Koch三角解剖与临床Koch三角解剖与临床第1页一、Koch三角解剖与组织学

Koch三角解剖与临床第2页Koch三角解剖Koch19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三角顶部解剖和功效上是心房和希氏束连接（房室交界区）Koch三角解剖与临床第3页Koch三角组织学房室结细胞: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Koch三角解剖与临床第4页房室结后延伸（PNE）Koch三角解剖与临床第5页人房室结后延伸（PNE）人房室结含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,可达冠状窦口周围,被认为参与了慢径传导Koch三角解剖与临床第6页房室结后延伸（PNE）N=8N=2N=6N=1右+左右左无InoueN=2113710周聊生N=178612Koch三角解剖与临床第7页二、Koch三角与房室结双径路Koch三角解剖与临床第8页房室结双径路1956年Moe在犬心脏找到房室结双径路电生理证据,即快径传导快/不应期长;慢径传导慢/不应期短1968年该概念应用于人心脏。Koch三角解剖与临床第9页Aschoff标准:组织学差异、踪迹连续、与正常心肌绝缘

Koch三角解剖与临床第10页房室结双径路房室结真结细胞和移行细胞虽有组织学差异和踪迹连续,但无绝缘层移行细胞即为房室结真结细胞与心房肌传导纽带Koch三角解剖与临床第11页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Koch三角解剖与临床第12页房室结双径路Koch三角解剖与临床第13页Koch三角解剖与临床第14页Koch三角传导异向性:

双径路解剖基础Koch三角内心房肌非均一排列传导异向性传导延缓/单向传导阻滞折返形成Hocin:犬和猪心脏方向依靠性早搏仅引发Koch三角传导延迟4－21ms,而AH延长达80－120ms。说明传导延迟关键发生在房室结后延伸与真结细胞Koch三角解剖与临床第15页房室结后延伸（PNE）:

慢径解剖与电生理基础Inoue:人右PNE沿三尖瓣环延伸,可统计到双电位,是慢径消融位置。Medkour:兔心PNE沿三尖瓣环延伸至冠状静脉窦口,与房室结相比,含有更短周长依靠性不应期,不连续传导,延迟房室结反应与折返Koch三角解剖与临床第16页Koch三角解剖与临床第17页Koch三角解剖与临床第18页慢径消融靶点Quintana:1例AVNRT行慢径消融患者尸检发觉消融线在心房肌慢径消融时消融可能是正常心房肌。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％位于冠状窦口周围心内膜下。冠状窦口周围消融及快径消融可消弱迷走神经支配,造成心脏迷走神经功效下降起搏标测Koch三角能够发觉快径缺如或靠近慢径,从而避免房室传导阻滞Koch三角解剖与临床第19页慢径消融靶点影像分区

A区:A1A2M区:M1M2P区:P1P2Koch三角解剖与临床第20页腺苷对房室结双径路作用EffectsofATP(20mg)onAVconductionbefore（A）andafter（B）radiofrequencyablationoftheslowpathwayKoch三角解剖与临床第21页三、Koch三角与迷走神经Koch三角解剖与临床第22页Koch三角内迷走神经分布与作用Koch三角迷走神经支配关键来自下腔静脉与左房交界处脂肪垫内迷走神经节团迷走神经关键支配结细胞刺激房室结区迷走神经能够减慢房颤心室率消融慢径能够缩短快径有效不应期Koch三角解剖与临床第23页Koch三角迷走神经分布与作用Shah:阈下刺激方法证实迷走神经多位于His束下（7/13）,也有位于His束和CSO（3/13,3/13）Koch三角解剖与临床第24页临床意义房颤时房室结递减性与隐匿性传导造成了慢和不规则心室率。房颤时慢径和快径均参与了传导,慢径前传多于快径前传。故消融慢径能够减慢房颤时心室率。消融慢径能够缩短快径有效不应期刺激房室结区迷走神经能够减慢房颤心室率Koch三角解剖与临床第25页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三角解剖与临床第26页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三角解剖与临床第27页谢谢!Koch三角解剖与临床第28页房室结后延伸（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周长依靠性不应期、不连续传导、延迟房室结反应及折返。MedkourKoch三角解剖与临床第29页房室结后延伸（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1Koch三角解剖与临床第30页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Koch三角解剖与临床第31页Koch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Koch三角解剖与临床第32页Koch三角解剖与临床第33页Koch三角解剖与临床第34页起搏标测Koch三角能够发觉快径缺如或靠近慢径,从而避免房室传导阻滞。theanterogradelyconductingfastpathway(AFP)basedontheshortestSt-Hintervalobtainedbystimulatingtheanteroseptal,