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1、 希氏希氏束旁起搏鉴别室上速束旁起搏鉴别室上速 Para-His Pacing 心内科心内科 王炎王炎 华中科技大大学同济医学院附属同济医院华中科技大大学同济医学院附属同济医院 Prepared from: Hirao K et al. Circulation 1996;94:1027-1035 Schematic representation of the responses to para-Hisian pacing. Hirao K et al. Circulation 1996;94:1027-1035 Copyright American Heart Association Figu
2、re1. Schematic representation of the responses to para-Hisian pacing. A1, In the presence of only retrograde AP conduction, ventricular capture results in early retrograde conduction over the AP. Since retrograde conduction over the AV node is absent, simultaneous capture of the HB-RB has no effects
3、 on retrograde atrial activation. A2, Loss of HB-RB capture has no effect on the timing of the retrograde atrial activation, which is dependent only on the timing of ventricular activation at the AP. The atrial activation sequence and the S-A interval remains the same, while the delay in the timing
4、of the retrograde His bundle activation results in the shortening of the H- A interval. B1, In the presence of only retrograde AV nodal conduction, HB-RB capture results in early retrograde atrial activation via the AV node. B2, With loss of HB-RB capture, the delay in the timing of the retrograde H
5、is bundle activation results in an equal delay in the timing of retrograde atrial activation. The atrial activation sequence and H-A interval remain the same, while the S-A interval increases in all electrograms. C1, In the presence of both retrograde AP and AV nodal conduction, HB-RB capture result
6、s in early retrograde atrial activation by both the AP and AV node. C2, Loss of HB-RB capture has little effect in the timing of retrograde atrial activation via the AP but delays the contribution to atrial activation from the AV node. This results in a change in the retrograde atrial activation seq
7、uence. The S-A interval will increase at sites near the AV node but may remain essentially the same near the AP. The H-A interval may remain the same or shorten. The degree of atrial fusion resulting from retrograde conduction over the AP and AV node is dependent on the magnitude of the delay in His
8、 bundle activation, the intraventricular conduction time from the para-Hisian pacing site to the AP, and the retrograde conduction times over the AP and AV node. Radiographs in the right anterior oblique projection illustrating the catheter positions used for para-Hisian pacing. Hirao K et al. Circu
9、lation 1996;94:1027-1035 Copyright American Heart Association Figure2. Radiographs in the right anterior oblique projection illustrating the catheter positions used for para-Hisian pacing. A, A deflectable octapolar catheter (2-mm spacing) was positioned to record activation of the His bundle or pro
10、ximal right bundle branch from the distal pair of electrodes (HB). A deflectable quadripolar catheter with 2-mm spacing between the distal pair of electrodes (RV) was positioned 1 cm anterior and apical to the His bundle. During continuous pacing at high output between the distal pair of electrodes,
11、 the RV catheter was slowly withdrawn to the position in B, which resulted in direct HB-RB capture in addition to ventricular capture. This para-Hisian pacing site (RVPH) was located 5 mm anterior and apical to the His bundle. RAA indicates electrode catheter in the right atrial appendage; CS, cathe
12、ter with eight groups of orthogonal electrodes positioned within the coronary sinus and great cardiac vein; and PS, mapping catheter positioned at the posteroseptal tricuspid annulus. Para-Hisian pacing demonstrating retrograde conduction over the slow AV nodal pathway (AVN/AVN pattern). Hirao K et
13、al. Circulation 1996;94:1027-1035 Copyright American Heart Association Figure3. Para-Hisian pacing demonstrating retrograde conduction over the slow AV nodal pathway (AVN/AVN pattern). The pacing stimulus (S) in the left complex resulted in ventricular capture and HB-RB capture, producing a relative
14、ly narrow QRS complex and early activation of the His bundle (H). HB-RB capture was lost in the right complex, resulting in widening of the QRS complex and a 60-ms increase in the S-H interval from 10 to 70 ms. This was also associated with a 60-ms increase in the S-A interval from 120 to 180 ms, wi
15、thout a change in the retrograde atrial activation sequence. The constant H-A interval (110 ms) and atrial activation sequence indicate that retrograde conduction was dependent on His bundle activation and not on local ventricular activation, indicating retrograde conduction exclusively over the AV
16、node. Earlier atrial activation in the proximal coronary sinus electrogram (CSp) than in the His bundle electrogram (HBp) suggests retrograde conduction over the slow AV nodal pathway. This tracing was recorded after ablation of a left lateral accessory AV pathway. Para-Hisian pacing demonstrating retrograde conduction over the fast AV nodal pathway (AVN/AVN pattern) in a patient with AVNRT. The pacing stimulus (S) in the left
