房室旁路的射频消融课件

房室旁路的射频消融房室旁路的射频消融中国协和医科大学阜外心血管病医院临床电生理研究室 楚建民房室旁路的射频消融中国协和医科大学阜外心血管病医院1 1如何判定左右侧旁路心律失常的形成机制旁路的解剖基础旁路的标测和消融技术如何判定左右侧旁路2 2Accessory AV PathwaysSymptoms:Range from asymptomatic to Symptoms:Range from asymptomatic to sudden cardiac death sudden cardiac death 症状症状:无症状到猝死无症状到猝死 SVT may be frequent or recurrentSVT may be frequent or recurrentSVTSVT频繁发作频繁发作,表现为心慌、胸闷。表现为心慌、胸闷。Up to 40%of patients remain asymptomaticUp to 40%of patients remain asymptomatic 40%40%无症状无症状Orthodromic reciprocating tachycardiaOrthodromic reciprocating tachycardia顺向型顺向型 (30%of PSVTs)clinical presentation:(30%of PSVTs)clinical presentation:Antegrade conduction over AV nodeAntegrade conduction over AV node房室结前传房室结前传 Retrograde conduction over accessory pathwayRetrograde conduction over accessory pathway旁路旁路逆传逆传Kay GN.Am J Med.1996;100:344-345.Accessory AV PathwaysSymptoms:3 3Wolff-Parkinson-White Syndrome心电图表现The electrocardiogram may show The electrocardiogram may show pre-excitation(delta wave)pre-excitation(delta wave)心电图心电图QRSQRS起始起始部粗钝形成预激波部粗钝形成预激波If accessory pathway not capable of If accessory pathway not capable of anterograde conduction,the ECG may not anterograde conduction,the ECG may not show pre-excitation(concealed pathway)show pre-excitation(concealed pathway)ECG ECG无预激无预激(隐匿性旁路隐匿性旁路)If accessory pathway capable of rapid If accessory pathway capable of rapid antegrade conductionantegrade conduction Increased risk to develop VF from rapid Increased risk to develop VF from rapid conduction of AFconduction of AF房扑发展为室颤房扑发展为室颤Wolff-Parkinson-White Syndrome4 4Pre-excitation预激体表心电图Kay NG.Am J of Med.1996;10:344-356.Pre-excitation预激体表心电图Kay NG.A5 5WPW:Case Study 病例 18 year old male basketball player 18 year old male basketball player 篮球运动员篮球运动员Presented to ER with:Presented to ER with:症状症状 Multiple episodes of near-syncope Multiple episodes of near-syncope 先兆晕厥先兆晕厥Adenosine 12 mg accelerated the heart rate Adenosine 12 mg accelerated the heart rate 12mg12mg腺苷心室率加快腺苷心室率加快Emergency cardioversion performed Emergency cardioversion performed 紧急电复律紧急电复律WPW:Case Study 病例 18 year o6 6WPW:Case Study ECG旁路前传Courtesy of Dr.Brian Olshansky.WPW:Case Study ECG旁路前传Courtes7 7WPW:Case StudyStudied in the electrophysiology laboratory 电生理检查Induced AF VF 诱发房扑演化为室扑Mapping:two pathways双旁路Posterior septalPosterior septal后间隔后间隔Left lateral accessory pathwayLeft lateral accessory pathway游离壁游离壁Ablation of both pathways 消融2条旁路No additional therapy needed无需药物治疗WPW:Case StudyStudied in the 8 8AF with Multiple Accessory Pathways房扑Courtesy of Dr.Brian Olshansky.AF with Multiple Accessory Pa9 9AF with Multiple Accessory Pathways房扑Courtesy of Dr.Brian Olshansky.AF with Multiple Accessory Pa1010AF VF 房扑转为室扑Courtesy of Dr.Brian Olshansky.AF VF 房扑转为室扑Courtesy of D1111心动过速时的心电图表现顺向型心动过速心电图特点：QRS后可见P波，RP70ms。P波与T波融合，导致T波僵硬、畸形。逆向型心动过速心电图：宽大QRS心动过速，形态与窦性心律时一致。心动过速时的心电图表现顺向型心动过速心电图特点：QRS后可见1212左右侧旁路的判定A型预激：V1预激波和QRS主波向上，旁路位于左心房和左心室之间，即二尖瓣环上。B型预激：V1预激波和QRS主波向下，旁路位于右心房和右心室之间，即三尖瓣环上。左右侧旁路的判定A型预激：V1预激波和QRS主波向上，旁路位1313Posterior Basal View Left Atrium左心房后面观R.superior pulmonary vein R.inferior pulmonary vein Coronary sinusL.inferior pulmonary vein L.atrium L.superior pulmonary vein L.auricle L.pulmonary arteryR.pulmonary arteryNetter F.Atlas of Human Anatomy.1989;Plate 202.Posterior Basal View Left A1414A型预激心电图A型预激心电图1515A型预激窦性心律时心内图A型预激窦性心律时心内图1616A型预激心动过速时心电图A型预激心动过速时心电图1717心内图心内图1818左侧旁路靶点图左侧旁路靶点图1919成功后靶点图成功后靶点图2020房室旁路的射频消融课件2121A型预激A型预激2222房室旁路的射频消融课件2323心室起搏诱发心动过速心室起搏诱发心动过速2424窦性心律靶点图窦性心律靶点图2525B型预激B型预激2626心动过速时心内图心动过速时心内图2727B型预激B型预激2828Orthodromic Reciprocating Tachycardia 顺向型Kay NG.Am J of Med.1996;10:344-356.Orthodromic Reciprocating Tach2929旁路形成的心律失常旁路逆传，房室结前传:顺向型心动过速旁路前传:房扑房颤时旁路前传导致：室速/室颤；阵发性心动过速时旁路前传：逆向型心动过速旁路形成的心律失常旁路逆传，房室结前传:顺向型心动过速3030顺向型AVRT形成机制顺向型AVRT形成机制3131逆向型房室折返性心动过速形成机制逆向型房室折返性心动过速形成机制3232B型预激心内图B型预激心内图3333心动过速心动过速3434另一种形态心动过速另一种形态心动过速3535左侧旁路参与左侧旁路参与3636第3种形态第3种形态3737房室旁路的射频消融课件3838所有旁路消融后心电图所有旁路消融后心电图3939旁路的性质Kent束：全和无 普通旁路、慢旁路 ATP无影响Mahim纤维：无逆传 只有前向递减性传导旁路的性质Kent束：全和无 4040房室旁路解剖示意图房室旁路解剖示意图4141Catheter Placement for Ablation of Left Free-Wall Accessory Pathway 左侧旁路导管放置Morady F.N Engl J of Med.1999;340:534-544.Catheter Placement for Ablatio4242Accessory AV PathwaysLocation:Right free-wall 右游离壁 部位Septal accessory pathways间隔部Left free-wall左游离壁Approach:Venous,transseptal or retrograde aortic途径 静脉,穿间隔,主动脉逆行Efficacy89-99%疗效Highest left-sided pathways 左侧旁路高Lower septal and right-sided pathways 右侧旁路低Recurrence 3-9%复发率Morady F.N Engl J of Med.1999;340:534-544.Accessory AV PathwaysLocation:4343旁路的标测旁路前传时:V波最早旁路逆传时:A波最早旁路的标测4444房室旁路的射频消融(右侧)房室旁路的射频消融(右侧)4545左侧旁路的旁路电位左侧旁路的旁路电位4646隐匿性旁路的旁路电位隐匿性旁路的旁路电位4747不同部位旁路的特点左前旁路:靠近左心耳，导管难以到位靶点靠近左心耳，导管难以到位靶点AVAV之比之比1:11:1左后间隔旁路:A A波变化大，导管容易移位，靠近房波变化大，导管容易移位，靠近房室结室结右后间隔旁路：注意心中静脉的可能性；左侧消融注意心中静脉的可能性；左侧消融右游离壁旁路：导管贴靠的问题导管贴靠的问题右前间隔旁路：靠近希氏束；不要轻易放电；能量靠近希氏束；不要轻易放电；能量滴定；小功率长时间。滴定；小功率长时间。不同部位旁路的特点左前旁路:靠近左心耳，导管难以到位靶点AV4848间隔部旁路、房速、双径路的鉴别诊断临床表现心电图表现电生理检查心动过速心内图表现ATP反应标测间隔部旁路、房速、双径路的鉴别诊断临床表现4949