Koch-三角解剖與臨床-課件

1、Koch三角解剖與臨床上海長(zhǎng)征醫(yī)院心內(nèi)科 廖德寧1PPT課件Koch三角解剖與臨床上海長(zhǎng)征醫(yī)院心內(nèi)科 1PPT課件一、Koch 三角解剖與組織學(xué)2PPT課件一、Koch 三角解剖與組織學(xué)2PPT課件Koch三角的解剖 Koch 1909年首先描述，由Todaro腱、冠狀靜脈竇口及三尖瓣膈環(huán)組成。房室結(jié)位于Koch三角的頂部解剖和功能上是心房和希氏束的連接（房室交界區(qū)）3PPT課件Koch三角的解剖 Koch 1909年首先Koch三角的組織學(xué)房室結(jié)細(xì)胞：小細(xì)胞、緊密無序排列，細(xì)胞間連接極少移行細(xì)胞：介于結(jié)細(xì)胞與心房肌細(xì)胞之間，有2個(gè)移行方向心房肌細(xì)胞4PPT課件Koch三角的組織學(xué)房室結(jié)細(xì)胞：

2、小細(xì)胞、緊密無序排列，細(xì)胞間房室結(jié)后延伸（PNE）5PPT課件房室結(jié)后延伸（PNE）5PPT課件人房室結(jié)后延伸（PNE）人房室結(jié)具有右和左后延伸左后延伸朝左行向房間隔右后延伸與三尖瓣隔瓣近乎平行,可達(dá)冠狀竇口附近，被認(rèn)為參與了慢徑傳導(dǎo)6PPT課件人房室結(jié)后延伸（PNE）人房室結(jié)具有右和左后延伸6PPT課件房室結(jié)后延伸（PNE）N=8N=2N=6N=17PPT課件房室結(jié)后延伸（PNE）N=8N=2N=6N=17PPT課件二、 Koch三角與房室結(jié)雙徑路8PPT課件二、 Koch三角與房室結(jié)雙徑路8PPT課件房室結(jié)雙徑路1956年Moe在犬的心臟找到房室結(jié)雙徑路的電生理證據(jù)，即快徑傳導(dǎo)快/不應(yīng)期長(zhǎng)

3、；慢徑傳導(dǎo)慢/不應(yīng)期短1968年該概念應(yīng)用于人的心臟。9PPT課件房室結(jié)雙徑路1956年Moe在犬的心臟找到房室結(jié)雙徑路的電生Aschoff 標(biāo)準(zhǔn)：組織學(xué)差別、蹤跡連續(xù)、與正常心肌絕緣 10PPT課件Aschoff 標(biāo)準(zhǔn)：組織學(xué)差別、蹤跡連續(xù)、與正常心肌絕緣 房室結(jié)雙徑路房室結(jié)真結(jié)細(xì)胞和移行細(xì)胞雖有組織學(xué)差別和蹤跡連續(xù)，但無絕緣層移行細(xì)胞即為房室結(jié)真結(jié)細(xì)胞與心房肌的傳導(dǎo)紐帶11PPT課件房室結(jié)雙徑路房室結(jié)真結(jié)細(xì)胞和移行細(xì)胞雖有組織學(xué)差別和蹤跡連續(xù)房室結(jié)雙徑路慢徑組成：Koch三角下后緣心房肌、移行細(xì)胞、PNE、真結(jié)細(xì)胞快徑：房間隔心肌細(xì)胞、移行細(xì)胞、真結(jié)細(xì)胞12PPT課件房室結(jié)雙徑路慢徑組成：

4、Koch三角下后緣心房肌、移行細(xì)胞、P房室結(jié)雙徑路13PPT課件房室結(jié)雙徑路13PPT課件14PPT課件14PPT課件Koch三角傳導(dǎo)的異向性：雙徑路的解剖基礎(chǔ)Koch三角內(nèi)心房肌非均一排列傳導(dǎo)的異向性傳導(dǎo)延緩/單向傳導(dǎo)阻滯折返形成Hocin：犬和豬心臟方向依賴性早搏僅引起Koch三角傳導(dǎo)延遲421ms，而AH延長(zhǎng)達(dá)80120ms。說明傳導(dǎo)延遲主要發(fā)生在房室結(jié)后延伸與真結(jié)細(xì)胞15PPT課件Koch三角傳導(dǎo)的異向性：雙徑路的解剖基礎(chǔ)Koch三角內(nèi)心房室結(jié)后延伸（PNE）：慢徑的解剖與電生理基礎(chǔ)Inoue: 人右PNE沿三尖瓣環(huán)延伸，可記錄到雙電位，是慢徑消融位置。Medkour: 兔心PNE沿三

5、尖瓣環(huán)延伸至冠狀靜脈竇口，與房室結(jié)相比，具有更短的周長(zhǎng)依賴性不應(yīng)期，不連續(xù)傳導(dǎo)，延遲的房室結(jié)反應(yīng)與折返16PPT課件房室結(jié)后延伸（PNE）：慢徑的解剖與電生理基礎(chǔ)Inoue:17PPT課件17PPT課件18PPT課件18PPT課件慢徑消融靶點(diǎn)Quintana：1例AVNRT行慢徑消融的患者尸檢發(fā)現(xiàn)消融線在心房肌慢徑消融時(shí)消融的可能是正常心房肌。慢徑消融時(shí)避免損傷房室結(jié)動(dòng)脈。Kozlowski：50例人心房室結(jié)動(dòng)脈中，20位于冠狀竇口附近心內(nèi)膜下。冠狀竇口附近消融及快徑消融可消弱迷走神經(jīng)的支配，導(dǎo)致心臟迷走神經(jīng)功能下降起搏標(biāo)測(cè)Koch三角可以發(fā)現(xiàn)快徑缺如或靠近慢徑，從而避免房室傳導(dǎo)阻滯19PPT

6、課件慢徑消融靶點(diǎn)Quintana：1例AVNRT行慢徑消融的患者慢徑消融靶點(diǎn)影像分區(qū) A區(qū) : A1 A2 M區(qū) : M1 M2 P區(qū) : P1 P220PPT課件慢徑消融靶點(diǎn)影像分區(qū)20PPT課件腺苷對(duì)房室結(jié)雙徑路的作用Effects of ATP (20 mg) on AV conduction before （A） and after （B） radiofrequency ablation of the slow pathway21PPT課件腺苷對(duì)房室結(jié)雙徑路的作用Effects of ATP (20三、 Koch三角與迷走神經(jīng)22PPT課件三、 Koch三角與迷走神經(jīng)22PPT課件Ko

7、ch三角內(nèi)迷走神經(jīng)分布與作用Koch三角的迷走神經(jīng)支配主要來自下腔靜脈與左房交界處脂肪墊內(nèi)的迷走神經(jīng)節(jié)團(tuán)迷走神經(jīng)主要支配結(jié)細(xì)胞刺激房室結(jié)區(qū)迷走神經(jīng)可以減慢房顫心室率消融慢徑可以縮短快徑有效不應(yīng)期23PPT課件Koch三角內(nèi)迷走神經(jīng)分布與作用Koch三角的迷走神經(jīng)支配主Koch三角迷走神經(jīng)分布與作用Shah：閾下刺激方法證明迷走神經(jīng)多位于His束下（7/13），也有位于His束和CSO（3/13，3/13）24PPT課件Koch三角迷走神經(jīng)分布與作用Shah：閾下刺激方法證明迷走臨床意義房顫時(shí)房室結(jié)的遞減性與隱匿性傳導(dǎo)導(dǎo)致了慢的和不規(guī)則的心室率。房顫時(shí)慢徑和快徑均參與了傳導(dǎo)，慢徑前傳多于快徑前傳

8、。故消融慢徑可以減慢房顫時(shí)的心室率。消融慢徑可以縮短快徑有效不應(yīng)期刺激房室結(jié)區(qū)迷走神經(jīng)可以減慢房顫心室率25PPT課件臨床意義房顫時(shí)房室結(jié)的遞減性與隱匿性傳導(dǎo)導(dǎo)致了慢的和不規(guī)則的Ventricular Rate Control by Selective Vagal Stimulation IsSuperior to Rhythm Regularization by AtrioventricularNodal Ablation and Pacing During Atrial Fibrillation Selective atrioventricular nodal (AVN) vagal st

9、imulation (AVN-VS) was delivered to the epicardial fat pad that projects parasympathetic nerve fibers to the AVN in 12 dogs during AF. A computer-controlled algorithm adjusted AVN-VS beat by beat to achieve a mean ventricular RR interval of 75%, 100%, 125%, or 150% of spontaneous sinus cycle length.

10、 The AVN was then ablated, and the right ventricular (RV) apex was paced either irregularly (i-RVP) using the RR intervals collected during AVN-VS or regularly (r-RVP) at the corresponding mean RR. The results indicated that all 3 strategies improved hemodynamics compared with AF. However, AVN-VS re

11、sulted in significantly better responses than either r-RVP or i-RVP. i-RVP resulted in worse hemodynamic responses than r-RVP. The differences among these modes became less significant when mean VR was slowed to 150% of sinus cycle length. ConclusionsAVN-VS can produce graded slowing of the VR durin

12、g AF without destroying the AVN. It was hemodynamically superior to AVN ablation with either r-RVP or i-RVP, indicating that the benefits of preserving the physiological antegrade ventricular activation sequence outweigh the detrimental effect of irregularity. ShaoweiZhuang Circulation. 2002;106:185

13、3-185826PPT課件Ventricular Rate Control by SeSelective AV nodal vagal stimulation improveshemodynamics during acute atrial fibrillation in dogs Electrophysiological-echocardiographic experiments were performed on 11 anesthetized open-chest dogs. Hemodynamic measurements were performed during three dis

14、tinct periods: 1) sinus rate, 2) AF, and 3) AF with vagal nerve stimulation. AF was associated with significant deterioration of all measured parameters (P ,0.025). The vagal nerve stimulation produced slowing of the ventricular rate, significant reversal of the pressure and contractile indexes (P ,

15、 0.025), and a sharp reduction in one-half of the abortive ventricular contractions. Slowing of the ventricular rate during AF by selective ganglionic stimulation of the vagal nerves that innervate the AVN successfully improved the hemodynamic responses.Wallick, Don W Am J Physiol Heart Circ Physiol

16、 2001；281: H1490H1497 27PPT課件Selective AV nodal vagal stimu謝 謝！28PPT課件謝 謝！28PPT課件房室結(jié)后延伸（PNE） 兔心PNE沿三尖瓣隔環(huán)延伸至冠狀靜脈竇口。與房室結(jié)相比有更短的周長(zhǎng)依賴性不應(yīng)期、不連續(xù)傳導(dǎo)、延遲的房室結(jié)反應(yīng)及折返。 Medkour29PPT課件房室結(jié)后延伸（PNE） 兔心PNE沿三尖瓣隔環(huán)延房室結(jié)后延伸（PNE）Inoue：21例人尸體心臟房室結(jié)有向右和向左后延伸，右后延伸沿三尖瓣隔環(huán)向下，被認(rèn)為參與了慢徑傳導(dǎo)右+左 13右 7左 130PPT課件房室結(jié)后延伸（PNE）Inoue：21例人尸體心臟房室結(jié)有向

17、上腔靜脈下腔靜脈卵圓窩房間隔右心耳梳狀肌冠狀竇口Todaro 腱31PPT課件上腔靜脈下腔靜脈卵圓窩房間隔右心耳梳狀肌冠狀竇口TodaroKoch 三角解剖與組織學(xué)Koch 三角與房室結(jié)雙徑路Koch 三角與迷走神經(jīng)Koch 三角與腺苷32PPT課件Koch 三角解剖與組織學(xué)32PPT課件33PPT課件33PPT課件34PPT課件34PPT課件起搏標(biāo)測(cè)Koch三角可以發(fā)現(xiàn)快徑缺如或靠近慢徑，從而避免房室傳導(dǎo)阻滯。 the anterogradely conducting fast pathway (AFP) based on the shortest St-H interval obtained by stimulating the anteroseptal, midseptal,