希氏束区及毗邻部位室性心律失常的心电图定位方法

Electrocardiogram identification method to distinguish ventricular arrhythmias originating from HIS bundle area and adjacent locations

目的 经导管射频消融是特发性室性心律失常(VA)的常用治疗手段。在消融前通过VA的心电图(ECG)形态多能有效判定VA的起源位置,指导消融。但对于希氏束区(HIS)、右心室流出道后部(pRVOT)和三尖瓣前侧壁(TA-AL)等毗邻位置的ECG形态定位仍有很大难度。本研究旨在提出一种ECG诊断方法鉴别它们的起源点位置。方法 本研究连续入组了75例HIS(n=18)、pRVOT(n=42)和TA-AL(n=15)成功消融的VA患者。应用ECG参数中具有最高诊断性能的测量值来开发诊断方法。结果 在得到的这些ECG参数中,具有区分这些不同起源部位最佳诊断效能的参数是Ⅰ导联R波振幅和QRS波时程。最佳的ECG鉴别方法是Ⅰ导联R波振幅和QRS波时程的组合应用。HIS:Ⅰ导联R波振幅> 0.49 mV,QRS时程≤125.5 ms(敏感性72.2%、特异性100%);pRVOT:Ⅰ导联R波振幅≤0.49 mV,QRS波时程> 125.5 ms(敏感性88.1%,特异性81.8%);TA-AL:Ⅰ导联R波振幅> 0.49 mV,QRS波时程> 125.5 ms(敏感性66.7%,特异性95.0%)。这些诊断标准应用于判定VA起源部位的总体准确率为88.9%。结论 起源于HIS附近的VA其Ⅰ导联多为正向R波,且QRS波时程较短。Ⅰ导联R波振幅和QRS波时程的联合应用可用于定位VA起源于HIS、pRVOT或TA-AL。

AIM To propose an ECG diagnostic method to distinguish ventricular arrhythmias originating from HIS bundle area(HIS),posterior right ventricular outflow tract(pRVOT) and anterolateral of tricuspid annulus(TA-AL).METHODS Seventy-five consecutive patients with ventricular arrhythmias(VA) that were successfully ablated from HIS(n=18),pRVOT(n=42) or TA-AL(n=15) were enrolled in this study.The measurements of ECG parameters showed highest diagnostic performance were used to develop the diagnostic criterion.RESULTS Among the ECG parameters,R wave amplitude in lead Ⅰ and QRS duration were found to have the best diagnostic performance in distinguishing these different origins.The best ECG identification method was the combination of R wave amplitude in lead Ⅰ and QRS duration:HIS,R wave amplitude in lead Ⅰ>0.49 mV and QRS duration≤125.5 ms(sensitivity 72.2%,specificity 100%);pRVOT,R-wave amplitude in lead Ⅰ≤0.49mV and QRS duration >125.5 ms(sensitivity 88.1%,specificity 81.8%) and TA-AL,R-wave amplitude in lead I > 0.49 mV and QRS duration >125.5 ms(sensitivity 66.7%,specificity 95.0%).The overall accuracy of these diagnostic criteria in determining the site of origin of VA was 88.9%.CONCLUSION The VAs originating near HIS usually show positive R wave in lead Ⅰ and short QRS duration.The combined application of R wave amplitude in lead Ⅰ and QRS duration can be used to distinguish VAs originating from HIS,pRVOT or TA-AL.