persistent junctional reentrant tachycardia
Introduction
Introduction to recurrent tachycardia in continuous handover area Permanent junctional reciprocating tachycardia (PJRT), also known as persistent intercourse repetitive tachycardia, persistent intercourse tachycardia, is an endless transitional tachycardia. basic knowledge The proportion of illness: 0.001% Susceptible people: no specific people Mode of infection: non-infectious Complications: cardiomyopathy
Cause
Causes of recurrent tachycardia in persistent junction
(1) Causes of the disease
Currently reported in patients with persistent reentry tachycardia in the transitional area, there is no basis for organic heart disease, but some patients may have decreased heart function due to repeated episodes of tachycardia for a long time, and even develop into cardiomyopathy, heart enlargement .
(two) pathogenesis
Current anatomy and electrophysiology, surgery and radiofrequency ablation have confirmed that PJRT is a recurrent tachycardia involving slow bypass near the posterior septum. It is a special type of occult pre-excitation syndrome. No organic heart disease.
Prevention
Persistent handover area reentry tachycardia prevention
1. If PJRT persists, intractable seizures, easy to cause severe hemodynamic effects, and arrhythmogenic cardiomyopathy, should be actively treated with radiofrequency ablation to completely eradicate.
2. In the radiofrequency ablation treatment, careful mapping, accurate search for the earliest activating site of the retrograde atrial is the key to successful ablation.
3. In daily life, avoid mental stress and excessive fatigue, to achieve the law of life, regular living, optimistic spirit, emotional stability can reduce the recurrence of this disease.
4. Avoid spicy, irritating food; quit smoking, coffee; food should be light.
Complication
Complications of recurrent tachycardia in persistent junction Complications , sudden death of cardiomyopathy
Patients with persistent anterior reentry tachycardia, such as long episodes and ventricular rate, may have complications such as tachycardia, heart failure, and sudden death.
Symptom
Persistent transition zone reentry tachycardia symptoms common symptoms tachycardia frequent premature atrial premature beats
1. The age of onset is more common in children and young people. It has been reported that tachycardia occurs from the fetal period, and it is also diagnosed after adulthood (64 years old). Because of the early onset, PJRT is more common in children and can continue into adulthood.
2. The tachycardia continues to be intractable and endless recurrent, the drug is usually difficult to control, and the attack can last for several months. Among the 5 cases reported by Lin Zhihu, 1 case lasted for 8 months, and the heart rate was 130 to 240 times / min, Balaji reported 1 case of seizures for up to 18 months.
Examine
Continuous handover area reentry tachycardia
Mainly rely on electrocardiogram, electrophysiological diagnosis.
Electrocardiogram examination
(1) PJRT is often shortened by sinus cycle criticality, atrial contraction, and ventricular premature contraction: sinus cycle changes induce or terminate supraventricular tachycardia is the main feature of this disease, often sinus The circadian rhythm gradually accelerates, and then PJRT occurs. What frequency does the sinus heart rate reach in order to induce PJRT, which varies from person to person, some are 80-90 times/min, and some are 100-150 times/min.
(2) The first PR interval at the beginning of tachycardia is not extended.
(3) tachycardia continues to recurrent: several sinus beats can be separated.
(4) The P-wave is negatively directed in the II, III, and aVF leads, and is positive in the aVR lead. The reason is that the atrial junction of the ventricular bypass is below the coronary sinus, which is equivalent to the right posterior septum. It is the retrograde branch of the ventricular bypass when the tachycardia is tachycardia, so the wave is reversed in the above-mentioned lead P- (Fig. 1, 2).
(5) Because the bypass conduction is slow: the P-wave is far from the R wave, forming a long RP-interval, a short P--R interval, RP-/P--R>1, but there is also a slight RP-interval Shorter than P--R interval or RP-interval = P--R interval.
(6) Intermittent ECG is normal: P-QRS-T waveform is normal, PR interval is normal, no pre-excitation pattern.
2. Electrophysiological examination features
(1) During the tachycardia, the chamber conduction time is long, VA>100ms.
(2) When the tachycardia is over-transmitted, the earliest activating part of the atrium is not the His bundle area, but the abnormal part, mostly the coronary sinus.
(3) Pre-ventricular contraction stimulation during the refractory period of the tachycardia during tachycardia: the atrial can be excited prematurely without changing the atrial activation sequence, that is, the earliest activation of the retrograde atrium is located in the coronary sinus At the site, this phenomenon indicates the presence of atrioventricular bypass, and ventricular premature contraction stimulation stimulates the atrium through bypass reversal.
(4) Using the appropriate method of pacing the ventricle, two different retrograde atrial activation sequences can be found:
1 is the earliest agitation of abnormal parts such as coronary sinus ostium, which is reversed from the atrium by the ventricular bypass;
2 The first part of the atrial septum was excited by the His bundle, and the atrial was reversed by the normal pathway of the His bundle.
(5) When the ventricular S1S1 stimulation interval is near or less than 300ms: Venturi phenomenon occurs in the bypass conduction of the ventricular chamber, that is, the Ventricular phenomenon can be seen in the ventricular stimulation, suggesting that the bypass has slow conduction and decreasing conduction. Characteristics.
(6) The bypass potential can sometimes be recorded before the A wave.
The above electrophysiological features demonstrate that the occult ventricular bypass with slow conduction and diminished conduction is the electrophysiological basis of PJRT, the chamber bypass is the retrograde branch of the tachycardia reentry loop, and the atrioventricular node is the anterior branch.
Slow conduction rate The site of concealed atrioventricular bypass with decreasing conduction characteristics: the classic site is at the coronary sinus ostium (posterior septum), and can also be located in other sites, such as: right atrial free wall, right anterior septum, left posterior septum, left Side free wall, right posterior wall, left posterior wall, etc., 9 cases of PJRT reported by Ticho et al were successfully cured by radiofrequency ablation (Fig. 3). Like other occult pre-excitation, PJRT can also have multiple bypasses. If two forms of long R-P-tachycardia are observed before ablation, there is a high probability of a double bypass (Figure 4).
Diagnosis
Diagnosis and diagnosis of recurrent tachycardia in persistent junction
Diagnostic criteria
There is no uniform diagnostic criteria and the following conditions can help diagnose:
1. The tachycardia is persistent and recurrent, and the drug is difficult to control.
2. Surface electrocardiogram showed ventricular supraventricular tachycardia RP->P--R, PII, PIII, PaVF inversion of 1:1 atrioventricular conduction.
3. Intracardiac electrophysiological mapping, the Hist beam A wave is later than the first excited back-transfer A wave, the earliest VA interval >110ms.
4. When the tachycardia is stimulating the ventricle in the refractory period of the His bundle, the atrium can be captured early, and the earliest activating part of the atrium is mostly in the coronary sinus, and the atrial reversal agitation order is unchanged.
5. During ventricular stimulation, the VA interval showed a decreasing conduction, prolonged >50ms.
6. There is no AH interval (PR interval) prolongation before the attack.
7. Catheter radiofrequency ablation can cure.
Differential diagnosis
PJRT is a type of RP- supraventricular tachycardia with long RP- supraventricular tachycardia with 1:1 atrioventricular conduction, RP-/P--P>1, II, III, aVF Lead P-wave inversion, the above-mentioned long RP-ventricular supraventricular tachycardia characteristics are also the following categories, should be identified.
1. Atrial tachycardia often shows autophysiological features of autonomic tachycardia, ventricular stimulation is generally not induced or terminated, tachycardia has nothing to do with delay or block of atrioventricular node conduction, using verapamil, Atrial or tachycardia may be unaffected when ATP or compression of the carotid sinus causes varying degrees of atrioventricular block, and these characteristics are different from PJRT.
2. Ebstein malformation combined with additional bypass Ebstein malformation combined with additional bypass caused by tachycardia, almost all showed right bundle branch block pattern, long ventricular conduction time and delayed ventricular conduction near the bypass, plus bypass itself excited atrial Delay-related, should be differentiated from long-term RP-combined right bundle branch block of supraventricular tachycardia, ultrasound examination can confirm the Ebstein malformation.
3. Occult bypass with long ventricular conduction time must exclude ventricular muscle or atrial conduction delay, in order to determine the long delay RP-line reverse bypass fiber slow delay conduction, ventricular stimulation, atrial eccentric excitation, help its It is distinguished from the reentry tachycardia at the interval.
4. The clinical and electrophysiological characteristics of fast-slow atrioventricular nodal reentry tachycardia are often similar to PJRT.
1 When the tachycardia is synchronized with the H wave, the ventricle is stimulated, and the ventricular stimulation cannot be reversed to the atria. Therefore, the His bundle is still in the refractory period, and the PJRT is the opposite.
2 This type of tachycardia is often unaffected when a block occurs in the area below the His bundle.
5. Atrial flutter on the surface electrocardiogram, when the atrial flutter is 2:1, it is sometimes difficult to distinguish from long RP-tachycardia, intracardiac electrophysiology can clearly show 2:1 downcast The characteristics of PJRT are 1:1 room conduction, which are easier to identify.
