中文字幕理论片,69视频免费在线观看,亚洲成人app,国产1级毛片,刘涛最大尺度戏视频,欧美亚洲美女视频,2021韩国美女仙女屋vip视频

患者女性，41歲，既往“突發(fā)心悸3年”，每次持續(xù)數(shù)分鐘后可自行停止，近兩月來(lái)發(fā)作較前頻繁，心電圖如圖1所示。

The ECG shown in Figure 1 was recorded in a 41-yearwoman with a 3-year history of palpitations of sudden onset, which lasted a few minutes and terminated spontaneously. The frequency of those episodes had increased during the past 2 months.

Figure 1:  12lead electrocardiogram showing a change from a regular rhythm with a narrow QRS to a much faster regular rhythm with left bundle branch block. Lowvoltage P waves seem to be located between 2 narrow QRS complexes.

1、圖1左側(cè)記錄的窄QRS波為何種心律？

1、What kind of narrow QRS rhythm is present on the left side of the recording?

2、圖1右側(cè)記錄的寬QRS波為何種節(jié)律？

2、What kind of wide QRS rhythm is present on the right?

3、窄QRS波和寬QRS波心律之間是否存在共同的心動(dòng)過(guò)速機(jī)制？

3、Is there a common tachycardia mechanism between the narrow and the wide QRS rhythm?

1. 房波在心率90次/分的窄QRS波心律時(shí)難以識(shí)別。P波在Ⅱ、Ⅲ 、aVF導(dǎo)聯(lián)中，呈負(fù)向、窄且低平；在V₂-V₆導(dǎo)聯(lián)中，P波似乎位于T波終末。圖中未見竇性心律。觀察窄QRS波顯示：在其末端存在負(fù)向房波與前面提及低平的房波極性一致，并精確地位于2個(gè)QRS波之間。如果判斷正確，房室呈2:1關(guān)系。

1.  During the narrowQRSrhythm, which has a rate of 90/min, atrial activity is difficult to identify. P waves, which are narrow and low in voltage and negative in leads II, III, aVF, and V2–V6 seem to be present at the end of the T wave. No sinus rhythm is present. Examination of the narrow QRS complexes reveals a negative deflection at their end with the same polarity as the low-voltage atrial deflections described earlier, exactly between 2 QRS complexes. If correct, there are 2 atrial deflections with 1 QRS complex.

2. 在該心電圖的中間段，心律變?yōu)?80次/分的寬QRS波心動(dòng)過(guò)速。其QRS波的寬度為130ms伴左束支傳導(dǎo)阻滯（LBBB）圖形。心動(dòng)過(guò)速時(shí)P波無(wú)法識(shí)別，但根據(jù)QRS波的形態(tài)和寬度，提示室上速伴L(zhǎng)BBB。

2.  In the middle of the tracing, the rhythm changes into a wide QRS tachycardia with a rate of 180/min. The QRS is 130 ms wide and has a left bundle branch block (LBBB) configuration. No P waves can be identified during the tachycardia, but QRS configuration and width suggest a supraventricular tachycardia with LBBB.

3. 結(jié)合以上兩點(diǎn)的討論，發(fā)現(xiàn)寬QRS波心動(dòng)過(guò)速的頻率恰好是窄QRS波的2倍。在窄QRS波心動(dòng)過(guò)速中，房波與QRS波的間期固定。故P波和QRS波之間存在固定的2:1的關(guān)系?；赑波的形態(tài)，考慮有2種診斷可能：

3.  Combining the findings described in 1 and 2, we note that the wide QRS tachycardia has exactly twice the rate of the episode with the narrow QRS. In view of the fixed distance between the atrial deflections and the QRS when the QRS is narrow, we conclude that, at that time, a fixed 2:1 relation between P waves and QRS was present. Two possible diagnoses should be considered in view of the Pwave configuration：

A.  低位房速，起源靠近房間隔，先以2:1房室傳導(dǎo)，后轉(zhuǎn)變?yōu)?:1房室傳導(dǎo)伴L(zhǎng)BBB。

A.  Low atrial tachycardia, with an origin close to the interatrial septum with 2:1 AV conduction to the ventricle changing to 1:1 AV conduction with LBBB.

B.  房室結(jié)折返性心動(dòng)過(guò)速（AVNRT），先以1:1傳導(dǎo)至心房，并以2:1傳導(dǎo)至心室，后變?yōu)?:1傳導(dǎo)至心室伴L(zhǎng)BBB。

B.   Atrioventricular nodal reentrant tachycardia(AVNRT),initially with 1:1 conduction to the atrium and 2:1 conduction to the ventricle, changing to 1:1 conduction to the ventricle with LBBB.

B的可能性較大，因?yàn)樵谡璔RS波心動(dòng)過(guò)速發(fā)作時(shí)，P波恰好精確位于2個(gè)QRS波之間，該診斷在電生理檢查中得到了證實(shí)（圖2）?？梢娗皞鱄is電圖與逆?zhèn)鞯姆坎ㄩg期為60ms，為典型慢-快AVNRT間期。1:1傳導(dǎo)至心室時(shí)出現(xiàn)LBBB，可能是因?yàn)榈?相束支阻滯或是左束支被逆行侵入所致。該患者接受導(dǎo)管射頻消融行房室結(jié)慢徑改良。

Possibility B is favored because of the P location exactly between 2 QRS complexes during the episode with a narrow QRS. That diagnosis was confirmed during electrophysiologic study (Figure 2). Note that the distance between the anterograde Hisbundle electrogram and the retrograde  atrial deflection measures 60 ms, a typical time interval in slow/fast AVNRT. The LBBB during 1:1 conduction to the ventricle can be the result of either phase 3 bundle branch block or retrograde invasion into the left bundle branch. Therapy consisted of radiofrequency catheter ablation of the slow AV nodal pathway.

Figure 2.  12lead electrocardiogram with 3 intracardiac registrations, from proximal and distal coronary sinus and His bundle, during the change from a narrow QRS to a wide QRS with doubling in rate. Note that during the 2:1 AV relation, the Hisbundle electrogram is located before the atrial electrogram, indicating impulse formation in the AV node with retrograde conduction to the atrium.