心电图诊断致心律失常性右室心肌病 表现和注意事项有哪些?

2017-08-07 廉姜芳 周建庆 临床心电图精解

本例患者反复胸闷、心悸十余年,经心电图诊断为致心律失常性右室心肌病。其心电图表现有哪些?Fontaine导联描记方法有什么优势?ε波的临床意义是什么?这些问题将在下文详细解答。

本例患者反复胸闷、心悸十余年,经心电图诊断为致心律失常性右室心肌病。其心电图表现有哪些?Fontaine导联描记方法有什么优势?ε波的临床意义是什么?这些问题将在下文详细解答。

【示教病例】

患者男性,56岁。反复胸闷、心悸十余年。胸闷心悸发作时行心电图检查(图4-9-1),予可达龙后再次检查心电图(图4-9-2)。超声心动图检查提示:右房、右室显着增大,右室整体收缩活动明显减低,三尖瓣重度关闭不全,少量心包积液。

【相关知识点】

1. Fontaine导联描记方法及临床意义

把4个肢体导联的夹子改成吸球电极,红色肢体导联电极(RA)放在胸骨柄作为阴极,黄色肢体导联电极(LA)放在剑突处作为阳极,绿色肢体导联电极(LL)放在常规V4导联位置作为阳极,常规Ⅰ导联描记的是RA(-)和LA(+)组成的FⅠ导联心电图,Ⅱ导联描记的是RA(-)和LL(+)组成的FⅡ导联心电图,Ⅲ导联描记的是LA(-)和LL(+)组成的FⅢ导联心电图。Fontaine导联能够更清晰地记录到右室部分心肌延迟除极产生的电位,与普通心电图相比,使记录ε波的敏感性提高2~3倍。



图4-9-1 心电图 心电图示宽QRS波心动过速,胸导联V1~V6主波一致向下,aVR导联呈R型(箭头所示),Ⅰ、Ⅱ、Ⅲ导联QRS主波均向下,心电轴位于“无人区”(-90°~±180°),部分导联T波形状不一致,提示有P波隐藏可能,以上心电图特征均支持室性心动过速诊断

心电图诊断:阵发性室性心动过速



图4-9-2 室性心动过速给予可达龙后恢复窦性心律 心电图呈窦性心动过缓,下壁、胸导联位于QRS之后ST段起始部可见低振幅的小棘波,以V1~V5最显着(向下箭头所示),提示为ε波,TV2~V6倒置,全导联低电压。右图为加做Fontaine导联,FⅠ、FⅡ、FⅢ导联的QRS时限长达240ms,ε波更加显着(斜箭头所示)

心电图诊断:室窦心动过缓,不完全性右束支传导阻滞,ε波(提示致心律失常性右室心肌病),T波改变,全导联低电压

2. 致心律失常性右室心肌病概述及心电图表现

致心律失常性右室心肌病(arrhythmogenic right ventricular cardiomyopathy,ARVC)或称致心律失常性右室发育不全(arrhythmogenic right ventricular dysplasia,ARVD)现以ARVD/C表示,主要是由于负责细胞黏附的桥粒蛋白基因突变所引起的一类遗传性疾病,其特征为右心室心肌不同程度的被纤维脂肪组织细胞替代,临床上常表现为右心室扩大、反复发作右室起源的室性心律失常、心力衰竭和猝死。1995年WHO/ISFC工作组专家委员会关于心肌病定义及分类的报告中,将ARVD/C列为与扩张型心肌病、肥厚型心肌病、限制型心肌病并列的第4类原发性心肌病。

ARVD/C患者纤维脂肪组织浸润好发于右室游离壁,使右室传导组织受损,导致QRS波增宽,多呈不典型右束支阻滞,有时在右胸前导联可见ε波,V1~V3导联T波倒置;右室瘢痕组织形成是产生室内折返的基础,易出现左束支阻滞图形的室性心动过速。同时超声心动图及MRI可发现右室整体和(或)局部运动障碍或无运动、收缩不协调及室壁瘤形成。

3. ε波的机制及临床意义

ε波位于QRS波之后、ST段起始处,呈高频、低振幅的小棘波或震荡波,持续几十毫秒不等,多见于V1~V3导联,亦可见于其他导联。本例ε波出现在V1~V5,以V3~V5导联最为明显,可能与右心室显着扩大,心脏顺钟向转位有关。ε波是由于右室部分心肌细胞萎缩被纤维脂肪组织替代,产生纤维脂肪组织包绕的岛状存活心肌细胞,使得该部分细胞除极延迟,延迟的除极波出现在QRS波后,ST段初始部分。ε波是ARVD/C较为特异的一个指标,但并非ARVD/C所特有,临床上引起右室心肌细胞延迟的病理过程都可出现ε波。

【复习题及答案解析】

1. 致心律失常性右室心肌病的心电图表现不包括

A. 常发作左束支阻滞图形室性心动过速

B. 常出现右束支阻滞

C. V1~V3导联T波倒置

D. V1、V2导联局限性QRS时限延长,部分可记录到Epsilon波

E. 右胸导联常见异常Q波

2. 下列哪些指标支持室性心动过速的诊断

A. 房室分离和室性融合波

B. 刺激迷走神经能抑制心动过速

C. 胸导联QRS波主波方向一致

D. 额面心电轴指向“无人区”

E. aVR导联呈R型



3. 下列临床上哪些可以出现V1~V3导联T波倒置

A. 部分正常人群,尤以女性、儿童多见

B. 急性肺栓塞

C. 致心律失常性右室心肌病

D. 急性前间壁心肌缺血

E. Brugada综合征

3. V1~V3导联T波倒置可见于各种病理因素导致右室损害而引起右室复极异常,如ARVD/C、Brugada综合征、急性肺栓塞、右心室肥大、急性前间壁心肌缺血或急性后壁心肌梗死的镜像改变等;各种除极异常而引起继发性复极异常,如RBBB;此外尚可见部分正常人群,幼稚性T波,尤以女性、儿童多见,其特点为V1~V3导联T波倒置逐渐变浅。答案:ABCDE

来源:《临床心电图精解》

作者:廉姜芳 周建庆

参编:叶明 葛世俊 巴艳娜 陈健

页码:106-109

出版:人民卫生出版社

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  4. 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beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c0a61971598, createdName=往日如昨, createdTime=Tue Aug 08 08:07:57 CST 2017, time=2017-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=231352, encodeId=ac6a2313522d, content=好深奥,学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo61WAV0ROeLAoicPxPKoKaogwLWLL8STv86qplbdOibN2YR4KxkJicqNectCXGR8gPJhGLc7yYLSdnpx4kaVXndTfu/0, createdBy=a6962042337, createdName=1391e9f2a7m, createdTime=Tue Aug 08 07:05:50 CST 2017, time=2017-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=231205, encodeId=feb0231205e0, content=学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Mon Aug 07 18:53:58 CST 2017, time=2017-08-07, status=1, ipAttribution=)]
    2017-09-04 海之蓝

    学习

    0

  5. 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channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Mon Aug 07 18:53:58 CST 2017, time=2017-08-07, status=1, ipAttribution=)]
    2017-08-15 大爰

    学习了谢谢分享!!

    0

  6. 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  7. 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channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Mon Aug 07 18:53:58 CST 2017, time=2017-08-07, status=1, ipAttribution=)]
    2017-08-09 ylzr123

    感谢小编为我们准备了如此丰盛的精神大餐,同时也向作者致谢!认真学习了,点赞!

    0

  8. 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channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Mon Aug 07 18:53:58 CST 2017, time=2017-08-07, status=1, ipAttribution=)]
    2017-08-08 往日如昨

    受益匪浅谢谢分享

    0

  9. 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channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Mon Aug 07 18:53:58 CST 2017, time=2017-08-07, status=1, ipAttribution=)]
    2017-08-08 1391e9f2a7m

    好深奥,学习一下

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  10. 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    2017-08-07 wxl882001

    学习一下

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