Koch 三角解剖與臨床1

1、KochKoch三角解剖與三角解剖與臨床臨床上海長(zhǎng)征醫(yī)院心內(nèi)科上海長(zhǎng)征醫(yī)院心內(nèi)科 廖德寧廖德寧一、一、Koch 三角解三角解剖與組織學(xué)剖與組織學(xué)KochKoch三角的解剖三角的解剖 1.Koch 1909年首先年首先描述，由描述，由Todaro腱、腱、冠狀靜脈竇口及三冠狀靜脈竇口及三尖瓣膈環(huán)組成。尖瓣膈環(huán)組成。2.房室結(jié)位于房室結(jié)位于Koch三三角的頂部角的頂部3.解剖和功能上是心解剖和功能上是心房和希氏束的連接房和希氏束的連接（房室交界區(qū)）（房室交界區(qū)）KochKoch三角的組織學(xué)三角的組織學(xué)v房室結(jié)細(xì)胞：房室結(jié)細(xì)胞：小細(xì)胞、小細(xì)胞、緊密無序排列，細(xì)胞間緊密無序排列，細(xì)胞間連接極少連接極少v

2、移行細(xì)胞：移行細(xì)胞：介于結(jié)細(xì)胞介于結(jié)細(xì)胞與心房肌細(xì)胞之間，有與心房肌細(xì)胞之間，有2 2個(gè)移行方向個(gè)移行方向v心房肌細(xì)胞心房肌細(xì)胞房室結(jié)后延伸（房室結(jié)后延伸（PNEPNE）人人房室結(jié)后延伸（房室結(jié)后延伸（PNEPNE）v人人房室結(jié)具有房室結(jié)具有右和左后右和左后延伸延伸v左后延伸朝左行向房間左后延伸朝左行向房間隔隔v右后延伸與三尖瓣隔瓣右后延伸與三尖瓣隔瓣近乎平行近乎平行,可達(dá)冠狀竇可達(dá)冠狀竇口附近，被認(rèn)為參與了口附近，被認(rèn)為參與了慢徑傳導(dǎo)慢徑傳導(dǎo)房室結(jié)后延伸（房室結(jié)后延伸（PNEPNE）N=8N=2N=6N=1右右+ +左左 右右左左無無InoueN=2113710周聊生周聊生N=178612二

3、、二、 KochKoch三角與三角與房室結(jié)雙徑路房室結(jié)雙徑路房室結(jié)雙徑路房室結(jié)雙徑路v1956年年Moe在犬的心臟在犬的心臟找到房室結(jié)雙徑路的電找到房室結(jié)雙徑路的電生理證據(jù)，即快徑傳導(dǎo)生理證據(jù)，即快徑傳導(dǎo)快快/不應(yīng)期長(zhǎng)；慢徑傳不應(yīng)期長(zhǎng)；慢徑傳導(dǎo)慢導(dǎo)慢/不應(yīng)期短不應(yīng)期短v1968年該概念應(yīng)用于人年該概念應(yīng)用于人的心臟。的心臟。AschoffAschoff 標(biāo)準(zhǔn)：組織學(xué)差別、蹤跡連續(xù)、與正常心肌絕緣標(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)雙徑路v房室結(jié)真結(jié)細(xì)胞和移行房室結(jié)真結(jié)細(xì)胞和移行細(xì)胞雖有組織學(xué)差別和細(xì)胞雖有組織學(xué)差別和蹤跡連續(xù)，但無絕緣層蹤跡連續(xù)，但無絕緣層v移行細(xì)胞即

4、為房室結(jié)真移行細(xì)胞即為房室結(jié)真結(jié)細(xì)胞與心房肌的傳導(dǎo)結(jié)細(xì)胞與心房肌的傳導(dǎo)紐帶紐帶房室結(jié)雙徑路房室結(jié)雙徑路v慢徑組成：慢徑組成：KochKoch三角下三角下后緣心房肌、移行細(xì)胞、后緣心房肌、移行細(xì)胞、PNEPNE、真結(jié)細(xì)胞真結(jié)細(xì)胞v快徑：房間隔心肌細(xì)胞、快徑：房間隔心肌細(xì)胞、移行細(xì)胞、真結(jié)細(xì)胞移行細(xì)胞、真結(jié)細(xì)胞房室結(jié)雙徑路房室結(jié)雙徑路KochKoch三角傳導(dǎo)的異向性：三角傳導(dǎo)的異向性：雙徑路的解剖基礎(chǔ)雙徑路的解剖基礎(chǔ)vKochKoch三角內(nèi)心房肌非均一三角內(nèi)心房肌非均一排列排列傳導(dǎo)的異向性傳導(dǎo)的異向性傳導(dǎo)傳導(dǎo)延緩延緩/ /單向傳導(dǎo)阻滯單向傳導(dǎo)阻滯折返折返形成形成vHocinHocin：犬和豬心臟方

5、向依：犬和豬心臟方向依賴性早搏僅引起賴性早搏僅引起KochKoch三角三角傳導(dǎo)延遲傳導(dǎo)延遲4 421ms21ms，而，而AHAH延延長(zhǎng)達(dá)長(zhǎng)達(dá)8080120ms120ms。說明傳導(dǎo)。說明傳導(dǎo)延遲主要發(fā)生在房室結(jié)后延遲主要發(fā)生在房室結(jié)后延伸與真結(jié)細(xì)胞延伸與真結(jié)細(xì)胞房室結(jié)后延伸（房室結(jié)后延伸（PNEPNE）：）：慢徑的解剖與電生理基礎(chǔ)慢徑的解剖與電生理基礎(chǔ)vInoue: 人右人右PNE沿三尖瓣沿三尖瓣環(huán)延伸，可記錄到雙電位，環(huán)延伸，可記錄到雙電位，是慢徑消融位置。是慢徑消融位置。vMedkour: 兔心兔心PNE沿三尖沿三尖瓣環(huán)延伸至冠狀靜脈竇口，瓣環(huán)延伸至冠狀靜脈竇口，與房室結(jié)相比，具有更短與房室

6、結(jié)相比，具有更短的周長(zhǎng)依賴性不應(yīng)期，不的周長(zhǎng)依賴性不應(yīng)期，不連續(xù)傳導(dǎo)，延遲的房室結(jié)連續(xù)傳導(dǎo)，延遲的房室結(jié)反應(yīng)與折返反應(yīng)與折返慢徑消融靶點(diǎn)慢徑消融靶點(diǎn)vQuintanaQuintana：1 1例例AVNRTAVNRT行慢徑消融行慢徑消融的患者尸檢發(fā)現(xiàn)消融線在心房肌的患者尸檢發(fā)現(xiàn)消融線在心房肌慢徑消融時(shí)消融的可能是正常慢徑消融時(shí)消融的可能是正常心房肌。心房肌。v慢徑消融時(shí)避免損傷房室結(jié)動(dòng)脈。慢徑消融時(shí)避免損傷房室結(jié)動(dòng)脈。KozlowskiKozlowski：5050例人心房室結(jié)動(dòng)例人心房室結(jié)動(dòng)脈中，脈中，2020位于冠狀竇口附近心位于冠狀竇口附近心內(nèi)膜下。內(nèi)膜下。v冠狀竇口附近消融及快徑消融可冠狀

7、竇口附近消融及快徑消融可消弱迷走神經(jīng)的支配，導(dǎo)致心臟消弱迷走神經(jīng)的支配，導(dǎo)致心臟迷走神經(jīng)功能下降迷走神經(jīng)功能下降v起搏標(biāo)測(cè)起搏標(biāo)測(cè)KochKoch三角可以發(fā)現(xiàn)快徑三角可以發(fā)現(xiàn)快徑缺如或靠近慢徑，從而避免房室缺如或靠近慢徑，從而避免房室傳導(dǎo)阻滯傳導(dǎo)阻滯慢徑消融靶點(diǎn)慢徑消融靶點(diǎn)影像分區(qū)影像分區(qū) A A區(qū)區(qū) : : A1 A2A1 A2 M M區(qū)區(qū) : : M1 M2M1 M2 P P區(qū)區(qū) : : P1 P2P1 P2腺苷對(duì)房室結(jié)雙徑路的作用腺苷對(duì)房室結(jié)雙徑路的作用Effects of ATP (20 mg) on AV conduction before （A） and after （B） rad

8、iofrequency ablation of the slow pathway三、三、 KochKoch三角與三角與迷走神經(jīng)迷走神經(jīng)KochKoch三角內(nèi)迷走神經(jīng)分布與作用三角內(nèi)迷走神經(jīng)分布與作用vKochKoch三角的迷走神經(jīng)支配三角的迷走神經(jīng)支配主要來自下腔靜脈與左房主要來自下腔靜脈與左房交界處脂肪墊內(nèi)的迷走神交界處脂肪墊內(nèi)的迷走神經(jīng)節(jié)團(tuán)經(jīng)節(jié)團(tuán)v迷走神經(jīng)主要支配結(jié)細(xì)胞迷走神經(jīng)主要支配結(jié)細(xì)胞v刺激房室結(jié)區(qū)迷走神經(jīng)可刺激房室結(jié)區(qū)迷走神經(jīng)可以減慢房顫心室率以減慢房顫心室率v消融慢徑可以縮短快徑有消融慢徑可以縮短快徑有效不應(yīng)期效不應(yīng)期KochKoch三角迷走神經(jīng)分布與作用三角迷走神經(jīng)分布與作用v

9、ShahShah：閾下刺激方法證明迷走神經(jīng)多位于：閾下刺激方法證明迷走神經(jīng)多位于HisHis束下束下（7/137/13），也有位于），也有位于HisHis束和束和CSCSO O（3/133/13，3/133/13）臨床意義臨床意義v房顫時(shí)房室結(jié)的遞減性與隱匿性傳導(dǎo)導(dǎo)致了房顫時(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。慢的和不規(guī)則的心室率。v房顫時(shí)慢徑和快徑均參與了傳導(dǎo)，慢徑前傳房顫時(shí)慢徑和快徑均參與了傳導(dǎo)，慢徑前傳多于快徑前傳。故消融慢徑可以減慢房顫時(shí)多于快徑前傳。故消融慢徑可以減慢房顫時(shí)的心室率。的心室率。v消融慢徑可以縮短快徑有效不應(yīng)期消融慢徑可以縮短快徑有效不應(yīng)期v刺激房室結(jié)

10、區(qū)迷走神經(jīng)可以減慢房顫心室率刺激房室結(jié)區(qū)迷走神經(jīng)可以減慢房顫心室率Ventricular Rate Control by Selective Vagal Stimulation IsSuperior to Rhythm Regularization by AtrioventricularNodal Ablation and Pacing During Atrial Fibrillationv Selective atrioventricular nodal (AVN) vagal stimulation (AVN-VS) was delivered to the epicardial fat

11、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. The AVN was then ablated, and the right ventricular (R

12、V) 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 resulted in significantly better responses than either r-

13、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.v ConclusionsAVN-VS can produce graded slowing of the VR during AF without destroying the AVN. It was hemodynamicall

14、y 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;106:1853-1858Selective AV nodal vagal stimulation improveshem

15、odynamics during acute atrial fibrillation in dogsv Electrophysiological-echocardiographic experiments were performed on 11 anesthetized open-chest dogs. Hemodynamic measurements were performed during three distinct periods: 1) sinus rate, 2) AF, and 3) AF with vagal nerve stimulation. AF was associ

16、ated 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 , 0.025), and a sharp reduction in one-half of the abortive ventricular contractions. v Slo

17、wing 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 2001；281: H1490H1497 謝謝 謝！謝！房室結(jié)后延伸（房室結(jié)后延伸（PNEPNE） 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

18、應(yīng)期、不連續(xù)傳導(dǎo)、延遲的房室結(jié)反應(yīng)及折返。 Medkour房室結(jié)后延伸（房室結(jié)后延伸（PNEPNE）vInoue：21例人尸體心例人尸體心臟臟房室結(jié)房室結(jié)有向右和向左有向右和向左后延伸，右后延伸沿三后延伸，右后延伸沿三尖瓣隔環(huán)向下，被認(rèn)為尖瓣隔環(huán)向下，被認(rèn)為參與了慢徑傳導(dǎo)參與了慢徑傳導(dǎo)v右右+左左 13v右右 7v左左 1上腔靜脈上腔靜脈下腔靜脈下腔靜脈卵圓窩卵圓窩房間隔房間隔右心耳右心耳梳狀肌梳狀肌冠狀竇口冠狀竇口Todaro 腱腱vKoch 三角解剖與組織學(xué)三角解剖與組織學(xué)vKoch 三角與房室結(jié)雙徑路三角與房室結(jié)雙徑路vKoch 三角與迷走神經(jīng)三角與迷走神經(jīng)vKoch 三角與腺苷三角與腺苷v起搏標(biāo)測(cè)起搏標(biāo)測(cè)KochKoch三角可以發(fā)現(xiàn)快徑缺如或靠近慢徑，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。從而避免房室傳導(dǎo)阻滯。 the the anterogradelyanterogradely conducting fast pa