Koch-三角解剖与临床

Koch三角解剖与临床上海长征医院心内科廖德宁1精选2021版课件一、Koch三角解剖与组织学

2精选2021版课件Koch三角的解剖

Koch1909年首先描述，由Todaro腱、冠状静脉窦口及三尖瓣膈环组成。房室结位于Koch三角的顶部解剖和功能上是心房和希氏束的连接（房室交界区）3精选2021版课件Koch三角的组织学房室结细胞：小细胞、紧密无序排列，细胞间连接极少移行细胞：介于结细胞与心房肌细胞之间，有2个移行方向心房肌细胞4精选2021版课件房室结后延伸（PNE）5精选2021版课件人房室结后延伸（PNE）人房室结具有右和左后延伸左后延伸朝左行向房间隔右后延伸与三尖瓣隔瓣近乎平行,可达冠状窦口附近，被认为参与了慢径传导6精选2021版课件房室结后延伸（PNE）N=8N=2N=6N=1右+左右左无InoueN=2113710周聊生N=1786127精选2021版课件二、Koch三角与房室结双径路8精选2021版课件房室结双径路1956年Moe在犬的心脏找到房室结双径路的电生理证据，即快径传导快/不应期长；慢径传导慢/不应期短1968年该概念应用于人的心脏。9精选2021版课件Aschoff标准：组织学差别、踪迹连续、与正常心肌绝缘

10精选2021版课件房室结双径路房室结真结细胞和移行细胞虽有组织学差别和踪迹连续，但无绝缘层移行细胞即为房室结真结细胞与心房肌的传导纽带11精选2021版课件房室结双径路慢径组成：Koch三角下后缘心房肌、移行细胞、PNE、真结细胞快径：房间隔心肌细胞、移行细胞、真结细胞12精选2021版课件房室结双径路13精选2021版课件14精选2021版课件Koch三角传导的异向性：

双径路的解剖基础Koch三角内心房肌非均一排列传导的异向性传导延缓/单向传导阻滞折返形成Hocin：犬和猪心脏方向依赖性早搏仅引起Koch三角传导延迟4－21ms，而AH延长达80－120ms。说明传导延迟主要发生在房室结后延伸与真结细胞15精选2021版课件房室结后延伸（PNE）：

慢径的解剖与电生理基础Inoue:人右PNE沿三尖瓣环延伸，可记录到双电位，是慢径消融位置。Medkour:兔心PNE沿三尖瓣环延伸至冠状静脉窦口，与房室结相比，具有更短的周长依赖性不应期，不连续传导，延迟的房室结反应与折返16精选2021版课件17精选2021版课件18精选2021版课件慢径消融靶点Quintana：1例AVNRT行慢径消融的患者尸检发现消融线在心房肌慢径消融时消融的可能是正常心房肌。慢径消融时避免损伤房室结动脉。Kozlowski：50例人心房室结动脉中，20％位于冠状窦口附近心内膜下。冠状窦口附近消融及快径消融可消弱迷走神经的支配，导致心脏迷走神经功能下降起搏标测Koch三角可以发现快径缺如或靠近慢径，从而避免房室传导阻滞19精选2021版课件慢径消融靶点影像分区

A区:A1A2M区:M1M2P区:P1P220精选2021版课件腺苷对房室结双径路的作用EffectsofATP(20mg)onAVconductionbefore（A）andafter（B）radiofrequencyablationoftheslowpathway21精选2021版课件三、Koch三角与迷走神经22精选2021版课件Koch三角内迷走神经分布与作用Koch三角的迷走神经支配主要来自下腔静脉与左房交界处脂肪垫内的迷走神经节团迷走神经主要支配结细胞刺激房室结区迷走神经可以减慢房颤心室率消融慢径可以缩短快径有效不应期23精选2021版课件Koch三角迷走神经分布与作用Shah：阈下刺激方法证明迷走神经多位于His束下（7/13），也有位于His束和CSO（3/13，3/13）24精选2021版课件临床意义房颤时房室结的递减性与隐匿性传导导致了慢的和不规则的心室率。房颤时慢径和快径均参与了传导，慢径前传多于快径前传。故消融慢径可以减慢房颤时的心室率。消融慢径可以缩短快径有效不应期刺激房室结区迷走神经可以减慢房颤心室率25精选2021版课件VentricularRateControlbySelectiveVagalStimulationIs

SuperiortoRhythmRegularizationbyAtrioventricular

NodalAblationandPacingDuringAtrialFibrillationSelectiveatrioventricularnodal(AVN)vagalstimulation(AVN-VS)wasdeliveredtotheepicardialfatpadthatprojectsparasympatheticnervefiberstotheAVNin12dogsduringAF.Acomputer-controlledalgorithmadjustedAVN-VSbeatbybeattoachieveameanventricularRRintervalof75%,100%,125%,or150%ofspontaneoussinuscyclelength.TheAVNwasthenablated,andtherightventricular(RV)apexwaspacedeitherirregularly(i-RVP)usingtheRRintervalscollectedduringAVN-VSorregularly(r-RVP)atthecorrespondingmeanRR.Theresultsindicatedthatall3strategiesimprovedhemodynamicscomparedwithAF.However,AVN-VSresultedinsignificantlybetterresponsesthaneitherr-RVPori-RVP.i-RVPresultedinworsehemodynamicresponsesthanr-RVP.ThedifferencesamongthesemodesbecamelesssignificantwhenmeanVRwasslowedto150%ofsinuscyclelength.Conclusions—AVN-VScanproducegradedslowingoftheVRduringAFwithoutdestroyingtheAVN.ItwashemodynamicallysuperiortoAVNablationwitheitherr-RVPori-RVP,indicatingthatthebenefitsofpreservingthephysiologicalantegradeventricularactivationsequenceoutweighthedetrimentaleffectofirregularity.ShaoweiZhuangCirculation.2002;106:1853-185826精选2021版课件SelectiveAVnodalvagalstimulationimproves

hemodynamicsduringacuteatrialfibrillationindogs

Electrophysiological-echocardiographicexperimentswereperformedon11anesthetizedopen-chestdogs.Hemodynamicmeasurementswereperformedduringthreedistinctperiods:1)sinusrate,2)AF,and3)AFwithvagalnervestimulation.AFwasassociatedwithsignificantdeteriorationofallmeasuredparameters(P,0.025).Thevagalnervestimulationproducedslowingoftheventricularrate,significantreversalofthepressureandcontractileindexes(P,0.025),andasharpreductioninone-halfoftheabortiveventricularcontractions.SlowingoftheventricularrateduringAFbyselectiveganglionicstimulationofthevagalnervesthatinnervatetheAVNsuccessfullyimprovedthehemodynamicresponses.Wallick,DonW

AmJPhysiolHeartCircPhysiol2001；281:H1490–H1497

27精选2021版课件谢谢！28精选2021版课件房室结后延伸（PNE）兔心PNE沿三尖瓣隔环延伸至冠状静脉窦口。与房室结相比有更短的周长依赖性不应期、不连续传导、延迟的房室结反应及折返。Medkour29精选2021版课件房室结后延伸（PNE）Inoue：21例人尸体心脏房室结有向右和向左后延伸，右后延伸沿三尖瓣隔环向下，被认为参与了慢径传导右+左13右7左130精选2021版课件上腔静脉下腔静脉卵圆窝房间隔右心耳梳状肌冠状窦口Todaro腱31精选2021版课件Koch三角解剖与组织学Koch三角与房室结双径路Koch三角与迷走神经Koch三角与腺苷32精选2021版课件33精选2021版课件34精选2021版课件起搏标测Koch三角可以发现快径缺如或靠近慢径，从而避免房室传导阻滞。theanterogradelyconductingfastpathway(AFP)basedontheshortestSt-Hintervalobtainedbystimulatingtheanteroseptal,mi