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1、1 2 3 4 1,3Fogoros, Electrophysiologic Testing, 2nd ed. 1995, p 1301; p 1322 5 A = atriofascicular B = nodofascicular C = nodoventricular* D = fasciculoventricular E = atrioventricular (Kent) *first described by Mahaim 6 7 8 9 10 11 Anywhere except here (fibrous trigone) 12 Atrium Ventricle AV Node

2、Right Bundle Branch Left Bundle Branch 13 Atrium Ventricle AV Node Right Bundle Branch Left Bundle Branch 14 Atrium Ventricle AV Node Right Bundle Branch Left Bundle Branch 15 Fusion of the QRS occurs because there is simultaneous conduction down the AV node and accessory pathway 16 If the HV interv

3、al is 35 msec it suggests there is pre-excitation of the ventricles In children the HV interval can normally be 35 msec 17 Manifest Antegrade and restrograde AP conduction present Delta wave present Concealed No atengrade AP conduction present (retrograde only) No delta wave 18 19 20 21 22 Fitzpatri

4、ck, et al., JACC, Vol. 23, No. 1, Jan. 1994, p. 110 23 Note the pre-excitation as evidenced by the delta wave, resulting in a short PR interval Delta Wave Short PR Interval Normal ECG with no delta wave and a normal PR interval and QRS 24 25 26 27Arruda, et.al., JCE Vol 9 #1 Jan 1998, pp. 2-12 28Arr

5、uda, et .al., JCE Vol 9 #1 Jan 1998, pp. 2-12 More examples 29 Fitzpatrick, Pace, Vol. 18, Aug. 1995, p. 1472 30Chen, et al., AJC, Vol. 76, July 1995, p. 44 31 Left lateral Cain, et al., AJC Vol. 59, May ,1987 p. 1096 32 Right postero - septal Cain, et al., AJC Vol. 59, May ,1987 p. 1096 33 DAvila,

6、et al., Pace Vol. 18, September ,1995 p. 1619-1626 This algorithm uses the polarity of the “QRS” wave since the polarity of the delta wave usually follows that of the “QRS” wave. Simple but accurate (92%)! 34 DAvila, et al., Pace Vol. 18, September ,1995 p. 1619-1626 This shows lead III in which the

7、re is a deep “Q” wave followed by a small “r” and small “s” with the “QRS” complex being negative, which is indicative of a mid- septal accessory pathway (100% accuracy) 35 DAvila, et al., Pace Vol. 18, September ,1995 p. 1619-1626 Leads V1 and lead III are both negative and lead III has no Qrs patt

8、ern. Lead II is negative and lead V2 negative suggesting a diagnosis of a: Right Lateral Accessory Pathway 36 Milstein, et al., Pace Vol. 10, May, 1987 p. 555-563 The QRS complex is positive in both leads V1 and III suggesting a diagnosis of a: Left Lateral Accessory Pathway 37 Milstein, et al., Pac

9、e Vol. 10, May, 1987 p. 555-563 The QRS complex is negative in leads V1 and III, with no Qrs pattern in lead III. Leads II and V2 are positive suggesting a diagnosis of a: Right Lateral Accessory Pathway 38 Milstein, et al., Pace Vol. 10, May, 1987 p. 555-563 The QRS complex is negative in leads V1

10、and III, with no Qrs pattern in lead III. Lead II is negative and V2 positive suggesting a diagnosis of a: Posteroseptal Accessory Pathway 39 Atrium Ventricle AV Node Right Bundle Branch Left Bundle Branch 40 Atrium Ventricle AV Node Right Bundle Branch Left Bundle Branch 41 Atrium Ventricle AV Node

11、 Right Bundle Branch Left Bundle Branch 42 Atrium Ventricle AV Node Right Bundle Branch Left Bundle Branch 43 44 45 Orthodromic Tachycardia Antidromic Tachycardia Antidromic Antegrade conduction (from the atrium to ventricle) occurs down the AP and retrograde conduction (from the ventricle to the at

12、rium) up the normal conduction system (AV node). Orthodromic Antegrade conduction occurs down the normal conduction system and retrograde conduction up the AP. These terms are only applicable when the patient is in tachycardia (i.e., during intrinsic rhythm patient may be manifest or concealed, but

13、during tachycardia it is define as either antidromic or orthodromic) 46 The other conducts faster but has a longer refractory period Unidirectional block in one limb “Sinus”“Reentry” 47 Atrium Ventricle AV Node Right Bundle Branch Left Bundle Branch 48 49 50 51 52 53 54 Atrium Ventricle AV Node Righ

14、t Bundle Branch Left Bundle Branch 55 56 57 TCL TCL+35mSec 58 59 60 Rickerd, The New EP Techs Book, 3rd ed., 2002, p. 100 61 Rickerd, The New EP Techs Book, 3 rd ed., 2002, p. 101 Maximum preexcitation 62 Atrium Ventricle AV Node Right Bundle Branch Left Bundle Branch 63 Atrium Ventricle AV Node Rig

15、ht Bundle Branch Left Bundle Branch 64 65 Atrium Ventricle AV Node Right Bundle Branch Left Bundle Branch 66 Atrium Ventricle AV Node Right Bundle Branch Left Bundle Branch 67 68 69 70 71 72 73 L 1 aVf V1 HRA HB Prox HB 5-6 HB 3-4 HB Dist RF Prox RF Dist CS Prox CS 7-8 CS 5-6 CS 3-4 CS Dist RVA 74 L

16、 1 aVf V1 HRA HB Prox HB 5-6 HB 3-4 HB Dist RF Prox RF Dist CS Prox CS 7-8 CS 5-6 CS 3-4 CS Dist RVA 75 L 1 aVf V1 HRA HB Prox HB 5-6 HB 3-4 HB Dist RF Prox RF Dist CS Prox CS 7-8 CS 5-6 CS 3-4 CS Dist RVA L 1 aVf V1 HRA HB Prox HB 5-6 HB 3-4 HB Dist RF Prox RF Dist CS Prox CS 7-8 CS 5-6 CS 3-4 CS D

17、ist RVA The general location of left sided APs can be found by “bracketing” the AP using the CS electrograms. You try to find an electrogram sequence in which the interval between the “A” and “V” waves, or vice versa, goes from a wide interval to narrow interval and back to a wide interval. The gene

18、ral location of the AP will be between the 2 wide intervals, near the narrow interval. In this case the narrowest interval is at CS3-4 (A), so the catheter was advanced a couple millimeters resulting in the narrowest interval being at CS5-6. 76 77 78 Svenson, et al., Circ., Vol. 52, Oct. 1971, p. 55

19、4 79 More on unipolar recording 80 81 1Wider Narrow The general location of a left sided AP can be located by bracketing, but that only locates it between 2 electrodes. Thus, you can then look at the unipolar recordings to see the site where the A and V fuse and you have the steepest slope (QS) as i

20、n CS2 above. 82 83 AnteriorPosterior “Essentially unfiltered” (1Hz to 2500Hz) bipolar recording Recorded during ORT (V-A activation) Catheter pulled from posterior to anterior Left lateral AP 84 85 86 87 88 Morady F. N Engl J of Med. 1999;340:534-544. 89 90 91 92 Narrow QRS Wide QRS His and V capture V capture only Variable Stim -A 93 Narrow QRS Wide QRS His and V capture V capture only Fixed Stim - A 94 TV MV CS 95 Swartz, et al., Circ., Vol.87, No.2, Feb. 1993, p. 492 96