Koch三角解剖與臨床醫(yī)學課件

Koch三角解剖與臨床Koch三角解剖與臨床第1頁一、Koch三角解剖與組織學

Koch三角解剖與臨床第2頁Koch三角解剖Koch19首先描述,由Todaro腱、冠狀靜脈竇口及三尖瓣膈環(huán)組成。房室結位于Koch三角頂部解剖和功效上是心房和希氏束連接（房室交界區(qū)）Koch三角解剖與臨床第3頁Koch三角組織學房室結細胞:小細胞、緊密無序排列,細胞間連接極少移行細胞:介于結細胞與心房肌細胞之間,有2個移行方向心房肌細胞Koch三角解剖與臨床第4頁房室結后延伸（PNE）Koch三角解剖與臨床第5頁人房室結后延伸（PNE）人房室結含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,可達冠狀竇口周圍,被認為參與了慢徑傳導Koch三角解剖與臨床第6頁房室結后延伸（PNE）N=8N=2N=6N=1右+左右左無InoueN=2113710周聊生N=178612Koch三角解剖與臨床第7頁二、Koch三角與房室結雙徑路Koch三角解剖與臨床第8頁房室結雙徑路1956年Moe在犬心臟找到房室結雙徑路電生理證據(jù),即快徑傳導快/不應期長;慢徑傳導慢/不應期短1968年該概念應用于人心臟。Koch三角解剖與臨床第9頁Aschoff標準:組織學差異、蹤跡連續(xù)、與正常心肌絕緣

Koch三角解剖與臨床第10頁房室結雙徑路房室結真結細胞和移行細胞雖有組織學差異和蹤跡連續(xù),但無絕緣層移行細胞即為房室結真結細胞與心房肌傳導紐帶Koch三角解剖與臨床第11頁房室結雙徑路慢徑組成:Koch三角下后緣心房肌、移行細胞、PNE、真結細胞快徑:房間隔心肌細胞、移行細胞、真結細胞Koch三角解剖與臨床第12頁房室結雙徑路Koch三角解剖與臨床第13頁Koch三角解剖與臨床第14頁Koch三角傳導異向性:

雙徑路解剖基礎Koch三角內(nèi)心房肌非均一排列傳導異向性傳導延緩/單向傳導阻滯折返形成Hocin:犬和豬心臟方向依靠性早搏僅引發(fā)Koch三角傳導延遲4－21ms,而AH延長達80－120ms。說明傳導延遲關鍵發(fā)生在房室結后延伸與真結細胞Koch三角解剖與臨床第15頁房室結后延伸（PNE）:

慢徑解剖與電生理基礎Inoue:人右PNE沿三尖瓣環(huán)延伸,可統(tǒng)計到雙電位,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,與房室結相比,含有更短周長依靠性不應期,不連續(xù)傳導,延遲房室結反應與折返Koch三角解剖與臨床第16頁Koch三角解剖與臨床第17頁Koch三角解剖與臨床第18頁慢徑消融靶點Quintana:1例AVNRT行慢徑消融患者尸檢發(fā)覺消融線在心房肌慢徑消融時消融可能是正常心房肌。慢徑消融時避免損傷房室結動脈。Kozlowski:50例人心房室結動脈中,20％位于冠狀竇口周圍心內(nèi)膜下。冠狀竇口周圍消融及快徑消融可消弱迷走神經(jīng)支配,造成心臟迷走神經(jīng)功效下降起搏標測Koch三角能夠發(fā)覺快徑缺如或靠近慢徑,從而避免房室傳導阻滯Koch三角解剖與臨床第19頁慢徑消融靶點影像分區(qū)

A區(qū):A1A2M區(qū):M1M2P區(qū):P1P2Koch三角解剖與臨床第20頁腺苷對房室結雙徑路作用EffectsofATP(20mg)onAVconductionbefore（A）andafter（B）radiofrequencyablationoftheslowpathwayKoch三角解剖與臨床第21頁三、Koch三角與迷走神經(jīng)Koch三角解剖與臨床第22頁Koch三角內(nèi)迷走神經(jīng)分布與作用Koch三角迷走神經(jīng)支配關鍵來自下腔靜脈與左房交界處脂肪墊內(nèi)迷走神經(jīng)節(jié)團迷走神經(jīng)關鍵支配結細胞刺激房室結區(qū)迷走神經(jīng)能夠減慢房顫心室率消融慢徑能夠縮短快徑有效不應期Koch三角解剖與臨床第23頁Koch三角迷走神經(jīng)分布與作用Shah:閾下刺激方法證實迷走神經(jīng)多位于His束下（7/13）,也有位于His束和CSO（3/13,3/13）Koch三角解剖與臨床第24頁臨床意義房顫時房室結遞減性與隱匿性傳導造成了慢和不規(guī)則心室率。房顫時慢徑和快徑均參與了傳導,慢徑前傳多于快徑前傳。故消融慢徑能夠減慢房顫時心室率。消融慢徑能夠縮短快徑有效不應期刺激房室結區(qū)迷走神經(jīng)能夠減慢房顫心室率Koch三角解剖與臨床第25頁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.;106:1853-1858Koch三角解剖與臨床第26頁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,DonWAmJPhysiolHeartCircPhysiol;281:H1490–H1497Koch三角解剖與臨床第27頁謝謝!Koch三角解剖與臨床第28頁房室結后延伸（PNE）兔心PNE沿三尖瓣隔環(huán)延伸至冠狀靜脈竇口。與房室結相比有更短周長依靠性不應期、不連續(xù)傳導、延遲房室結反應及折返。MedkourKoch三角解剖與臨床第29頁房室結后延伸（PNE）Inoue:21例人尸體心臟房室結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右+左13右7左1Koch三角解剖與臨床第30頁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Koch三角解剖與臨床第31頁Koch三角解剖與組織學Koch三角與房室結雙徑路Koch三角與迷走神經(jīng)Koch三角與腺苷Koch三角解剖與臨床第32頁Koch三角解剖與臨床第33頁Koch三角解剖與臨床第34頁起搏標測Koch三角能夠發(fā)覺快徑缺如或靠近慢徑,從而避免房室傳導阻滯。theanterogradelyconductingfastpathway(AFP)basedontheshortestSt-Hintervalobtainedbystimulatingtheanteroseptal,