作者：王婷婷，王一丹，王蓉

单位：

100072 北京市，北京航天总医院心血管内科

Units：

Department of Cardiovascular, Beijing Aerospace General Hospital, Beijing 100072, China

关键词：

特发性室性期前收缩；特发性室性心动过速；左房室瓣环；间隔部；游离壁；心电图

Keywords：

Idiopathic premature ventricular contractions; Idiopathic ventricular tachycardia; Left atrioventricular annulus; Septum; Free wall; Electrocardiogram

CLC：

R 541.7　

DOI：

10.12114/j.issn.1008-5971.2021.00.146

Funds：

摘要：

背景　特发性室性期前收缩（IPVC）和特发性室性心动过速（IVT）多起源于左心室中后间隔和右心 室流出道，但经临床实践发现，不少患者起源于非典型部位，如起源于左房室瓣环等，而该类患者的电生理特征目前 尚无确切定论。目的　分析邻近左房室瓣环间隔与游离壁起源的IPVC/IVT 患者的心电图特征及其鉴别诊断，以期为 临床诊疗提供参考。方法　回顾性分析2016 年1 月—2020 年6 月北京航天总医院收治的96 例邻近左房室瓣环起源的 IPVC/IVT 患者的临床资料，根据起源部位的不同将所有患者分为A 组（邻近左房室瓣环间隔起源）51 例和B 组（邻 近左房室瓣环游离壁起源）45 例。患者均于进行射频消融治疗前行12 导联同步心电图检查。比较两组患者射频消融 治疗成功率、不同起源部位患者的心电图特征及胸前导联QRS 波群特征。绘制受试者工作特征（ROC）曲线评价心电 图胸前导联R、S 波振幅对邻近左房室瓣环间隔、游离壁起源的IPVC/IVT 的鉴别诊断价值。结果　B 组患者射频消融 治疗成功率高于A 组（P ＜ 0.05）。A 组不同起源部位患者Ⅱ、Ⅲ导联的r（R）、s（S）波，QSaVR、RaVL 波，aVF、 V1 导联的r（R）、s（S）波，V3 导联的r（R）波振幅比较，差异有统计学意义（P ＜ 0.05）；B 组不同起源部位患者Ⅱ、 Ⅲ导联的r（R）、s（S）波，RⅠ、QSaVR、RaVL 波，aVF 导联的r（R）、s（S）波，V2 导联的s（S）波，V4 导联的r（R） 波，RV5 波振幅比较，差异有统计学意义（P ＜ 0.05）。A、B 组Ⅰ、aVL、V5~V6 导联以R 波多见，少见左房室瓣环 前侧壁、前间隔起源者于aVL 导联出现qs、qr 波。A 组前间隔起源者心电图主要表现为Ⅱ、Ⅲ、aVF 导联QRS 波群 多为正向波，且r、R 波振幅Ⅲ导联＜ aVF 导联＜Ⅱ导联，s、S 波振幅Ⅱ导联＜ aVF 导联＜Ⅲ导联，aVR 导联多为负 向波。B 组V1~V3 导联以rS 波为多见，V4 导联则呈现R、Rs、RS、rS 或rSr' 波，B 组由左房室瓣间隔、游离壁上部、 中部、下部，下壁导联R 波递增而S 波呈递减趋势，r、R 波振幅Ⅲ导联＜ aVF 导联＜Ⅱ导联，s、S 波振幅Ⅱ导联＜ aVF 导联＜Ⅲ导联。A 组胸前导联移行区＜ V3 导联、胸前导联移行指数＜ 0、V1 导联QRS 波群以QS 波为主者所占比例高 于B 组（P ＜ 0.05）。ROC 曲线分析结果显示，V2 导联s（S）波振幅预测邻近左房室瓣环间隔、游离壁起源的IPVC/ IVT 的曲线下面积（AUC）最大，最佳截断值为-1.80 mV，灵敏度为88.24%，特异度为95.56%。结论　邻近左房室 瓣环起源的IPVC/IVT 患者的心电图特征为Ⅰ、aVL、V5~V6 导联以R 波多见，但不同起源部位的IPVC/IVT 患者在胸 前导联QRS 波群特征上存在不同的表现，V2 导联s（S）波振幅可作为临床鉴别诊断邻近左房室瓣环间隔和左房室瓣 环游离壁起源的IPVC/IVT 的指标。

Abstract：

Backgroud　Idiopathic premature ventricular contraction (IPVC) and idiopathic ventricular tachycardia (IVT) mostly originate from the left ventricular middle posterior septum and right ventricular outflow tract. However, clinical practice have found that many cases originate from atypical parts, such as left atrioventricular annulus. There is no definite view on the electrophysiological characteristics of these patients. Objective　To analyze the electrocardiogram characteristics and differential diagnosis of IPVC/IVT with the origin of left atrioventricular annulus septum and free wall, in order to provide reference for clinical diagnosis and treatment. Methods　Clinical data of 96 patients with IPVC/IVT with the origin of left atrioventricular annulus from January 2016 to June 2020 in Beijing Aerospace General Hospital. According to the location of origin, 51 cases were divided into group A (adjacent left atrioventricular annulus septum) and 45 cases were divided into group B (adjacentleft atrioventricular annulus free wall) . Patients were given 12-lead synchronous electrocardiogram examination before radiofrequency ablation therapy. Success rate of radiofrequency ablation, electrocardiogram characteristics of patients with different origin parts and QRS complex characteristics of chest lead were compared between the two groups, and receiver operating characteristic (ROC) curve was drawn to evaluate the differential value of R and S wave amplitude of anterior lead in IPVC/IVT with the origin of left atrioventricular annulus septum and free wall. Results　The success rate of radiofrequency ablation therapy in group B was significantly higher than that in group A (P < 0.05) . In group A, there were statistically significant differences in amplitude of r (R) , s (S) in leads Ⅱ and Ⅲ , QSaVR, RaVL waves, r (R) , s (S) waves in leads aVF and V1, and r (R) wave in lead V3 among patients with different origin parts (P < 0.05） ; in group B, there were statistically significant differences in amplitude of r (R) and s (S) waves in leads Ⅱ and Ⅲ , RⅠ , QSaVR, RaVL waves, r (R) and s (S) waves in lead aVF, s (S) wave in lead V2, r (R) wave in lead V4, RV5 wave among patients with different orgin parts (P < 0.05) . In groups A and B, Ⅰ , aVL, V5-V6 leads were seen as R wave, and qs and qr waves were rare appeared in aVL lead in patients with the origin of anterior wall and anterior septum of left atrioventricular annulus. In group A, IPVC/IVT ECG originated from the anterior septum mainly showed that, QRS complex in leads Ⅱ , Ⅲ and aVF were mostly positive wave, and r and R wave amplitude was lead Ⅲ < lead aVF < lead Ⅱ , s and S wave amplitude was lead Ⅱ < lead aVF < lead Ⅲ , aVR was mostly negative wave. In group B, rS wave was the most common in leads V1-V3, while R, Rs, RS, rS or rSr' waves appeared in lead V4, group B of septum from the left atrioventricular septum, the upper, middle and lower free wall, the R wave increased while the S wave decreased, the amplitude of r and R waves was lead Ⅲ < lead aVF < lead Ⅱ , and the amplitude of s and S waves as lead Ⅱ < lead aVF < lead Ⅲ . The proportion of transition area of thoracic lead < lead V3， transition index < 0 and QRS complex in V1 lead was dominated by QS wave in group A was higher than that in group B (P < 0.05) . The results of ROC curve showed that, area under curve (AUC) of the amplitude of s (S) wave in lead V2 in predicting IPVC/IVT originated from adjacent left atrioventricular annulus septum and free wall was the biggst, with the best cutoff value of -1.80 mV, sensitivity of 88.24% and specificity of 95.56%. Conclusion　The ECG characteristics of IPVC/IVT patients with adjacent left atrioventricular annulus origin are R wave in leads Ⅰ , aVL and V5-V6 , but IPVC/IVT patients with different origin parts have different characteristics of chest lead QRS complex, and s (S) wave amplitude in V2 lead can be used as a clinical differential diagnosis of IPVC/IVT patients with adjacent left atrioventricular annulus septum and origin of left atrioventricular annulus free wall.

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