Koch-三角解剖與臨床

Koch三角解剖與臨床上海長征醫(yī)院心內(nèi)科廖德寧1精選2021版課件一、Koch三角解剖與組織學(xué)

2精選2021版課件Koch三角的解剖

Koch1909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)）3精選2021版課件Koch三角的組織學(xué)房室結(jié)細胞：小細胞、緊密無序排列，細胞間連接極少移行細胞：介于結(jié)細胞與心房肌細胞之間，有2個移行方向心房肌細胞4精選2021版課件房室結(jié)后延伸（PNE）5精選2021版課件人房室結(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,可達冠狀竇口附近，被認為參與了慢徑傳導(dǎo)6精選2021版課件房室結(jié)后延伸（PNE）N=8N=2N=6N=1右+左右左無InoueN=2113710周聊生N=1786127精選2021版課件二、Koch三角與房室結(jié)雙徑路8精選2021版課件房室結(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；慢徑傳導(dǎo)慢/不應(yīng)期短1968年該概念應(yīng)用于人的心臟。9精選2021版課件Aschoff標準：組織學(xué)差別、蹤跡連續(xù)、與正常心肌絕緣

10精選2021版課件房室結(jié)雙徑路房室結(jié)真結(jié)細胞和移行細胞雖有組織學(xué)差別和蹤跡連續(xù)，但無絕緣層移行細胞即為房室結(jié)真結(jié)細胞與心房肌的傳導(dǎo)紐帶11精選2021版課件房室結(jié)雙徑路慢徑組成：Koch三角下后緣心房肌、移行細胞、PNE、真結(jié)細胞快徑：房間隔心肌細胞、移行細胞、真結(jié)細胞12精選2021版課件房室結(jié)雙徑路13精選2021版課件14精選2021版課件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4－21ms，而AH延長達80－120ms。說明傳導(dǎo)延遲主要發(fā)生在房室結(jié)后延伸與真結(jié)細胞15精選2021版課件房室結(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16精選2021版課件17精選2021版課件18精選2021版課件慢徑消融靶點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消融的可能是正常心房肌。慢徑消融時避免損傷房室結(jié)動脈。Kozlowski：50例人心房室結(jié)動脈中，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)功能下降起搏標測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19精選2021版課件慢徑消融靶點影像分區(qū)

A區(qū):A1A2M區(qū):M1M2P區(qū):P1P220精選2021版課件腺苷對房室結(jié)雙徑路的作用EffectsofATP(20mg)onAVconductionbefore（A）andafter（B）radiofrequencyablationoftheslowpathway21精選2021版課件三、Koch三角與迷走神經(jīng)22精選2021版課件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)團迷走神經(jīng)主要支配結(jié)細胞刺激房室結(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23精選2021版課件Koch三角迷走神經(jīng)分布與作用Shah：閾下刺激方法證明迷走神經(jīng)多位于His束下（7/13），也有位于His束和CSO（3/13，3/13）24精選2021版課件臨床意義房顫時房室結(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25精選2021版課件VentricularRateControlbySelectiveVagalStimulationIs

SuperiortoRhythmRegularizationbyAtrioventricular

NodalAblationandPacingDuringAtrialFibrillationSelectiveatrioventricularnodal(AVN)vagalstimulation(AVN-VS)wasdeliveredtotheepicardialfatpadthatprojectsparasympatheticnervefiberstotheAVNin12dogsduringAF.Acomputer-controlledalgorithmadjustedAVN-VSbeatbybeattoachieveameanventricularRRintervalof75%,100%,125%,or150%ofspontaneoussinuscyclelength.TheAVNwasthenablated,andtherightventricular(RV)apexwaspacedeitherirregularly(i-RVP)usingtheRRintervalscollectedduringAVN-VSorregularly(r-RVP)atthecorrespondingmeanRR.Theresultsindicatedthatall3strategiesimprovedhemodynamicscomparedwithAF.However,AVN-VSresultedinsignificantlybetterresponsesthaneitherr-RVPori-RVP.i-RVPresultedinworsehemodynamicresponsesthanr-RVP.ThedifferencesamongthesemodesbecamelesssignificantwhenmeanVRwasslowedto150%ofsinuscyclelength.Conclusions—AVN-VScanproducegradedslowingoftheVRduringAFwithoutdestroyingtheAVN.ItwashemodynamicallysuperiortoAVNablationwitheitherr-RVPori-RVP,indicatingthatthebenefitsofpreservingthephysiologicalantegradeventricularactivationsequenceoutweighthedetrimentaleffectofirregularity.ShaoweiZhuangCirculation.2002;106:1853-185826精選2021版課件SelectiveAVnodalvagalstimulationimproves

hemodynamicsduringacuteatrialfibrillationindogs

Electrophysiological-echocardiographicexperimentswereperformedon11anesthetizedopen-chestdogs.Hemodynamicmeasurementswereperformedduringthreedistinctperiods:1)sinusrate,2)AF,and3)AFwithvagalnervestimulation.AFwasassociatedwithsignificantdeteriorationofallmeasuredparameters(P,0.025).Thevagalnervestimulationproducedslowingoftheventricularrate,significantreversalofthepressureandcontractileindexes(P,0.025),andasharpreductioninone-halfoftheabortiveventricularcontractions.SlowingoftheventricularrateduringAFbyselectiveganglionicstimulationofthevagalnervesthatinnervatetheAVNsuccessfullyimprovedthehemodynamicresponses.Wallick,DonW

AmJPhysiolHeartCircPhysiol2001；281:H1490–H1497

27精選2021版課件謝謝！28精選2021版課件房室結(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。Medkour29精選2021版課件房室結(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，被認為參與了慢徑傳導(dǎo)右+左13右7左130精選2021版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Todaro腱31精選2021版課件Koch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32精選2021版課件33精選2021版課件34精選2021版課件起搏標測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。theanterogradelyconductingfastpathway(AFP)basedontheshortestSt-Hintervalobtainedbystimulatingtheanteroseptal,mi