Koch-三角解剖与临床-课件

1、Koch三角解剖与临床上海长征医院心内科 廖德宁1PPT课件Koch三角解剖与临床上海长征医院心内科 1PPT课件一、Koch 三角解剖与组织学2PPT课件一、Koch 三角解剖与组织学2PPT课件Koch三角的解剖 Koch 1909年首先描述，由Todaro腱、冠状静脉窦口及三尖瓣膈环组成。房室结位于Koch三角的顶部解剖和功能上是心房和希氏束的连接（房室交界区）3PPT课件Koch三角的解剖 Koch 1909年首先Koch三角的组织学房室结细胞：小细胞、紧密无序排列，细胞间连接极少移行细胞：介于结细胞与心房肌细胞之间，有2个移行方向心房肌细胞4PPT课件Koch三角的组织学房室结细胞：

2、小细胞、紧密无序排列，细胞间房室结后延伸（PNE）5PPT课件房室结后延伸（PNE）5PPT课件人房室结后延伸（PNE）人房室结具有右和左后延伸左后延伸朝左行向房间隔右后延伸与三尖瓣隔瓣近乎平行,可达冠状窦口附近，被认为参与了慢径传导6PPT课件人房室结后延伸（PNE）人房室结具有右和左后延伸6PPT课件房室结后延伸（PNE）N=8N=2N=6N=17PPT课件房室结后延伸（PNE）N=8N=2N=6N=17PPT课件二、 Koch三角与房室结双径路8PPT课件二、 Koch三角与房室结双径路8PPT课件房室结双径路1956年Moe在犬的心脏找到房室结双径路的电生理证据，即快径传导快/不应期长

3、；慢径传导慢/不应期短1968年该概念应用于人的心脏。9PPT课件房室结双径路1956年Moe在犬的心脏找到房室结双径路的电生Aschoff 标准：组织学差别、踪迹连续、与正常心肌绝缘 10PPT课件Aschoff 标准：组织学差别、踪迹连续、与正常心肌绝缘 房室结双径路房室结真结细胞和移行细胞虽有组织学差别和踪迹连续，但无绝缘层移行细胞即为房室结真结细胞与心房肌的传导纽带11PPT课件房室结双径路房室结真结细胞和移行细胞虽有组织学差别和踪迹连续房室结双径路慢径组成：Koch三角下后缘心房肌、移行细胞、PNE、真结细胞快径：房间隔心肌细胞、移行细胞、真结细胞12PPT课件房室结双径路慢径组成：

4、Koch三角下后缘心房肌、移行细胞、P房室结双径路13PPT课件房室结双径路13PPT课件14PPT课件14PPT课件Koch三角传导的异向性：双径路的解剖基础Koch三角内心房肌非均一排列传导的异向性传导延缓/单向传导阻滞折返形成Hocin：犬和猪心脏方向依赖性早搏仅引起Koch三角传导延迟421ms，而AH延长达80120ms。说明传导延迟主要发生在房室结后延伸与真结细胞15PPT课件Koch三角传导的异向性：双径路的解剖基础Koch三角内心房室结后延伸（PNE）：慢径的解剖与电生理基础Inoue: 人右PNE沿三尖瓣环延伸，可记录到双电位，是慢径消融位置。Medkour: 兔心PNE沿三

5、尖瓣环延伸至冠状静脉窦口，与房室结相比，具有更短的周长依赖性不应期，不连续传导，延迟的房室结反应与折返16PPT课件房室结后延伸（PNE）：慢径的解剖与电生理基础Inoue:17PPT课件17PPT课件18PPT课件18PPT课件慢径消融靶点Quintana：1例AVNRT行慢径消融的患者尸检发现消融线在心房肌慢径消融时消融的可能是正常心房肌。慢径消融时避免损伤房室结动脉。Kozlowski：50例人心房室结动脉中，20位于冠状窦口附近心内膜下。冠状窦口附近消融及快径消融可消弱迷走神经的支配，导致心脏迷走神经功能下降起搏标测Koch三角可以发现快径缺如或靠近慢径，从而避免房室传导阻滞19PPT

6、课件慢径消融靶点Quintana：1例AVNRT行慢径消融的患者慢径消融靶点影像分区 A区 : A1 A2 M区 : M1 M2 P区 : P1 P220PPT课件慢径消融靶点影像分区20PPT课件腺苷对房室结双径路的作用Effects of ATP (20 mg) on AV conduction before （A） and after （B） radiofrequency ablation of the slow pathway21PPT课件腺苷对房室结双径路的作用Effects of ATP (20三、 Koch三角与迷走神经22PPT课件三、 Koch三角与迷走神经22PPT课件Ko

7、ch三角内迷走神经分布与作用Koch三角的迷走神经支配主要来自下腔静脉与左房交界处脂肪垫内的迷走神经节团迷走神经主要支配结细胞刺激房室结区迷走神经可以减慢房颤心室率消融慢径可以缩短快径有效不应期23PPT课件Koch三角内迷走神经分布与作用Koch三角的迷走神经支配主Koch三角迷走神经分布与作用Shah：阈下刺激方法证明迷走神经多位于His束下（7/13），也有位于His束和CSO（3/13，3/13）24PPT课件Koch三角迷走神经分布与作用Shah：阈下刺激方法证明迷走临床意义房颤时房室结的递减性与隐匿性传导导致了慢的和不规则的心室率。房颤时慢径和快径均参与了传导，慢径前传多于快径前传

8、。故消融慢径可以减慢房颤时的心室率。消融慢径可以缩短快径有效不应期刺激房室结区迷走神经可以减慢房颤心室率25PPT课件临床意义房颤时房室结的递减性与隐匿性传导导致了慢的和不规则的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课件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课件Selective AV nodal vagal stimu谢 谢！28PPT课件谢 谢！28PPT课件房室结后延伸（PNE） 兔心PNE沿三尖瓣隔环延伸至冠状静脉窦口。与房室结相比有更短的周长依赖性不应期、不连续传导、延迟的房室结反应及折返。 Medkour29PPT课件房室结后延伸（PNE） 兔心PNE沿三尖瓣隔环延房室结后延伸（PNE）Inoue：21例人尸体心脏房室结有向右和向左后延伸，右后延伸沿三尖瓣隔环向下，被认为参与了慢径传导右+左 13右 7左 130PPT课件房室结后延伸（PNE）Inoue：21例人尸体心脏房室结有向

17、上腔静脉下腔静脉卵圆窝房间隔右心耳梳状肌冠状窦口Todaro 腱31PPT课件上腔静脉下腔静脉卵圆窝房间隔右心耳梳状肌冠状窦口TodaroKoch 三角解剖与组织学Koch 三角与房室结双径路Koch 三角与迷走神经Koch 三角与腺苷32PPT课件Koch 三角解剖与组织学32PPT课件33PPT课件33PPT课件34PPT课件34PPT课件起搏标测Koch三角可以发现快径缺如或靠近慢径，从而避免房室传导阻滞。 the anterogradely conducting fast pathway (AFP) based on the shortest St-H interval obtained by stimulating the anteroseptal, midseptal,