心脏房室双径路和多径路课件

2006双径路和多径路 陈清枝陈清枝 教授教授 徐州医学院附院心内科 Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College双径路和多径路 Affiliated Hospita12006缩略语缩略语 SF-AVNRT 慢-快型房室结折返型心动过速 PJRT 交接区折返性心动过速 AVNRT 房室结折返型心动过速 FS-AVNRT 快-慢型房室结折返性心动过速PAS 房性期前收缩 W-P-W 典型预激综合征 AVRT 房室折返型心动过速 Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College缩略语 Affiliated Hospital o22006 概述 根据心脏电生理学分类，将正常房室传导系统以外的附加房室连接组织分为两类:房室旁道 房室结双径路或多径路 Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College 概述 A32006 房室间的各种附加连接组织及其引发的心电现象和心律失常是心脏科常见的临床病症。Dopirak等（1980）认为房室结的传导通路可以是2个、3个或4个，即所谓房室结双径路、三径路或多径路。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College 房室间的各种附加连接组织及其引发的心电现象和心律失常42006 以双径路最为常见，正常人群中的发生率约为30%。房室结双径路和房室旁道是产生折返性室上性心动过速的电生理和解剖学基础。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College 以双径路最为常见，正常人群中的发生率约为30%。52006 可直接反映在常规ECG上，也可间接反映在由其引发的各种心律失常上，有些则需要通过电生理检查而得以显露及/或证实。广泛意义上讲，由房室结双径路或多径路和房室旁道引发的各种心电现象，都可以称为双径路和多径路现象。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College Affiliated Hospital of 62006 房室结双径路房室结双径路 房室结双径路是指房室结在解剖学基础上的功能性纵向分离所形成的快慢传导通路。传导速度较慢的称为慢径路（径路），其电生理特点是传导速度慢、不应期较短；Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College 房室结双径路 Affiliated 72006 传导速度较快的称为快径路（径路），其电生理特点是传导速度快、不应期较长；发生心动过速时慢径路常作为下行支，快径路作为逆行支参与折返，形成SF-AVNRT；快径路下传形成的FS-AVNRT较少见。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College Affiliated Hospital of 82006房室结双径路的电生理特点房室结双径路的电生理特点 房室结双径路在电生理检查时（程序刺激），可出现房室传导的跳跃现象，即S1S2缩短10ms，房室传导时间（S2R2）突然延长50ms(体表ECG60 ms)，程序刺激扫查可得到清楚的P-R间期跳跃曲线。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College房室结双径路的电生理特点 房室结双径路在电生理92006 多数情况下，在出现跳跃的同时发生室上速。房室传导的跳跃现象是房室结双径路特有的电生理现象。(见下图)Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College 多数情况下，在出现跳跃的同时发生室上速。(见下图)102006房室结双径路的跳跃现象房室结双径路的跳跃现象 Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College房室结双径路的跳跃现象 Affiliated Hosp112006 机制：快径路的传导速度快，有效不应期长，通常情况下激动沿快径路下传心室，因此P-R间期正常（或相对较短）；当心房程序刺激（适时的PAS）到达快径路有效不应期时，激动便沿慢径路继续下传心室，因而P-R间期突然出现明显延长。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College Affiliated Hospital 122006 多数人都可能存在房室结双径路，但是能否发生室上速或其他心律失常，则取决于快慢径路不应期和传导速度的微妙变化及两者的差异。(见下图)Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College Affiliated Hospital 132006房室结双径路传导现象 Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College房室结双径路传导现象 Affiliated Hosp142006前向性房室结内双径路伴3相完全性右束支阻滞 Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College前向性房室结内双径路伴3相完全性右束支阻滞 Affili152006房室结双径路同步传导引起房室结双径路同步传导引起双重心室反应现象双重心室反应现象 一次室上性激动沿快慢两条通道顺序下传，引起两次激动心室的心电现象。1975年有学者报道，心房期前刺激可经快慢径路引起双重心室反应，形成非折返性阵发性室上速。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College房室结双径路同步传导引起双重心室反应现象 一次室162006 在双径路情况下出现双重心室反应取决于快慢径路的传导速度和有效不应期的巧妙配合。两条径路的差别愈大愈有利于形成此种心电现象。(见下图)Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College 在双径路情况下出现双重心室反应取决于快慢径路的传导速172006心室双重反应现象并诱发室上速心室双重反应现象并诱发室上速 Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College心室双重反应现象并诱发室上速 Affiliated H182006 SF-AVNRT 房室结双径路引发的室上速多为此种类型。心动过速时慢径路作为下行支激动心室、快径路作为上行支逆行激动心房。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College SF-AVNRT 房室结双径路引发的室上速多为此种192006心电图特点：QRS波时间及形态与窦性心律时相同或相似，心率150190次/分，多在160次/分左右，R-P间期70ms,V1、V2导联可见假性R波。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College心电图特点：QRS波时间及形态与窦性心律时相同或相似，心率1202006电生理检查:可见跳跃现象并同时诱发室上速;心内电生理检查表现为H-V-A，而且V-A间期很短（70 ms或V-A融合）。(见下图)Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College电生理检查:可见跳跃现象并同时诱发室上速;心内电生理检查表现212006慢快型AVNRT合并CRBBB Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College慢快型AVNRT合并CRBBB Affiliated 222006 FS-AVNRT 是一种少见的AVNRT。快径路作为下行支激动心室,慢径路作为上行支逆传心房。快慢径路的不应期相似或接近。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College FS-AVNRT 是一种少见的AVNRT。A232006心电图特点:与SF-AVNRT相似，但R-P间期相对较长。电生理检查:无跳跃现象，但仍可诱发室上速；心内电图仍表现为H-V-A。(见下图)Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College心电图特点:与SF-AVNRT相似，但R-P间期相对较长。242006快慢型AVNRT Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College快慢型AVNRT Affiliated Hospit252006 房室结三径路房室结三径路 临床上较为少见。在房室结同时存在快、慢和特慢三条径路，分别称为快径、慢径和中间径。三条传导径路的传导速度和不应期各不相同。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College 房室结三径路 临床上较为少见。Affiliat262006电生理检查：可见两次房室传导的跳跃现象，多数情况下可在某一次跳跃的同时引发室上速。发生机制同前。(见下图)Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College电生理检查：可见两次房室传导的跳跃现象，多数情况下可在某一次272006房室结三径路现象房室结三径路现象 Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College房室结三径路现象 Affiliated Hospita282006 房室间的混合附加通路房室间的混合附加通路 指同时存在房室结双径路和房室旁道，后者表现为显性或隐匿性预激综合征。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College 房室间的混合附加通路 指同时存在房室结双径路和房292006 发生心动过速时可以是双方共同参与，亦可以由一方引起室上速，另一方参与并维持，此时对不参与心动过速的一方称为旁观者。Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College 发生心动过速时可以是双方共同参与，亦可以由一方引起302006 谢谢各位谢谢各位 Affiliated Hospital of Affiliated Hospital of Xuzhou Medical CollegeXuzhou Medical College Affiliated Hospital o31