V_(1)呈qrS或QS型伴下降支有顿挫的流出道室性心律失常鉴别流程  

The results of radiofrequency ablation in ventricular arrhythmia with qrS or QS morphology in lead V_(1) with a notch on the downward deflection

作　　者：谢尚合 林佳选[1] 李岳春[1] 李进[1] 林加锋[1] XIE Shang-he;LIN Jia-xuan;LI Yue-chun;LI Jin;LIN Jia-feng(The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University,Wenzhou 325027,Zhejiang,China)

机构地区：[1]温州医科大学附属第二医院育英儿童医院,浙江温州325000

出　　处：《中国心脏起搏与心电生理杂志》2022年第6期523-529,共7页Chinese Journal of Cardiac Pacing and Electrophysiology

基　　金：国家自然基金(项目编号:82070333);浙江省温州市科技局重大科研项目(ZY2020018)。

摘　　要：目的 探讨心电图下壁呈R型,且V_(1)呈qrS或QS型伴下降支有顿挫的室性心律失常(VAs)的起源并提出鉴别流程。方法 2008年1月至2021年7月,心电图V_(1)呈qrS或QS型伴下降支有顿挫且射频消融成功的连续性流出道VAs病例纳入本研究。根据有效靶点分为2组:(1)右室起源组(RV组):包括右室流出道(RVOT),肺动脉左窦与前窦,右室前间隔上部(His上方);(2)左室起源组(LV组):包括左冠窦(LCC)、右冠窦(RCC),左右冠窦交界处(L-RCC),主动脉窦-二尖瓣连接区(AMC)。分析2组心电图特征的差异并提出鉴别流程。结果 研究共纳入患者99例。其中LV组49例,RV组50例,LV组胸导联移行区≤V3及胸导联移行指数<0的发生率分别为89.8%(44/49)及91.8%(45/49)均明显高于RV组的48.0%(24/50)及18.0%(9/50)(P<0.001);亚组分析显示,在LV组中,L-RCC及RCC在Ⅰ导联呈R、r或Rs型的发生率相似分别96.0%(24/25)和86.7%(13/15)且明显高于LCC及AMC的14.3%(1/7)和50%(1/2)(P均<0.001)。若以胸导联移行指数<0作为LV起源,Ⅰ导联呈r、R或Rs型作为L-RCC或RCC起源的指标,其灵敏度、特异度、阳性预测值、阴性预测值分别为91.8%、82.0%、83.3%、91.1%与92.5%、77.8%、94.9%、70.0%。结论 V_(1)呈qrS或QS型伴下降支有顿挫的流出道VAs并非均起源于L-RCC,亦可起源于RVOT、肺动脉窦、右室前间隔上部(右His上方)及RCC、LCC和AMC,根据胸导联移行指数<0预测LV起源,再结合Ⅰ导联呈r、R或Rs型预测L-RCC或RCC起源简单可行。Objective To investigate the origin of ventricular arrhythmias(VAs) with R wave in inferior leads, qrS or QS wave with a notch on the downward deflection in lead V_(1), and put forward the identification process. Methods All the patients were divided into two groups according to the site of effective target:(1)Right ventricle(RV) group including right ventricular outflow tract(RVOT), pulmonary sinus(PS), upper of anterior septum right ventricular side(above His);(2)left ventricle(LV)group, including left coronary cusp(LCC), right coronary cusp(RCC), left and right coronary cusp(L-RCC) and aortic mitral coronary junction(AMC). The ECG characteristics were analyzed between the two groups. Results A total of 99 patients were included in this study, including 49 cases in LV group, 50 cases in RV group. The incidence of precordial transitional zone≤V3and precordial transitional zone index<0 in LV group was 89.8%(44/49) and 91.8%(45/49), higher than 48.0%(24/50) and 18.0%(9/50) in RV group(P<0.001). In LV group, The ratio of R, r and Rs in lead Ⅰ were similar between L-RCC(96.0%, 24/25) and RCC(86.7%, 13/15)(P>0.05) but were relatively lower in LCC(14.3%, 1/7)and AMC(50%, 1/2)(P<0.05). The precordial transitional zone index<0 indicate LV-VAs origin and r, R or Rs wave in leadⅠindicate L-RCC and RCC origin,with sensitivity,specificity,positive predictive value and negative predictive value were 91.8%,82.0%,83.3%,91.1% and92.5%,77.8%,94.9%,70.0%. Conclusions R wave in inferior leads and qrS wave or QS wave with a notch on the downward deflection in lead V_(1)is not allorigin in L-RCC.The precordial transitional zone index<0could help indicate LV-VAs origin and r,R or Rs wave in leadⅠcould help indicate L-RCC and RCC origin.[Chinese Journal of Cardiac Pacing and Electrophysiology,2022,36(6):523-529]

关 键 词：心血管病学 室性早搏 室性心动过速 射频消融 心电图 

分 类 号：R541.7[医药卫生—心血管疾病] R454.1[医药卫生—内科学] R540.41[医药卫生—临床医学]