curs 6 ecg tulburari de conducere
DESCRIPTION
Tulburari de conducereTRANSCRIPT
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Asist. Univ. Dr. Mihaela PopescuCatedra de Cardiologie Spitalul
Universitar de Urgenta Elias
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CD (proximal)-art. NSA LAD -ramul septal, ramul drept proximal si
fascicul anterior ram stang LAD(septal)&CD(terminal)- fasciculul
posterior al ramului stang A interventriculara posterioara- NAV si Hiss
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Localizarea blocului:◦ Sinoatrial◦ Intra-atrial◦ Atrioventricular◦ Intra-ventricular◦ Blocuri de ramura
Gradul blocului◦ Tip I: prelungirea timpului de conducere◦ Tip II: bloc partial◦ Tip III: bloc complet
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Cresterea tonusului vagal Ischemie Endocardita Miocardita Tulburari degenerative (boala Lev, boala Lenegre) Scleroza (Aortica) Chirurgie cardiaca RAA; Cardiomiopatii Toxicitate medicamentoasa Diselectrolitemii Boli de colagen Hipotiroidie
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Localizarea blocului:◦ Sinoatrial◦ intra-atrial◦ atrioventricular◦ intra-ventricular
Gradul blocului◦ Tip I: prelungirea timpului de conducere◦ Tip II: bloc partial◦ Tip III: bloc complet
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• Bloc SA de grad I
• Bloc SA de grad II1.Tip 1 (Mobitz 1)2.Tip 2 (Mobitz 2)
• Bloc SA de grad III
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Prelungirea timpului in care impulsul
paraseste NSA
Nu se poate detecta pe ECG de suprafata
Doar prin studiu electrofiziologic se poate
masura timpul de conducere
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Tip I (SA Wenckebach) 1. intervalele PP se scurteaza progresiv pana apare o pauza (impulsul sinusal nu mai ajunge in atrii)
2.Durata pauzei este < decat doua intervale PP
3.Intevalul PP de dupa pauza este mai mare decat cel de dinainte de pauza
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1000ms 1000ms 1000ms 1000ms
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Tip II Intervale PP constante apoi brusc nu se
mai produce conducerea
Pauza este aproximativ 2 PP
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Nu se poate deosebi de o pauza sinusala
Poate fi identificat doar prin studiu electrofiziologic
Se asociaza cu un ritm de scapare
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Blocul atrioventricular = intarziere sau blocarea transmiterii depolarizarii de la atrii la ventriculi
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BAV este impartit in trei categorii:1. BAV grad I2. BAV grad II
1. BAV grad II tip I2. BAV grad II tip II
3. BAV grad III= BAV complet
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BAV GRAD I
BRD SAU BLOC
FASCICULAR
BLOC BIFASCICULA
RBAV GRAD II, WENCKEBAC
H
BAV GRAD II, TIP II
BAV GRAD INALT
BAV COMPLET
SUPRA HIS INFRA HIS
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PR lung
Bloc grad II tip I
Bloc grad II tip II
Bloc complet
NAV
HIS
HIS-Ventricul
NSA- atriu
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PR interval > 0.20 second Interval PR constant PR> 0.20s
P R
P R
P R
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Intervale PR constante
Brusc, o unda p este blocata
P R
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PR = .24 sec PR = .36 sec PR = .40 secP blocat
Unde p blocate
“bloc 2:1” “bloc 3:1”
PR = CONSTANT
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Supra His- NAV Sub His
Atropina Scade gradul de bloc Creste gradul de bloc
Efort fizic Scade gradul de bloc Creste gradul de bloc
Masaj sinus carotidian Creste gradul de bloc Scade gradul de bloc
Important in blocul 2:1
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SINDROM STOKES-ADAMS
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Manifestari BAV grad I: de obicei asimptomatic; BAV grad II: palpitatii, fatigabilitate BAV grad III: ameteala, stare presincopala
sincopa◦ Variabilitatea Zg 1, poate aparea zgomotul de
tun
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1. BAV grad I nu necesita tratament2. Vagolitice (atropina) pentru
cresterea frecventei3. BAV cronic simptomatice grad II si
III necesita implantare de pace maker permanent
4. Boli neuromusculare asociate cu BAV grad II sau III necesita implantare de pace maker permanent
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1. Bloc de ram drept (BRD)2. Bloc de ram stang (BRS)3. Hemibloc anterior stang (HBAS)4. Hemibloc posterior stang (HBPS)
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•BRD incomplet cand
100ms < QRS < 120ms
•BRD complet cand
QRS>120ms
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QRS ≥ 120ms Pattern rSR’ sau R fragmentat in V1
Unda S larga in DI si V6
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•BRS incomplet cand
100ms < QRS < 120ms
•BRS complet cand
QRS>120ms
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QRS ≥ 120ms R larg in DI si V6
QS larg in V1
Absenta undei q in DI si V6
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BRS BRD
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FPI
FAS
Ram stang
1.
2.
D III
D I
AVF
• Deviatie axiala stanga, QRS la
>-45 grd
• Depolarizarea se face de jos
in sus si de la stanga la
dreapta
• Unde S adanci in derivatiile
inferioare
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FPI
FAS
Ram stang
1.
2.
D III
D I
AVF
• Deviere axiala dreapta, QRS
la >120 grd
• Depolarizarea se face de sus
in jos si de la stanga la
dreapta
• Unde S adanci in derivatiile
laterale
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Bloc bifascicular: BRD + HBAS / HBPI
Bloc trifascicular: BRD + HBAS / HBPI
asociat cu BAV grad I
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K= 8.1
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K= 1.7
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Brugada I: ST supradenivelat in V1-V3 >2mm, T negativ.
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Anomalie a canalelor de Na care predispune la moarte cardiaca
Pattern ECG caracteristic:◦ Tip I diagnostic cand se asociaza FV
documentata, MS in familie la varsta tanara, AHC de tip I
◦ Tipurile II and III ridica suspiciunea de Brugada dar sunt diagnostice doar daca se convertesc in tip I la test de provocare cu blocant de canal de Na
Terapie: defibrilator implantabil, testarea rudelor de gr I
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• Afectiune transmisa genetic in principal autozomal dominant
• Produsa de mutatii ale genelor ce codifica proteine desmozomale
• Miocitele sunt inlocuite cu tesut fibro-grasos, predominant la nivelul VD
• Varsta medie de prezentare – 29 ani• Palpitatii 27-60%• Sincopa /presincopa 26-47%• Deces ca prima manifestare 25%• Dureri toracice nelegate de stress sau patologie
coronariana (pana la 80%)• Insuficienta cadica - tardiv• Efortul fizic accelereaza evolutia bolii si aparitia
simptomatologiei
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Aspect ECG
• Unde T negative in V1-V3• Bloc parietal –QRS >110 ms in V1-V3 sau
V1+V2+V3/V4+V5+V6= 1.2• BRD complet sau incomplet• Microvoltaj in derivatiile drepte• Slurring al undei S(>55ms) cel mai frecvent semn de CAVD• Potentiale tardive• Unde epsilon• ESV frecvente (dublete, triplete) cu aspect de BRS• TV mono/polimorfe, sustinute sau nesustinute• FV• posibil
• Aritmii supraventriculare• Blocuri atrioventriculare avansate
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Sindrom de QT lung
•QTc > 460 femei•QTc > 450 barbati•13 tipuri de sdr de QT lung descrise
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QTc<300ms3 tipuri de sdr de QT scurt