[AF-FORUM] 186E Clinical case. Dr. Perez Riera
AF Symposium
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星期一 四月 30 23:10:02 ART 2007
186E Clinical case. Dr. Perez Riera
尊敬的 Dr. Sidney Campodonico ：
对Prof Carlos Alberto Pastore的这个病例我的诊断是：预激
综合征伴房颤。这是一个宽QRS心动过速（QRS大于
120ms），发生机制可能是室上性也可能是室性。鉴别
室上性与室性心动过速非常重要，因为这将决定患者
的诊断和治疗。通过旁路机制不能完全解释房颤的始
发。VPC逆传到心房产生心动过速是非常少见的原因。
1.心室率高达200-350 bpm；
2. QRS波宽大畸形，形态多变。
3.包括明显的不规则快速心室率和QRS波形态多变这种
无秩序性是预激伴房颤的典型图形。这种大体上的无
规则性可除外PVT。有时心室率超过300次/分。
4.当心室率超过250次/分时，QRS波形态变得更规则一
些，心电图形态类似于室扑。
5.心室反应有轻微的不规则，经常误诊为室速。
6.恶化为室颤的风险很高：记录到RR间期减低到270ms
时，有室颤的危险。
7.当急性发作这种快心室率时，治疗选择应尽快地进
行电击复律。
8.如果选择药物，30分钟内静脉应用乙胺碘呋酮300mg，
继之24小时内持续给予900mg。乙胺碘呋酮是首选。最
近的AHA和ACLS指南显示静脉应用乙胺碘呋酮是AF-WPW的
一线治疗。然而，证据表明有潜在的危险，没有事实
根据。
(1) 第二选择包括IA类抗心律失常药disopyramide和
procainamide，或者IC类maline, flecainide 或 propafenone.
9.食道电图可以快速鉴别WPW发生快速心律失常可能产
生晕厥的高风险。发生晕厥和潜在严重的WPW型的原因
与年龄没有明显的关系
10. 对门诊大于10岁孩子进行经食道心电图检查可发现
潜在的严重类型， 特别对有头晕及晕厥症状的患者
发生率明显增高。无症状的儿童22%具有潜在恶性类
型，建议对所有大于10岁的活泼好动的儿童进行心电
图检查 ，旨在检测出预激综合征并建议进一步经食
道心电图检查。
11.以不同的心动周期使用1和2个额外刺激进行程序心
房刺激，以此确定旁路不应期并诱发室上性心动过
速。通过旁路的快速传导(> 240/min ，使用 isoproterenol后
> 300/min)可以诱发房颤可以预示发生猝死风险的WPW类
型。WPW伴房颤的孩子其有效不应期是短的。儿科WPW伴
房颤的患者与不伴有房颤的患者有不同的电生理特点
12.鉴别射频消融治疗后阵发性房颤的再发风险是非常
重要的，因为必须进行进一步的治疗。P波离散度
Pd≥32.5 ms，以及最大的P波间期Pmax≥103.0 ms可以预测
消融治疗后阵发性房颤的再发。Pd≥32.5 ms对预激伴房
颤患者射频消融治疗后阵发性房颤的再发具有独立的
预测意义。
13. 年龄、性别和晕厥史是WPW患者发生房颤的独立危
险因素。经旁路前传是发展为房颤的重要原因。应该
对旁路早期进行射频消融治疗，因为这时发生房颤的
风险很小。随着年龄的增加，发生房颤的风险性增加。
参考文献
1) Tijunelis MA, Herbert ME Myth: Intravenous amiodarone is
safe in patients with atrial fibrillation and Wolff-Parkinson-White
syndrome in the emergency department. CJEM. 2005; 7:262-265.
2) Chometon F, Brembilla-Perrot B.Influence of age on the
presumed cause of syncope in patients with the Wolff-Parkinson-White
syndrome Arch Mal Coeur Vaiss. 2007; 100:34-39.
3) Brembilla-Perrot B, Marcon F, Bosser G, et al.Feasibility
and significance of a transoesophageal electrophysiological
investigation in children and adolescents with Wolff-Parkinson-White
syndrome Arch Mal Coeur Vaiss. 2005;98:25-30.
4) Brembilla-Perrot B.Electrophysiological evaluation of Wolff-
Parkinson-White Syndrome. Indian Pacing Electrophysiol J. 2002;
2:143-152.
5) Lee PC, Hwang B, Tai CT, et al.The different
electrophysiological characteristics in children with Wolff-Parkinson-
White syndrome between those with and without atrial fibrillation.
Pacing Clin Electrophysiol. 2004 Feb;27(2):235-239.
6) Aytemir K, Amasyali B, Kose S, et al. Maximum P-wave
duration and P-wave dispersion predict recurrence of paroxysmal
atrial fibrillation in patients with Wolff-Parkinson-White syndrome
after successful radiofrequency catheter ablation. J Interv Card
Electrophysiol. 2004; 11:21-27.
7) Szumowski L, Walczak F, Urbanek P, et al. Risk factors of
atrial fibrillation in patients with Wolff-Parkinson-White syndrome.
Kardiol Pol. 2004; 60:206-216.
All the best for all
Andrés Ricardo Pérez Riera MD
Chief of Electro-Vectocardiology Sector of the Discipline of
Cardiology,
ABC Faculty of Medicine (FMABC), Foundation of ABC (FUABC) - Santo
André São
Paulo - Brazil.
riera在uol.com.br
--
Dr. Sergio Dubner
President of Scientific Committee
Dr. Edgardo Schapachnik
President of Steering Committee
各位专家：
我提出一个病例讨论，这是由Dr. Alberto Pastore提供的
病例。患者30岁，因心悸、不适到急诊室就诊，既往
没有心脏病史。此症状于另一天又发作了一次，曾口
服β受体阻滞剂治疗心悸，症状加重。这个病例的可
能诊断及治疗措施是什么？
> Sidney Campodonico .F, MD
> Brazil
>
> 可见心电图
> http://www.af-symposium.org/files/Campodonico.jpg
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186E Clinical case. Dr. Perez Riera
Dear Dr. Sidney Campodonico My diagnosis and approach in this case
of Prof Carlos Alberto Pastore is: Atrial fibrillation in patients
with Wolf-Parkinson-White syndrome. Here we have a broad QRS complex
tachycardia (QRS complex more than 120m) and caused by various
mechanisms, either supraventricular or ventricular. It is important
to differentiate between ventricular and supraventricular because it
will determine treatment and prognosis of patients. The mechanism by
which AF is initiated in patients with accessory pathways is not
fully understood. Retrograde conduction of VPCs to the atrium,
causing the arrhythmia, is a very rare cause.
1) The ventricular rate is very high 200 a 350 bpm;
2) The QRS complex are wide and bizarre and often changing in
form;
3) The chaotic pattern consisting of a markedly irregular rapid
ventricular rate and changing configuration of the QRS complexes.
This pattern is characteristic of AF in the WPW syndrome. The gross
overall disorganization rules out PVT. At times, the ventricular rate
>300/min.
4) When the rate exceed 250/min the QRS complex become more
regular in form and the ECG pattern resembles that of ventricular
flutter
5) There is gross irregularity of the ventricular response
against a misdiagnosis of ventricular tachycardia.
6) There are a high risk of deterioration into ventricular
fibrillation: The recording of the minimal RR interval in the range
of 270ms has risk of VF
7) During acute attack episode with very rapid ventricular rate
the treatment of choice is DC cardioversion preformed as fast as
possible.
8) If drug is chosen IV bolus of 300 mg amiodarone administered
within 30 minutes and continued with 900 mg/24 hours. amiodarone is
the first drug. The most recent American Heart Association guidelines
for the treatment of patients with WPW, published in conjunction with
the 2000 Advanced Cardiac Life Support (ACLS) guidelines, suggests
that intravenous amiodarone is a first-line therapy for AF-WPW;
however the evidence suggests this is a potentially dangerous myth
(1). Second chose include Class IA drugs disopyramide and
procainamide or IC aja=maline, flecainide or propafenone.
9) Esophageal electrophysiological investigations enable rapid
identification of a high incidence of tachycardias probably
responsible for syncope in WPW. The causes of syncope and incidence
of potentially severe forms of WPW are not significantly influenced
by the age(2)
10) A transoesophageal electrophysiological investigation is
possible as an outpatient procedure in children older than 10 years,
and allowed the detection of potentially serious forms whatever the
indication for the investigation, with nevertheless a significantly
higher incidence in those presenting with dizziness or syncope. The
incidence of 22% for potentially malignant forms in asymptomatic
children provides an incentive to recommend an ECG in all children
older than 10 years participating in an active sport in order to
detect WPW and to propose esophageal investigation(3).
11) Programmed atrial stimulation using 1 and 2 extrastimuli
delivered at different cycle lengths is then used to determine the
accessory pathway refractory period and to induce a supraventricular
tachycardia. The induction of an AF with rapid conduction through the
accessory pathway (> 240/min in control state, > 300/min after
isoproterenol) is the sign of a form of WPW at risk of SCD(4).The
atrial effective refractory period (ERP)is shorter in WPW syndrome
children with AF. The pediatric WPW syndrome patients with AF had
different electrophysiological characteristics from those without AF(5).
12) Identification of patients at risk for Paroxysmal AF(PAF)
recurrence after AP ablation is important because of the necessity
for additional therapies. P-wave dispersion Pd > or = 32.5 ms and
Maximum P-wave duration (Pmax)Pmax > or = 103.0 ms predict the
recurrence of PAF after ablation with acceptable positive and
negative predictive values. Pd > or = 32.5 ms is an independent
predictor of recurrence of PAF after catheter ablation in patients
with WPW syndrome (6).
13) Age, gender and a history of syncope are the independent risk
factors of AF in patients with WPW syndrome. Anterograde conduction
via accessory pathway is of major importance in the development of
AF. RFCA of an accessory pathway should be performed early because
the risk of the procedure is small and there is an increasing risk of
AF with ageing(7).
References
1) Tijunelis MA, Herbert ME Myth: Intravenous amiodarone is
safe in patients with atrial fibrillation and Wolff-Parkinson-White
syndrome in the emergency department. CJEM. 2005; 7:262-265.
2) Chometon F, Brembilla-Perrot B.Influence of age on the
presumed cause of syncope in patients with the Wolff-Parkinson-White
syndrome Arch Mal Coeur Vaiss. 2007; 100:34-39.
3) Brembilla-Perrot B, Marcon F, Bosser G, et al.Feasibility
and significance of a transoesophageal electrophysiological
investigation in children and adolescents with Wolff-Parkinson-White
syndrome Arch Mal Coeur Vaiss. 2005;98:25-30.
4) Brembilla-Perrot B.Electrophysiological evaluation of Wolff-
Parkinson-White Syndrome. Indian Pacing Electrophysiol J. 2002;
2:143-152.
5) Lee PC, Hwang B, Tai CT, et al.The different
electrophysiological characteristics in children with Wolff-Parkinson-
White syndrome between those with and without atrial fibrillation.
Pacing Clin Electrophysiol. 2004 Feb;27(2):235-239.
6) Aytemir K, Amasyali B, Kose S, et al. Maximum P-wave
duration and P-wave dispersion predict recurrence of paroxysmal
atrial fibrillation in patients with Wolff-Parkinson-White syndrome
after successful radiofrequency catheter ablation. J Interv Card
Electrophysiol. 2004; 11:21-27.
7) Szumowski L, Walczak F, Urbanek P, et al. Risk factors of
atrial fibrillation in patients with Wolff-Parkinson-White syndrome.
Kardiol Pol. 2004; 60:206-216.
All the best for all
Andrés Ricardo Pérez Riera MD
Chief of Electro-Vectocardiology Sector of the Discipline of
Cardiology,
ABC Faculty of Medicine (FMABC), Foundation of ABC (FUABC) - Santo
André São
Paulo - Brazil.
riera在uol.com.br
--
Dr. Sergio Dubner
President of Scientific Committee
Dr. Edgardo Schapachnik
President of Steering Committee
>
> Dear moderators and cardiologist colleagues,
> I send a case for discussion, presented by Dr. Alberto Pastore. The
> patient is 30 years old and he presented at the emergency room with
> palpitations and discomfort, without cardiological background. He
> presented once again another day, and he had beta-blockers prescribed
> for palpitations and he felt worse. What are the possible diagnosis
> and therapeutic managements?
>
> Sidney Campodonico .F, MD
> Brazil
>
> SEE THE ECG
> http://www.af-symposium.org/files/Campodonico.jpg
--
Dr. Sergio Dubner
President of Scientific Committee
Dr. Edgardo Schapachnik
President of Steering Committee
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