一份“蹊跷”的心电图,如何揪出“元凶”?

2018-06-28 张恩象 医学界心血管频道

今天就来讲一讲一种销声匿迹多年的武林绝学:一石二鸟。可凭四两拨千斤之势,决胜千里之外。哈哈,不扯了,让我们来看看Vereckei教授提供的精彩病例[1]。

今天就来讲一讲一种销声匿迹多年的武林绝学:一石二鸟。可凭四两拨千斤之势,决胜千里之外。哈哈,不扯了,让我们来看看Vereckei教授提供的精彩病例[1]。

病例简介

61岁女性因近期心悸气促就诊,既往高血压,二尖瓣脱垂病史。射血分数51%。第一张心电图示窦律,左前分支阻滞,左房增大,心电图详见图1、图2、图3。


图1:Holter乍看很像基础窦律下,房早伴差传及室早二联律交替出现


图2:有时患者的心电图却呈现窄QRS心动过速伴长短RR间期交替规律出现


图3:还有时呈现完全规律的窄QRS心动过速,只是QRS波呈现两种不同形态

图2、图3各种形态的QRS心动过速均不能持续,并且被1-2个窦律隔开。后来另一份心电图提示窦律隔开的短阵重复室上速,QRS形态与刚刚就诊时一致。

可以看出窦性P波以78-86次/分钟的频率规律出现,心房率<心室率,室上速发作过程中,每个P波后跟着两个QRS波,由于室上速两个P波之间的第一个T波与窦性心律时的T波形态一致,所以可以排除有P波藏在T波内的可能。

此外,作者还发现了在两跳窦律之前PR间期逐渐延长,RP间期逐渐缩短。因此,更加确认房室文氏周期传导,即一次窦房结搏动经房室结双径路(一条快径,一条慢径)两次下传心室,他与AVNRT不同,虽然也需要房室结参与,两条路径却都是前传,故称作房室结双径路非折返性心动过速(DAVNNT)。

由梯形图可见,快径及慢径的PR间期均逐渐延长,加上窦性心律的增快,直至窦房结激动不能通过房室结,窦性心律通过快径夺获心室,室上速得以暂时终止,表现为文氏现象(图4)。
 

图4

至于为何窦性心律不通过慢径夺获心室,作者也给出了解释:

首先,窦房结信号经过快径下传后会显著延长希氏束以下区域的有效不应期,因此很容易阻滞由慢径传导下来的电信号。

其次,慢径单向逆向阻滞是正常窦性心律能够经房室结1:2传导的先决条件,窦律减慢时逆向阻滞会暂时缓解,所以窦律会短暂地经快径下传并由慢径上传,慢径前传被阻滞。这些猜想也经过了电生理检查的验证:A幅第一个窦性冲动1:2传导到心室,第二个窦性冲动后没有发现希氏束电位,提示阻滞在房室结水平。A幅窦房结第三跳及B幅窦房结第二跳均为室上速终止后第一次窦性激动,经过快径前传后,没有发现慢径前传的希氏束电位(图5)。


图5

DAVNNT非常少见[2][3],且容易漏诊,或误诊为不典型室上速,房颤(肺静脉隔离消融及不必要的抗凝治疗),或II度1型房室传导阻滞(起搏器),如合并显著差传,甚至容易被误诊为室速(ICD植入,且频繁误放电),只有慢径消融才是正确的治疗[4],所以做出准确诊断显得尤为重要。

以下情况下应考虑DAVNNT:

窦律下观察到显著变化的PR间期合并不规则阵发性室上速;
规律发生的与RR间期持续变化相关的不规则室上速(仅仅当快慢径传导时间差异正好为窦性周期一半时才会发生,此患者正是如此,图3、图6);


图6

室上速发作时观察到P波数目约为QRS一半。而DAVNNT的维持条件如下:1 慢径传导显著延迟;2房室结远端及希普系统有效不应期比快慢径传导时间差距要短;窦性周期足够长,使前一次激动通过慢径向下传导后再发动下一次激动;

室房逆传很难或几乎不可能(否则,就是典型的AVNRT了)。最难与DAVNNT进行鉴别的当属交界区早搏二联律或交界区并行心律:DAVNNT心室两次搏动的联律间期在一定时间内恒定,而交界区早搏的心室联律间期始终在变化,并且可以见到逆行P波,不存在房室文氏周期。交界区并行心律则需要有稳定的RR间期[5]。

领略了Vereckei大神的经典病例报道,我有如下体会:

1.遇到影响血流动力学的快速性心律失常,在保证原则的情况下,药物可以用于诊断性治疗,但是一旦涉及进一步有创操作,则一定要谨慎判断患者心电图变化及电生理检查结果,反复推敲,做出正确判断。

2. 遇到杂乱却又隐约有些规律的心电图时,我们容易脱口而出:XX并行心律,想到这种心律固然值得嘉奖,但是临床思维还是鼓励一元论,如果发现并行心律还在不断变化,就要勇于否定,另辟蹊径。

3. 除了分析P-QRS-ST-T这些心电图一手资料,还需动态观察RR间期,PR间期,RP间期,P与QRS关系等等,这些重要的“二手”数据在有些心电图分析中可堪大用。

4.唯有膜拜。

原始出处:

[1]Vereckei A, Gellér L. Repetitive narrowQRS tachycardia in a 61-year-old female patient with recentpalpitations. JGeriatr Cardiol. 2018;15(2):193-198.

[2] Aasbo J, Prasertwitayakij N, Morady F, et al. Nonreentrant dualatrioventricular nodal tachycardia in a patient with atrioventricular nodalconduction abnormality. Heart Rhythm 2009;6:1504-6.


[4]Wang NC, Razak EA, Jain SK, et al. Isoproterenol facilitation of slow pathway ablation  inincessant dual atrioventricular nodalnonreentrant tachycardia. Pacing Clin Electrophysiol. 2012;35(2):e31-4.

[5] Peiker C, Pott C, Eckardt L,et al. Dual  atrioventricular nodal non-re-entrant tachycardia. Europace. 2016;18(3):332-9.

版权声明:
本网站所有内容来源注明为“梅斯医学”或“MedSci原创”的文字、图片和音视频资料,版权均属于梅斯医学所有。非经授权,任何媒体、网站或个人不得转载,授权转载时须注明来源为“梅斯医学”。其它来源的文章系转载文章,或“梅斯号”自媒体发布的文章,仅系出于传递更多信息之目的,本站仅负责审核内容合规,其内容不代表本站立场,本站不负责内容的准确性和版权。如果存在侵权、或不希望被转载的媒体或个人可与我们联系,我们将立即进行删除处理。
在此留言
评论区 (5)
#插入话题
  1. [GetPortalCommentsPageByObjectIdResponse(id=327916, encodeId=398f32e9166a, content=进一步补充了经验.受用匪浅., beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7881672775, createdName=通通, createdTime=Fri Jun 29 08:18:59 CST 2018, time=2018-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327881, encodeId=102f32e881ac, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Fri Jun 29 07:18:32 CST 2018, time=2018-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327767, encodeId=57a932e76781, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Thu Jun 28 22:24:38 CST 2018, time=2018-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327758, encodeId=a18332e758df, content=学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzaiabIFicf63hKvVMjL6aJlx4yX4UcXmzX9DyibCRcicq0QtCRWMaQKh8MYjE1D3EKUBopgiaGWYuqbeR/0, createdBy=0c2b1999806, createdName=三生有幸9135, createdTime=Thu Jun 28 21:36:57 CST 2018, time=2018-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327745, encodeId=dfec32e7452d, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Thu Jun 28 21:12:33 CST 2018, time=2018-06-28, status=1, ipAttribution=)]
    2018-06-29 通通

    进一步补充了经验.受用匪浅.

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=327916, encodeId=398f32e9166a, content=进一步补充了经验.受用匪浅., beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7881672775, createdName=通通, createdTime=Fri Jun 29 08:18:59 CST 2018, time=2018-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327881, encodeId=102f32e881ac, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Fri Jun 29 07:18:32 CST 2018, time=2018-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327767, encodeId=57a932e76781, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Thu Jun 28 22:24:38 CST 2018, time=2018-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327758, encodeId=a18332e758df, content=学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzaiabIFicf63hKvVMjL6aJlx4yX4UcXmzX9DyibCRcicq0QtCRWMaQKh8MYjE1D3EKUBopgiaGWYuqbeR/0, createdBy=0c2b1999806, createdName=三生有幸9135, createdTime=Thu Jun 28 21:36:57 CST 2018, time=2018-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327745, encodeId=dfec32e7452d, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Thu Jun 28 21:12:33 CST 2018, time=2018-06-28, status=1, ipAttribution=)]
    2018-06-29 张新亮1853311252142e2fm

    好文献学习了

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=327916, encodeId=398f32e9166a, content=进一步补充了经验.受用匪浅., beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7881672775, createdName=通通, createdTime=Fri Jun 29 08:18:59 CST 2018, time=2018-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327881, encodeId=102f32e881ac, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Fri Jun 29 07:18:32 CST 2018, time=2018-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327767, encodeId=57a932e76781, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Thu Jun 28 22:24:38 CST 2018, time=2018-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327758, encodeId=a18332e758df, content=学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzaiabIFicf63hKvVMjL6aJlx4yX4UcXmzX9DyibCRcicq0QtCRWMaQKh8MYjE1D3EKUBopgiaGWYuqbeR/0, createdBy=0c2b1999806, createdName=三生有幸9135, createdTime=Thu Jun 28 21:36:57 CST 2018, time=2018-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327745, encodeId=dfec32e7452d, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Thu Jun 28 21:12:33 CST 2018, time=2018-06-28, status=1, ipAttribution=)]
    2018-06-28 天地飞扬

    了解一下.谢谢分享!

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=327916, encodeId=398f32e9166a, content=进一步补充了经验.受用匪浅., beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7881672775, createdName=通通, createdTime=Fri Jun 29 08:18:59 CST 2018, time=2018-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327881, encodeId=102f32e881ac, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Fri Jun 29 07:18:32 CST 2018, time=2018-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327767, encodeId=57a932e76781, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Thu Jun 28 22:24:38 CST 2018, time=2018-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327758, encodeId=a18332e758df, content=学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzaiabIFicf63hKvVMjL6aJlx4yX4UcXmzX9DyibCRcicq0QtCRWMaQKh8MYjE1D3EKUBopgiaGWYuqbeR/0, createdBy=0c2b1999806, createdName=三生有幸9135, createdTime=Thu Jun 28 21:36:57 CST 2018, time=2018-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327745, encodeId=dfec32e7452d, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Thu Jun 28 21:12:33 CST 2018, time=2018-06-28, status=1, ipAttribution=)]
    2018-06-28 三生有幸9135

    学习一下

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=327916, encodeId=398f32e9166a, content=进一步补充了经验.受用匪浅., beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7881672775, createdName=通通, createdTime=Fri Jun 29 08:18:59 CST 2018, time=2018-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327881, encodeId=102f32e881ac, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Fri Jun 29 07:18:32 CST 2018, time=2018-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327767, encodeId=57a932e76781, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Thu Jun 28 22:24:38 CST 2018, time=2018-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327758, encodeId=a18332e758df, content=学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzaiabIFicf63hKvVMjL6aJlx4yX4UcXmzX9DyibCRcicq0QtCRWMaQKh8MYjE1D3EKUBopgiaGWYuqbeR/0, createdBy=0c2b1999806, createdName=三生有幸9135, createdTime=Thu Jun 28 21:36:57 CST 2018, time=2018-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327745, encodeId=dfec32e7452d, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Thu Jun 28 21:12:33 CST 2018, time=2018-06-28, status=1, ipAttribution=)]
    2018-06-28 明月清辉

    谢谢分享.学习了

    0