Janse M J, Rosen M R
The Experimental and Molecular Cardiology Group, Academic Medical Center, M 051, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
Handb Exp Pharmacol. 2006(171):1-39. doi: 10.1007/3-540-29715-4_1.
A historical overview is given on the techniques to record the electrical activity of the heart, some anatomical aspects relevant for the understanding of arrhythmias, general mechanisms of arrhythmias, mechanisms of some specific arrhythmias and nonpharmacological forms of therapy. The unravelling of arrhythmia mechanisms depends, of course, on the ability to record the electrical activity of the heart. It is therefore no surprise that following the construction of the string galvanometer by Einthoven in 1901, which allowed high-fidelity recording of the body surface electrocardiogram, the study of arrhythmias developed in an explosive way. Still, papers from McWilliam (1887), Garrey (1914) and Mines (1913, 1914) in which neither mechanical nor electrical activity was recorded provided crucial insights into re-entry as a mechanism for atrial and ventricular fibrillation, atrioventricular nodal re-entry and atrioventricular re-entrant tachycardia in hearts with an accessory atrioventricular connection. The components of the electrocardiogram, and of extracellular electrograms directly recorded from the heart, could only be well understood by comparing such registrations with recordings of transmembrane potentials. The first intracellular potentials were recorded with microelectrodes in 1949 by Coraboeuf and Weidmann. It is remarkable that the interpretation of extracellular electrograms was still controversial in the 1950s, and it was not until 1962 that Dower showed that the transmembrane action potential upstroke coincided with the steep negative deflection in the electrogram. For many decades, mapping of the spread of activation during an arrhythmia was performed with a "roving" electrode that was subsequently placed on different sites on the cardiac surface with a simultaneous recording of another signal as time reference. This method could only provide reliable information if the arrhythmia was strictly regular. When multiplexing systems became available in the late 1970s, and optical mapping in the 1980s, simultaneous registrations could be made from many sites. The analysis of atrial and ventricular fibrillation then became much more precise. The old question whether an arrhythmia is due to a focal or a re-entrant mechanism could be answered, and for atrial fibrillation, for instance, the answer is that both mechanisms may be operative. The road from understanding the mechanism of an arrhythmia to its successful therapy has been long: the studies of Mines in 1913 and 1914, microelectrode studies in animal preparations in the 1960s and 1970s, experimental and clinical demonstrations of initiation and termination of tachycardias by premature stimuli in the 1960s and 1970s, successful surgery in the 1980s, the development of external and implantable defibrillators in the 1960s and 1980s, and finally catheter ablation at the end of the previous century, with success rates that approach 99% for supraventricular tachycardias.
本文给出了心脏电活动记录技术的历史概述，介绍了一些与心律失常理解相关的解剖学方面、心律失常的一般机制、某些特定心律失常的机制以及非药物治疗形式。当然，心律失常机制的阐明取决于记录心脏电活动的能力。因此，1901年艾因托芬发明弦线电流计，使得能够高保真记录体表心电图后，心律失常的研究呈爆发式发展，这并不奇怪。尽管如此，麦克威廉（1887年）、加里（1914年）和迈因斯（1913年、1914年）的论文，虽然未记录机械或电活动，但却为折返作为心房和心室颤动、房室结折返以及具有房室旁道的心脏中房室折返性心动过速的机制提供了关键见解。只有将心电图以及直接从心脏记录的细胞外电信号与跨膜电位记录进行比较，才能很好地理解它们的组成部分。1949年，科拉博夫和魏德曼用微电极首次记录到细胞内电位。值得注意的是，20世纪50年代细胞外电信号的解释仍存在争议，直到1962年道尔才表明跨膜动作电位的上升支与电信号中的陡峭负向偏转相一致。几十年来，心律失常发作期间激动传播的标测是用一个“移动”电极进行的，该电极随后放置在心脏表面的不同部位，同时记录另一个信号作为时间参考。只有当心律失常严格规则时，这种方法才能提供可靠的信息。20世纪70年代末多路复用系统出现，80年代光学标测出现后，可以从多个部位同时进行记录。心房和心室颤动的分析随后变得更加精确。心律失常是由局灶性机制还是折返机制引起的这个老问题得以解答，例如对于心房颤动，答案是两种机制都可能起作用。从理解心律失常机制到成功治疗的道路漫长：1913年和1914年迈因斯的研究、20世纪60年代和70年代在动物制剂上进行的微电极研究、20世纪60年代和70年代过早刺激引发和终止心动过速的实验及临床证明、20世纪80年代的成功手术、20世纪60年代和80年代体外和植入式除颤器的发展，以及上世纪末的导管消融，室上性心动过速的成功率接近99%。
