Olshansky B, Okumura K, Hess P G, Waldo A L
Department of Medicine, Case Western Reserve University, Cleveland, Ohio.
J Am Coll Cardiol. 1990 Dec;16(7):1639-48. doi: 10.1016/0735-1097(90)90314-f.
Ten patients with chronic atrial flutter were studied prospectively using electrophysiologic mapping and pacing techniques to assess the mechanism of atrial flutter and the presence of an area of slow conduction in the atria. Electrograms recorded from greater than or equal to 30 right atrial sites for each patient during atrial flutter demonstrated that right atrial free wall activation was craniocaudal and that the interatrial septum activation was caudocranial, consistent with a reentrant circuit involving the right atrium. In six patients, slow conduction occurred during atrial flutter in the inferior right atrium and was spatially associated with fractionated electrographic recordings. In the other four patients, a "missing" interval of electrical activity occurred in the inferior right atrium for an average of 40% of the atrial flutter cycle. Transient entrainment criteria were demonstrated in each patient during rapid high right atrial pacing. The mean activation time from the high right atrial pacing site to the coronary sinus (inferior left atrial) recording site was long (228 ms) and consistent with activation through an area of slow conduction. During rapid pacing of atrial flutter from the coronary sinus site, no transient entrainment criteria could be demonstrated. The mean activation time from the coronary sinus pacing site to the high right atrial recording site was relatively short (134 ms) and consistent with orthodromic activation of the high right atrium not through an area of slow conduction. High right atrial pacing during sinus rhythm at rates similar to atrial flutter demonstrated a short activation time to the coronary sinus and low right atrial sites (mean 169 and 88 ms, respectively), indicating activation that did not traverse an area of slow conduction. Coronary sinus pacing during sinus rhythm demonstrated the same phenomena. Low right atrial electrograms recorded during sinus rhythm and during rapid pacing of sinus rhythm were not fractionated, although they were during atrial flutter. Thus, atrial mapping and pacing data were complementary, indicating that human atrial flutter in the patients studied was generated by a reentrant circuit in the right atrium, with an area of slow conduction in the low right atrium present only during atrial flutter.
对10例慢性心房扑动患者进行了前瞻性研究，采用电生理标测和起搏技术评估心房扑动的机制以及心房中缓慢传导区域的存在情况。在心房扑动期间，对每位患者≥30个右心房部位记录的心电图显示，右心房游离壁的激动是从头向尾的，而房间隔的激动是从尾向头的，这与涉及右心房的折返环一致。6例患者在右心房下部心房扑动期间出现缓慢传导，且在空间上与碎裂电图记录相关。在另外4例患者中，右心房下部平均有40%的心房扑动周期出现电活动“缺失”间期。在快速右心房高位起搏期间，每位患者均符合短暂拖带标准。从右心房高位起搏部位到冠状窦（左心房下部）记录部位的平均激动时间较长（228毫秒），且与通过缓慢传导区域激动一致。从冠状窦部位快速起搏心房扑动时，未显示出短暂拖带标准。从冠状窦起搏部位到右心房高位记录部位的平均激动时间相对较短（134毫秒），且与右心房高位的顺向激动不通过缓慢传导区域一致。在窦性心律期间以与心房扑动相似的频率进行右心房高位起搏时，到冠状窦和右心房低位部位的激动时间较短（分别平均为169和88毫秒），表明激动未穿过缓慢传导区域。窦性心律期间冠状窦起搏也显示出同样的现象。窦性心律期间及窦性心律快速起搏期间记录的右心房低位心电图未出现碎裂，尽管在心房扑动期间出现了碎裂。因此，心房标测和起搏数据相互补充，表明所研究患者的人类心房扑动是由右心房的折返环产生的，右心房下部的缓慢传导区域仅在心房扑动期间存在。
