New Features of Electrocardiogram in a Case Report of Arrhythmogenic Right Ventricular Cardiomyopathy: A Care-Compliant Article.
New Features of Electrocardiogram in a Case Report of Arrhythmogenic Right Ventricular Cardiomyopathy: A Care-Compliant Article.
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致心律失常性右心室心肌病病例报告中心电图的新特征
DOI：
10.1097/md.0000000000003442
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发表时间：
2016-04
期刊：
影响因子：
1.6
通讯作者：
Li D
中科院分区：
文献类型：
--
作者：
Pei H;Yu Q;Su X;Wang Z;Zhao H;Yang D;Yang Y;Li D
致心律失常性右心室心肌病（ARVC）是一个严重的健康问题。由于猝死往往是第一个表现，早期诊断ARVC是必不可少的。心电图是目前广泛使用的无创性诊断方法。为了更好地诊断和治疗ARVC，我们应该清楚地阐明其病理生理学改变。一名66岁的农民因持续心悸、胸闷、多汗和恶心到急诊室就诊，无明显诱因。ECG显示室性心动过速（VT）。患者出现血压突然下降和急性意识模糊。立即进行电转换后，他的意识逐渐恢复，症状缓解。然后将患者转至心脏科接受ECG、超声心动图、冠状动脉造影、生化测定、心内示踪和射频消融。最后，他被诊断为ARVC，表现为双侧心室扩张和V1-V3导联的A波。为该患者提供了适当的治疗，包括药物干预和射频消融。虽然ARVC的诊断并不困难，但该患者的心电图表现出几个有趣的特征，需要进一步研究：在前下导联发现广泛的T波倒置，显示双心室受累;室性心动过速的形态和周期长短不一，部分室性心动过速表现为不规则节律，提示我们要仔细鉴别某些特殊的室性心动过速与房颤（AF），并且自ARVC发病以来，V1-V3和avR导联逐渐出现了慢波。最重要的是，QRS波群后的E1波出现在窦性心律和起源于心尖的室性早搏/VT中，而QRS波群前的E1波出现在起源于右心室流出道（RVOT）的VT中。心电图T波倒置和T波倒置的特点及不同形态室性心动过速的出现可反映ARVC的进展情况。室性心动过速时QRS波群与心动过速的位置关系取决于心室激动顺序，即室性心动过速时QRS波群的定位取决于室性心动过速的起源部位。
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a crucial health problem. With sudden death often being the first presentation, early diagnosis for ARVC is essential. Up to date, electrocardiogram (ECG) is a widely used diagnostic method without invasive harms. To diagnose and treat ARVC as well as possible, we should clearly elucidate its pathophysiological alterations. A 66-year-old farmer presented to the Emergency Department with continuous palpitation, chest tightness, profuse sweating, and nausea with no obvious predisposing causes. An ECG indicated ventricular tachycardia (VT). The patient experienced a sudden drop in blood pressure and acute confusion. After an immediate electrical conversion, his consciousness was gradually restored, and symptoms relieved. The patient was then transferred to the Department of Cardiology to receive ECG, echocardiography, coronary angiogram, biochemical assays, endocardiac tracing, and radiofrequency ablation. In the end, he was diagnosed with ARVC, evidenced by bilateral ventricle dilation and epsilon waves in leads V1–V3. Appropriate therapies were provided for this patient including pharmacological intervention and radiofrequency ablation. Although the diagnosis of ARVC is not difficult, this patient's ECG manifested several interesting features and should be further investigated: T wave inversions were found extensively in the anterior and inferior leads, revealing the involvement of bilateral ventricles; VTs with different morphologies and cycle lengths were found, and some VTs manifested the feature of irregularly irregular rhythm, reminding us to carefully differentiate some special VTs from atrial fibrillation (AF); and epsilon waves gradually appeared in leads V1–V3 and avR since the onset of ARVC. Most importantly, the epsilon waves behind QRS complex appeared in both sinus rhythm and ventricular premature beats/VT originating from cardiac apex, whereas the epsilon waves prior to QRS complex occurred in VT originating from right ventricular outflow tract (RVOT). The features of T wave inversion and epsilon wave in ECGs and the appearance of VTs with different morphologies can reflect the progression of ARVC. The position relationship between epsilon wave and QRS complex in VT depends on ventricular activation sequence, that is, the localization of epsilon wave depends on where VT is originating from.