的差异。
希氏束旁起搏刺激法使用靠近希氏束或最接近右束支的右室起搏,心室起搏电极位置随着呼吸运动精细调整,反复升高或降低起搏电压,使起搏夺获部位发生改变,这些起搏夺获部位的改变导致希氏束激动时间与心室激动时间不同,比较刺激心房(SA)间期以及逆行心房激动顺序的变化。
结果:
1、心内电生理检查发现28例O-AVRT和37例AVNRT患者,除2例AVNRT患者外均成功拖带,28例O-AVRT患者校正的PPI—TCL差值(68±20ms)短于35例AVNRT患者校正的PPI—TCL差值(151±16ms)(P＜0.01)。确定所有O-AVRT患者除1例外,其校正的PPI—TCL差值＜110ms,而AVNRT患者校正的PPI—TCL差值均＞110ms。
2、间隔部旁路患者校正的PPI—TCL差值比游离壁旁路患者更短一些。
3、60例患者希氏束旁起搏刺激检测,33例AVNRT患者宽QRS时SA间期长,窄QRS时SA间期短,无论宽QRS图形、窄QRS图形其逆传心房激动顺序相同并且HA间期不变。27例O-AVRT患者SA间期(宽QRS时)与SA间期(窄QRS时)相同或相差很小,无论宽、窄QRS图形其逆传心房激动顺序不变。
结论:
1、经校正的PPI—TCL差值测定是一项快速、有效的方法来鉴别AVNRT和隐匿性O-AVRT,具有重要的临床意义;校正的PPI—TCL差值＜110ms对确诊O-AVRT患者能提供更大的判断价值。
2、希氏束旁起搏刺激方法对隐匿性旁路O-AVRT有一定的帮助,但操作存在一定难度。
Objective To determine whether the corrected difference of Postpaceing interval (PPI) between tachycardia cycle length (TCL) after entrainment of tachycardia during ventricular stimulation and para-Hisian pacing are useful, simple maneuvers in differentiating AV nodal reentrant tachycardia (AVNRT) from orthodromic reciprocating tachycardia (ORT) using a concealed accessory pathway.
Methods From September 2006 to December 2007, a total of 65 patients in Second Xiangya Hospital of Central South University who underwent electrophysiological study and ablation of regular paroxysmal supraventricular tachycardia were enrolled. The patients did not show preexcitation during sinus rhythm, of which 37 patients diagnosed AVRT and the rests(28 patients) diagnosed O-AVRT.Tachycardia entrainment was attempted through trains of 5-15 right ventricular apex pacing pulses. To compare the difference of the Postpaceing interval (PPI) between tachycardia cycle length (TCL) in the two groups..
The increment in AV nodal conduction time in the first PPI was subtracted from the PPI-TCL difference (namely, corrected PPI—TCL).
Right ventricular pacing close to the His bundle or proximal right bundle branch was used in para-Hisian pacing. The pacing stimulus changed the capture position as the position of the ventricular pacing catheter changed subtly during respiration (or by changing pacing output). These changes in pacing capture resulted in abrupt changes in the timing of His bundle activation and the timing of ventricular activation. The presence or absence of a change in atrial activation sequence, stimulus-atrial intervals, and His bundle-atrial interval was identified.
Methods Electrophysiological study demonstrated ORT in 28 patients and AVNRT in 35 patients. Transient entrainment was achieved in all but 2 patients. The mean corrected PPI-TCL difference was significantly shorter in the 28 patients with ORT (68±20 ms) than in the 35 AVNRT patients (151±16 ms; P<0.01). The presence of a corrected PPI-TCL difference <110 ms was identified in all but 1 patient with ORT, and no patients with AVNRT had such a difference. Patients with septal accessory pathways had shorter corrected PPI—TCL difference than patients with free-wall accessory pathways. Surface QRS complex showed narrow or wide among 60 patients during para-Hisian Pacing. Wide QRS complex SA interval was longer than narrow QRS complex SA interval with the same retrograde atrial activation and unchanged HA interval in the 33 AVNRT patients. While SA interval of wide or narrow QRS complex remained unchanged or changed slightly, with the same retrograde atrial activation in the 27 ORT patients.
Conclusions The return cycle after tachycardia entrainment by right ventricular apex stimulation with correction for AV nodal delay is a rapid and useful maneuver for differential diagnosis of AVNRT or ORT in patients without preexcitation. The presence of a corrected PPI—TCL <110 ms may accurately identify those patients with ORT. Para-Hisian Pacing is a effective way in diagnosing O-AVRT, but it is not to be used widely in clinical practice because of difficulty in operation.
观察经校正的心室起搏拖带的起搏后间期(PPI)与心动过速周长(TCL)差值和希氏束旁起搏刺激方法在隐匿性旁路介导的顺向房室折返性心动过速(O-AVRT)与房室结双径路所致房室结折返性心动过速(AVNRT)鉴别诊断中的价值。
方法:
2006年9月～2007年12月间中南大学湘雅二医院心导管室经过心内电生理检查和射频消融的65例室上速心动过速患者,窦律时无预激波出现。其中AVNRT 37例,O-AVRT 28例,以快于心动过速频率5～15次/min的刺激频率进行心动过速拖带,比较校正的心室起搏拖带的起搏后间期(PPI)与心动过速周长(TCL)差值[校正PPI—TCL=PPI—TCL—(起搏后AH间期—心动过速时AH间期)]等参数在这两组中的差异。
希氏束旁起搏刺激法使用靠近希氏束或最接近右束支的右室起搏,心室起搏电极位置随着呼吸运动精细调整,反复升高或降低起搏电压,使起搏夺获部位发生改变,这些起搏夺获部位的改变导致希氏束激动时间与心室激动时间不同,比较刺激心房(SA)间期以及逆行心房激动顺序的变化。
结果:
1、心内电生理检查发现28例O-AVRT和37例AVNRT患者,除2例AVNRT患者外均成功拖带,28例O-AVRT患者校正的PPI—TCL差值(68±20ms)短于35例AVNRT患者校正的PPI—TCL差值(151±16ms)(P＜0.01)。确定所有O-AVRT患者除1例外,其校正的PPI—TCL差值＜110ms,而AVNRT患者校正的PPI—TCL差值均＞110ms。
2、间隔部旁路患者校正的PPI—TCL差值比游离壁旁路患者更短一些。
3、60例患者希氏束旁起搏刺激检测,33例AVNRT患者宽QRS时SA间期长,窄QRS时SA间期短,无论宽QRS图形、窄QRS图形其逆传心房激动顺序相同并且HA间期不变。27例O-AVRT患者SA间期(宽QRS时)与SA间期(窄QRS时)相同或相差很小,无论宽、窄QRS图形其逆传心房激动顺序不变。
结论:
1、经校正的PPI—TCL差值测定是一项快速、有效的方法来鉴别AVNRT和隐匿性O-AVRT,具有重要的临床意义;校正的PPI—TCL差值＜110ms对确诊O-AVRT患者能提供更大的判断价值。
2、希氏束旁起搏刺激方法对隐匿性旁路O-AVRT有一定的帮助,但操作存在一定难度。
Objective To determine whether the corrected difference of Postpaceing interval (PPI) between tachycardia cycle length (TCL) after entrainment of tachycardia during ventricular stimulation and para-Hisian pacing are useful, simple maneuvers in differentiating AV nodal reentrant tachycardia (AVNRT) from orthodromic reciprocating tachycardia (ORT) using a concealed accessory pathway.
Methods From September 2006 to December 2007, a total of 65 patients in Second Xiangya Hospital of Central South University who underwent electrophysiological study and ablation of regular paroxysmal supraventricular tachycardia were enrolled. The patients did not show preexcitation during sinus rhythm, of which 37 patients diagnosed AVRT and the rests(28 patients) diagnosed O-AVRT.Tachycardia entrainment was attempted through trains of 5-15 right ventricular apex pacing pulses. To compare the difference of the Postpaceing interval (PPI) between tachycardia cycle length (TCL) in the two groups..
The increment in AV nodal conduction time in the first PPI was subtracted from the PPI-TCL difference (namely, corrected PPI—TCL).
Right ventricular pacing close to the His bundle or proximal right bundle branch was used in para-Hisian pacing. The pacing stimulus changed the capture position as the position of the ventricular pacing catheter changed subtly during respiration (or by changing pacing output). These changes in pacing capture resulted in abrupt changes in the timing of His bundle activation and the timing of ventricular activation. The presence or absence of a change in atrial activation sequence, stimulus-atrial intervals, and His bundle-atrial interval was identified.
Methods Electrophysiological study demonstrated ORT in 28 patients and AVNRT in 35 patients. Transient entrainment was achieved in all but 2 patients. The mean corrected PPI-TCL difference was significantly shorter in the 28 patients with ORT (68±20 ms) than in the 35 AVNRT patients (151±16 ms; P<0.01). The presence of a corrected PPI-TCL difference <110 ms was identified in all but 1 patient with ORT, and no patients with AVNRT had such a difference. Patients with septal accessory pathways had shorter corrected PPI—TCL difference than patients with free-wall accessory pathways. Surface QRS complex showed narrow or wide among 60 patients during para-Hisian Pacing. Wide QRS complex SA interval was longer than narrow QRS complex SA interval with the same retrograde atrial activation and unchanged HA interval in the 33 AVNRT patients. While SA interval of wide or narrow QRS complex remained unchanged or changed slightly, with the same retrograde atrial activation in the 27 ORT patients.
Conclusions The return cycle after tachycardia entrainment by right ventricular apex stimulation with correction for AV nodal delay is a rapid and useful maneuver for differential diagnosis of AVNRT or ORT in patients without preexcitation. The presence of a corrected PPI—TCL <110 ms may accurately identify those patients with ORT. Para-Hisian Pacing is a effective way in diagnosing O-AVRT, but it is not to be used widely in clinical practice because of difficulty in operation.
引文
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[31] Hirao K, Otomo K, Wang X, et al .Pare-Hisian Pacing a new Method for differentiating retrograde conduction over an accessory AV Pathway from conduction over the AV node. Circulation, 1996, 94:1027.
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[33] Hirao K, Toshida N, Kawabata M, Motokawa K, et al. New diagnostic finding to assess para-Hisian pacing observed in a patient with a permanent form of junctional reciprocating tachycardia. J Cardiovasc Electrophysiol, 1998, 9:1363-1369.
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[2]Benditt DG,Pritchett EL,Smith WM,et al.Ventriculoatrial intervals:diagnostic use in paroxysmal supraventricular tachycardia.Ann Intern Med,1979,91:161-166.
[3]Miles WM,Yee R,Klein GJ,et al.The preexcitation index:an aid in determining the mechanism of supraventricular tachycardia and localizing accessory pathways.Circulation,1986,74:493-500.
[4]Crozier I,Wafa S,Ward D,et al.Diagnostic value of comparison of ventriculoatrial interval during junctional tachycardia and right ventricular apical pacing.Pacing Clin Electrophysiol,1989,12:942-953.
[5]Kadish AH,Morady F.The response of paroxysmal supraventricular tachycardia to overdrive atrial and ventricular pacing:can it help determine the tachycardia mechanism? J Cardiovasc Electrophysiol,1993,4:239-252.
[6]Hirao K,Otomo K,Wang X,et al.Para-Hisian pacing:a new method for differentiating retrograde conduction over an accessory AV pathway from conduction over the AV node.Circulation,1996,94:1027-1035.
[7]Knight BP,Ebinger M,Oral H,et al.Diagnostic value of tachycardia features and pacing maneuvers during paroxysmal supraventricular tachycardia.J Am Coll Cardiol,2000,36:574-582.
[8]Josephson ME.Supraventricular tachycardias.In:Josephson ME,ed.Clinical cardiac electrophysiology:Techniques and Interpretations.Philadelphia:Lippincott Williams & Wilkins,2002,168-271.
[9]Reddy VY,Jongnarangsin K,Albert CM,et al.Para-Hisian entrainment:a novel pacing maneuver to differentiate Orthodromic atrioventricular reentrant tachycardia from atrioventricular nodal reentrant tachycardia.J Cardiovasc Electrophysiol,2003,14:1321-1328.
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