左室不同部位起源室性心律失常的体表心电图特征分析

Electrocardiographic characteristics of ventricular arrhythmia origin from left ventriculer

目的探讨左室起源室性心律失常基本心电图特征及左室不同部位起源室性心律失常的心电图特征。方法连续入选2005年3月至2014年10月大连医科大学附属第一医院收治的频发室性早搏(PVCs)和(或)室性心动过速(VT)并进行导管射频消融治疗成功的患者。所有患者均有临床PVCs/VT发作时的体表十二导联心电图,以术中消融治疗成功靶点作为室性心律失常的起源点,分析体表心电图QRS波群总体特征以及左室不同起源部位PVCs/VT的体表心电图各QRS波群形态特点。结果共纳入237例接受导管射频消融治疗成功的室性心律失常患者,其中78例起源于左室(78/237,32.9%)。左室起源的PVCs/VT在V1导联绝大多数呈rsR′或R形(72%),呈右束支传导阻滞图形特点,少部分V1呈rS或RS形(23.5%);胸导联R波移行多在V3导联之前(73.5%),移行在V3导联之后者少见(7.3%),移行在V3导联者为19.1%。其中V3导联移行指数常<0者占绝大多数(92.3%)。左室流出道主动脉瓣上(主动脉窦)与主动脉瓣下起源者下壁导联及V5-V6导联均呈高R形(87.5%);主动脉瓣上起源者特点为:V1导联多有S波呈rS/RS或QS形(84.2%),V1导联主波向下(84.2%)。主动脉瓣下起源者V1导联多呈R/rsR′形(80%),无S波,V1导联主波向上呈右束支阻滞图形(80%),主动脉瓣下起源者所有胸前导联均呈高R波(80%)。左纤维三角及二尖瓣环前壁起源者下壁导联呈高R形、V5-V6导联呈Rs形(100%),V1导联呈R/rsR′形呈右束支阻滞图形(100%)。左前分支及左前乳头肌起源者下壁导联主波向上为100%(下壁导联至少有1个导联呈qR形),且Ⅰ、aVL导联100%呈rS/QS形、V5-V6导联呈Rs形(100%)。左后分支及左后乳头肌起源者下壁导联主波向下(100%呈rS/QS形),且Ⅰ、aVL导联100%呈qR形、V5-V6导联呈rS/RS形(85.2%)。心尖部起源者下壁导联主波方向向下且均呈rS/QS形、V5-V6导联呈QS形(100%),其中Ⅰ导联均呈QS形。结论根据体表心电图胸导联R波移行导联、V3导联移行指数,可以明确PVCs/VT起源于左室;根据下壁导联、Ⅰ、aVL导联、V1导联、V5-V6导联QRS波群特征,可初步判断PVCs/VT在左室的各起源部位。

Objective To investigate electrocardiographic(ECG)features of left ventricular arrhythmias and ventricular arrhythmias originated from different sites of left ventricle Methods A total of 237 continuous patients with ventricular complexes(PVCs)and(or)ventricular tachycardia(VT)and underwent radiofrequency catheter ablation(RFCA)were collected from March 2005 to October 2014 in 1 st hospital of Dalian Medical University.All the patients received 12 leads ECGs were record when PVCs/VT occurred.The origin of ventricular arrhythmias was located as the ablate target inoperation record.Morphology features of QRS waves on the ECGs ofPVCs/VT were analyzed.Results 237 patients withventricular arrhythmias those who accepted RFCA successfully selected as final sample.According to the target of ablation,159 cases of ventricular arrhythmias derived from the right ventricle(159/237,67.1%)and 78 cases from the left ventricle(78/237,32.9%).56 patients(72%)which origin from the left ventricle appeared as rsR’or R in lead V1 and matched the features of right bundle branch block(RBBB).23.5%of that appeared as rS or RS in lead V1.The migration of R wave appeared before lead V3 in 50 patients(64.1%).Migration index of V3 lead was less than 0 in92.3%patients(12/13).QRS waves usually appear as high R shape in the inferior and V5-V6 leads when PVCs/VT derived from the superior/inferior of the aortic valve,rS/QS patternand R/rsR’pattern without S wave in lead V1,respectively.The main waves of QRS presented as positive(at least 1 qR shape in inferior leads,100%rS/QS in lead I,aVL,100%Rs in lead V5-V6)when PVCs/VT origin from the left anterior branch/papillary muscle.In contrast,the main waves of QRS waves were all negative in inferior leads and appeared as rS/QS,100%qR appeared in leads I,aVL,rS/QS appeared in leads V5-V6(85.2%),in patients which PVCs/VT derived from the left posterior branch and papillary muscle.PVCs/VT origin from left ventricular apex,the ECG with rS/QS in inferior leads,and QS in leads V5-V6,100%QS in lead I.Conclusion The migration lead of R wave and migration index of lead V3 can be used for primary identified the origin ventricle of PVCs/VT.The origin site of PVCs/VT could be further estimated according to the features of QRS waves in the inferior leads I,aVL,V1,V5-V6.[Chinese Journal of Cardiac Pacing and Electrophysiology,2019,33(4):312-309]