基础电生理：心室拖带鉴别室上速及房速

2018-01-29 佚名心电生理之声

xujie.L

医生/

窄QRS波室上性心动过速(SVT)最常需要鉴别的类型是房速、房室结折返性心动过速、间隔部顺向性房室折返性心动过速。于SVT发作时进行心室拖带，根据最后一个心室刺激后的心房反应是A-A-V还是A-V模式可用来鉴别房速。

窄QRS波室上性心动过速(SVT)最常需要鉴别的类型是房速、房室结折返性心动过速、间隔部顺向性房室折返性心动过速。于SVT发作时进行心室拖带，根据最后一个心室刺激后的心房反应是A-A-V还是A-V模式可用来鉴别房速。

原理：心室起搏拖带室上性心动过速时，逆传房波经过的途径不同。

1、心室拖带后的A-A-V反应

房速发作时心室起搏，激动经房室结逆传产生逆传房波(A波)，这个逆传A波不可能在这么短时间内再次顺传激动心室；如房速不终止，房速的A波可以经房室结下传，所以表现为A(逆传的)-A(房速的)-V的反应模式 (图A)。

2、心室拖带后的A-V反应模式

对于房室折返和房室结折返性心动过速，逆传A波经旁路或房室结另一不应期短的径路逆传心房激动A波，再从房室结或不应期长的径路顺传激动心室，表现为A(逆传的)-V的反应模式(图B)。

3、起搏位置和方法

起搏位置：右室心尖或基底部，推荐基底部，但注意避开室间隔前基底部，因为前间隔基底部容易夺获希氏束。

起搏方法：在右室心尖或基底部以短于心动过速周长20-30ms的周长进行起搏拖带，并保证每一起搏的V波均能逆传产生A波，也就是必须室房1：1逆传，这一点非常重要。否则可产生假性A-A-V反应模式(图C) 或者假性的A-V反应模式(图D)。

4、两点注意事项

小心假性A-A-V反应：当室上速发生是由不典型旁路或逆传的VA是经过较慢的径路逆传产生时(慢旁道产生的AVRT，快慢型AVNRT，慢慢型AVNRT)可导致假的A-A-V反应，这时第一个A波由倒数第二个心室刺激的V波逆传产生，第二个A波由最后一个心室刺激的V波逆传产生而表现为类似房速的反应现象，所以只有心室刺激后的第一个A波由最后一个心室刺激V波逆传产生，才是真正的A-A-V反应。

鉴别要点：如A-A-V的A-A间期等于起搏周长要考虑假性A-A-V反应(图E)。

His束电极很重要：如果His电位在A-A-V中的第二个A波之前，可以除外房速，为假性A-A-V反应(图F)。

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2018-06-08 风铃829

#室上速#

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2018-01-31 虈亣靌

谢谢分享学习了

85 0
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2018-01-30 sunfeifeiyang

阅

88 0
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2018-01-30 131****1460

学习了受益匪浅

80 0
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2018-01-30 情途末路

学习了.获益匪浅!感谢分享

83 0
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2018-01-30 雾夜芭蕾

这些都是很重要的

68 0
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2018-01-30 雾夜芭蕾

如何更好地利用发挥

37 0
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2018-01-30 雾夜芭蕾

还是在临床凸显出来

29 0
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2018-01-30 雾夜芭蕾

一些基础研究的重要性

28 0
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content=基础电生理的作用, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLBkyaelI9ia3n9SbuKmBdaY0PqCOzd0nhRUstroXmUmXZ5EBTmibtLEvCCIpyHAqxQXGfZz49ibrwjkg/0, createdBy=39781652829, createdName=雾夜芭蕾, createdTime=Tue Jan 30 06:49:57 CST 2018, time=2018-01-30, status=1, ipAttribution=)]
2018-01-30 雾夜芭蕾

基础电生理的作用

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