David D, Cabanis C, Guize L, Le Heuzey J Y, Carcone P, Née M, Brenot P, Maurice P
Arch Mal Coeur Vaiss. 1985 Jul;78(7):1009-18.
The clinical and electrophysiological features and the natural history of median intra-His block with a normal resting electrocardiogram were studied: 11 patients had a fixed split H1-H2 potential with a spontaneous or induced block between H1 and H2. The patients (5 men and 6 women) were aged 17 to 70 years (average 53 years). Associated pathology included 2 cases of aortic stenosis (1 severe), 1 case of ischaemic heart disease (effort angina), 1 case of mitral valve prolapse and 2 cases of hypertension. The presenting symptoms were syncope (4 cases), dizziness (2 cases), effort angina (1 case) and tiredness (3 cases); 1 patient was asymptomatic. Holter monitoring (24 hours) was performed in 8 patients and s-owed paroxysmal conduction defects in 6 cases; 4 Mobitz II 2nd degree AV block, 1 3rd degree AV block with narrow QRS complexes and 1 case of blocked atrial extrasystoles at coupling intervals longer than 480 ms and sinus cycle lengths of over 800 ms. Exercise testing by bicycle ergometry (4 patients) was normal in 1 case and revealed Mobitz II 2nd degree AV block in 3 cases. Baseline electrophysiological studies showed an A-H1 interval ranging from 60 to 100 ms (average 78 ms), a H1-H2 interval of 20 to 40 ms (average 31 ms) and a H2-V interval of 30 to 50 ms (average 32 ms). Block between H1 and H2 was observed: "spontaneously" during electrophysiological investigation in 6 cases, after IV atropine in 1 case, during overdrive atrial pacing at rates slower than 150/min in 7 cases, after atrial extrastimulus with a functional intra-His refractory period of over 420 ms in 7 cases, after ajmaline in 3 of the 4 cases in which this test was performed. A cardiac pacemaker was implanted in 10 patients in whom the initial symptoms have all regressed; the remaining patient considered to be "epileptic" had another syncopal attack under therapy and was finally paced. This series demonstrates that the diagnosis of median intra-His block depends on precise electrophysiological criteria and should be looked for even when the presenting symptoms are atypical; some of our patients complained only of tiredness. The value of Holter monitoring and careful endocavitary investigation is emphasised. Median intra-His block should be distinguished from longitudinal and functional His bundle dissociation.
对静息心电图正常的希氏束内中位阻滞的临床、电生理特征及自然病史进行了研究：11例患者H1-H2电位固定分裂，H1与H2之间存在自发或诱发阻滞。患者（5例男性和6例女性）年龄在17至70岁之间（平均53岁）。相关病理情况包括2例主动脉瓣狭窄（1例重度）、1例缺血性心脏病（劳力性心绞痛）、1例二尖瓣脱垂和2例高血压。主要症状为晕厥（4例）、头晕（2例）、劳力性心绞痛（1例）和疲劳（3例）；1例患者无症状。8例患者进行了24小时动态心电图监测，6例显示阵发性传导缺陷；4例莫氏Ⅱ型二度房室阻滞、1例三度房室阻滞伴窄QRS波群以及1例房性期前收缩阻滞，其联律间期超过480毫秒且窦性周期长度超过800毫秒。4例患者进行了踏车运动试验，1例结果正常，3例显示莫氏Ⅱ型二度房室阻滞。基础电生理研究显示A-H1间期为60至100毫秒（平均78毫秒），H1-H2间期为20至40毫秒（平均31毫秒），H2-V间期为30至50毫秒（平均32毫秒）。观察到H1与H₂之间的阻滞：电生理检查时“自发”出现6例，静脉注射阿托品后出现1例，心房超速起搏频率低于150次/分钟时出现7例，心房期外刺激且希氏束内功能性不应期超过420毫秒后出现7例，4例进行此试验的患者中有3例在注射阿义马林后出现。10例初始症状均已消退的患者植入了心脏起搏器；其余1例被认为“癫痫”的患者在治疗期间再次发生晕厥发作，最终也接受了起搏治疗。本系列研究表明，希氏束内中位阻滞的诊断取决于精确的电生理标准，即使主要症状不典型也应进行排查；我们的一些患者仅主诉疲劳。强调了动态心电图监测和仔细的心腔内检查的价值。希氏束内中位阻滞应与纵向和功能性希氏束分离相鉴别。
