关键词： 房性心动过速；持续性交界区反复性心动过速；鉴别诊断

【摘要】 目的初步探讨房性心动过速(房速)与持续性交界区反复性心动过速(permanent junctional reciprocating tachycardia,PJRT)快速鉴别方法。方法36例室上性心动过速患者，经心内电生理检查，其中30例诊断为房速，6例诊断为PJRT；心动过速时于右心室行S₁S₁起搏(S₁S₁间期较心动过速周长短10～40 ms)，观察心室起搏呈1∶1室房(VA)传导者停止起搏后即刻心电激动顺序，分为“房房室”(AAV)及“房室”(AV)顺序。结果右心室起搏时，30例房速中6例为PJRT，其VA传导呈1∶1，停止起搏后即刻心电激动顺序分别为AAV及AV。结论提示鉴别房速与PJRT，心室起搏时VA分离固然有助于前者诊断，但对呈1∶1 VA传导者，观察起搏停止后心电激动顺序，具有快速、准确鉴别作用。

Rapid differentiation of atrial tachycardia from permanent junctional reciprocating tachycardia

ZHAN Xianzhang

(Department of Cardiology,Guangdong Cardiovarscular Institute,Guangzhou 510100,China)

WU Shulin

(Department of Cardiology,Guangdong Cardiovarscular Institute,Guangzhou 510100,China)

LI Haijie

(Department of Cardiology,Guangdong Cardiovarscular Institute,Guangzhou 510100,China)

【Abstract】ObjectiveTo explore the rapid differentiation of atrial tachycardia (AT) from permanent form of junctional reciprocating tachycardia (PJRT).MethodThirty-six patients with supraventricular tachycardia underwent electrophysiologic study.ATs were induced in 30 cases and PJRTs were diagnosed in 6 cases.Right ventricular pacing (S₁S₁) was initiated at a cycle length 10 to 40 msec shorter than the tachycardia cycle length to observe the electrogram sequence upon cessation of the ventricular pacing associated with 1∶1 ventriculoatrial conduction during tachycardia in each patient.The electrogram sequence immediately after the last ventricular paced complex was categorized as “atrial-atrial-ventricular” (AAV) or “atrial-ventricular” (AV).Result1∶1 ventriculoatrial conduction during right ventricular pacing was observed in 6 patients with AT and 6 cases with PJRT.The AAV response was recorded in the 6 patients of AT and the AV response was observed in all cases of PJRT.Conclusion This result suggests that VA dissociation in vertricular pacing is useful for the diagnosis of AT,however,the electrogram sequence upon cessation of the pacing allows for the rapid and accurate differentiation of AT from PJRT.

【Key words】Atrial tachycardia;Permanent junctional reciprocating tachycardia;Differential diagnosis

在射频消融治疗心律失常时代，房性心动过速(房速)的鉴别诊断尤为重要，但有时很困难，很费时^［1，2］，如房速与持续性交界区反复性心动过速(permanent junctional reciprocating tachycardia,PJRT)的鉴别。本组分析了房速和PJRT在右心起搏停止后即刻心电激动情况，分为“房房室”(AAV)及“房室”(AV)顺序，旨在初步探讨两者快速、准确鉴别方法。

资料和方法

临床资料1995年5月至1998年12月经电生理检查证实为房速或PJRT患者，共36例，男性15例，女性21例，年龄15～63岁，均有阵发性心悸史，病程3个月～13年，发作时心电图示室上性心动过速，频率140～220次/min，用过1～3种抗心律失常药物治疗，效果欠佳。其中高血压性心脏病、扩张型心肌病各1例，心动过速性心肌病2例，房间隔缺损2例，其余病例无器质性心脏病(占84%)。

心内电生理检查及观察指标术前停用抗心律失常药至少1周。经静脉途径放置电极导管于冠状静脉窦、高位右心房、希氏束记录部位和右心室心尖部。进行常规心内电生理检查，根据有关诊断标准^［2-4］，30例诊断为房速，6例诊断为PJRT。心动过速时于右心室行S₁S₁(S₁S₁间期较心动过速周长短10～40 ms)起搏，观察室房(VA)呈1∶1传导者停止起搏后即时心电激动顺序，分为AAV与AV两种顺序。

结果

右心室起搏时，30例房速中6例及所有(6例)PJRT VA传导呈1∶1。心室起搏停止后，前者均记录到AAV心电激动顺序，后者全为AV顺序(如图1、2)。

图1房性心动过速在心室起搏停止后

即时的心电激动顺序，呈AAV顺序

图2持续性交界区反复性心动过速于心室起搏停止后

即刻心电激动顺序，呈AV顺序

讨论

Knight等^［1］对房室结折返性心动过速102例、房室折返性心动过速43例、房速19例及心房起搏模拟房速32例进行心室起搏，观察起搏停止后心电激动顺序，结果显示所有房速及模拟房速，均为AAV顺序，而房室结折返性心动过速、房室折返性心动过速则全部呈AV顺序，提示此两种顺序有助于房速快速诊断，但其中未包括PJRT病例。房速与PJRT在窦性心律时心室起搏，VA均呈递减传导，心动过速时心室起搏均可呈1∶1 VA传导，虽然逆传心房激动顺序不同有助于诊断，但房间隔下部房速与中间隔慢旁路介导的PJRT，鉴别很难。

本组观察了房速与PJRT于心室起搏停止后心电激动顺序，结果示房速均为AAV，而PJRT为AV顺序。原因在于前者心室起搏时冲动经希氏束逆传并激动心房，产生第1个A波，该A波不能经仍处于有效不应期的希氏束进入心室，而第2个非逆传A波则可下传心室产生V波，从而形成AAV^［1］；后者心室起搏经慢旁路逆传，逆传A波可经希氏束下传至心室，形成AV顺序。

本组结果提示，鉴别房速与PJRT，通过心室起搏，VA分离固然有助于前者诊断，但对呈1∶1VA传导者，观察起搏停止后心电激动顺序，具有快速、准确鉴别作用。

参考文献

1，Knight BP,Zivin A,Souza J,et al.A technique for the rapid diagnosis of atrial tachycardia in the electrophysiology laboratory.J Am Coll Cardial,1999,33∶775-780.

2，Kay GN,Chang F,Epstein AE,et al.Radio-frequency ablation for treatment of primary atrial tachycardias.J Am Coll Cardiol,1993,21∶901-909.

3，Chien WW,Cohn TJ,Lee MA,et al.Electrophysiological findings and long-term follow up of patients with the permanent form of junctional reciprocating tachycardia treated by catheter ablation.Circulation,1992,85∶1329-1336.

4，杨延宗，林治湖，高连君，等.导管射频消蚀隐匿性慢旁路心动过速五例报告.中华心血管病杂志，1995，23∶224-225.

(收稿日期：1999-08-01)