经皮间隔支化学消融治疗肥厚梗阻性心肌病英文课件(模板)

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,Introduction,Treatment of symptomatic patients with HOCM aims to reduce symptoms, improve function capacity and provide better quality life.,Aims directly to reduce the hypertrophied interventricular septum with consecutive expansion of the LV outflow tract and reduction of the LV outflow tract gradient and improve distolic function LV.,First choice druges treatment,.,At least,10%,of patients with marked outflow tract obstruction have severe symptoms, which are unresponsive to medical therapy.,HOCM Myectomy,DDD-PM,ICD,PTSMA,IntroductionTreatment of sympt,1,Hypertrophic cardiomyopathy Epidemiological characteristics,Hypertrophic cardiomyopathy incidence of,0.2%,(1:500),0.16%,in our country,.,The vast majority of patients with no symptoms,25%,of outflow tract obstruction occurred,only about,5-10%,of patients with drug treatments fail or cause serious side effects of drugs effective dose.,Require treatment or surgical intervention in patients treated with only very few parts.,Hypertrophic cardiomyopathy Ep,2,Pathophysiologic and clinical characteristics of HOCM,Ventricular hypertrophy,Left ventricular outflow tract pressure gradient,Myocardial ischemia-angina pectoris.,Arrhythmia -,ventricular tachycardia, fibrillation,.,Clinical manifestations: dizziness, amaurosis, syncope, exertional shortness of breath, angina pectoris, heart disfunction and sudden death.,Generally considered: more severe hypertrophy, outflow tract obstruction near the LVOT sit, the more higher the obstructive pressure gradient were the more obvious clinical symptoms and the greater the potential threat.,Pathophysiologic and clinical,3,The natural course of outflow tract obstruction,Level any ages.,there is a big difference in Natural history,The natural course,not sure.,The more cardiac hypertrophy, the higher the pressure gradient, the greater the risk of sudden death.,The outflow tract pressure gradient of the clinical importance of the issue remains controversial, but it is generally considered an important clinical process indicators.,Nnual mortality rate of,2-4%,the incidence of,sudden death,1%,The natural course of outflow,4,T,he symptoms,Whether the obstruction produced the clinical symptoms? not only with the degree of outflow tract obstruction and outflow tract pressure gradient, as well as the obstruction site. But also with ventricular diastolic function and the adequacy of venous return is also closely related. Increase the heart before and after load and myocardial contractility often cause noticeable clinical symptoms. Therefore, it will become more apparent after exercise . The patients should be treatment.,The symptoms Whether the obs,5,Diastolic dysfunction,All patients had diastolic dysfunction ,How the pressure gradient and symptoms,And the extent and distribution of the hypertrophy has nothing to do.,Whether normal or small ventricular cavity, due to increased heart weight, ventricular volume reduction, myocardial fibrosis, leaving ventricular stiffness increased, compliance decreased and caused the diastolic function damage. Pulmonary venous pressure and end-diastolic pressure,were increased and heart disfunction.,Diastolic dysfunction All pati,6,systolic function,Systolic function is normal or supranormal in HCOM,Both obstruction and non-obstruction, Systolic dysfunction occurs in small subset,(10-15%),Result of progressive impairment of systolic function.,This transformation: wall thinning, cavity dilation, and fibrosis, increased mortality,11%,(annual ) and risk of SCD.,Conventional UCG, M-mode, or EF, fractional shortening preserved despite impaiment long-axis function,Tissue Doppler image (TD)-derived systolic velocities: in the basal inferoseptal and anterolateral wall routinely in all patients on subsequent scans.,systolic functionSystolic func,7,PTSMA indication (1),Clinical indication,No dobutamine gradients (Drugs),Coronary angiography,Verapamil,Remove balloon should be emptying alcohol of the balloon catheter and stagnation injection alcohol,Outflow tract obstruction sign in Echocardiograph,Septal thickness,Hypertrophic Cardiomyopathy Survival According to Outflow Tract Gradient,Systolic function is normal or supranormal in HCOM,MCE,Morophologic indication,Beta-blockers,asymmetrical septal hypertrophy (ASH), 2.,Target vessel supply to non-obstruction other regions such as: papillary muscle, free wall, etc.,CONCLUSIONS,Beta-blockers,CONCLUSIONS,Characteristics,Hypertrophic cardiomyopathy Epidemiological characteristics,Myocardial ischemia,Myocardial ischemia, the symptoms of angina pectoris are:,High-power so that left ventricular myocardial oxygen consumption increased;,Cardiac contraction strength of oppression the large myocardial coronary artery;,Intramyocardial small coronary artery stenosis and intimal thickening abnormalities,leading to cardiac hypertrophy and coronary artery oxygen required due to an imbalance of oxygen supply,.,PTSMA indication (1)Myocardia,8,Arrhythmia and,sudden death,HOCM of patients with abnormal myocardial cells and the arrangement of disorder provides a basis for the arrhythmia.,However, abnormal myocardial arrangement and spontaneous arrhythmias and ventricular fibrillation threshold, the precise relationship is unclear.,About,25%,of patients may have non-sustained ventricular tachycardia, the arrhythmia is sudden death of a good predictor,and negative predictive accuracy is 97%.,Arrhythmia and sudden death HO,9,Risk factors for sudden death,High-risk:,1 Sudden death occurred in a successful rescue2 continuous monomorphic ventricular tachycardia,Clinical risk factors:,1 non-sustained ventricular tachycardia2 movement abnormal blood pressure response (,25mmHg)3 unexplained syncope4 early-onset family history of sudden death5 severe left ventricular hypertrophy 30mm,Risk factors for sudden death,10,The purpose of the treatment PTMSA,Treatment of symptomatic patients with,HOCM,The PTMSA treatment of HOCM is a obstruction by,blocking,a the supply blood of parts of the septal hypertrophy of myocardial and myocardial,injury,in the region, leading to the area of myocardial,necrosis, myocardial,contractile,function disappeared,Widened,the left ventricular outflow tract, while,lowering,the outflow tract obstruction and the cardiac,output,increase. And improve clinical symptoms and hemodynamics.,The purpose of the treatment P,11,PTSMA,indication,(1),Clinical indication,Symptomatic patients,Drug refractory severe said effects medical treatment,Functional class III or IV,Functional class II with objective limitation or risk factors,Recurrent exercise-induced syncopes,Failure of prior myectomy or DDD-PM,Comorbitiy with increased surgical risk.,PTSMA indication (1)Clinical,12,PTSMA,indication,(2),Hemodynamic indication in symptomatic patients,The pressure gradient at rest ,50,mmHg or ,100,mmHg with provocation.,In 2008 ESC meeting, Seggewise that,LV gradient,30,mmHg at rest or Provocable LV gradient, 60,mmHg.,Valsalva,Post extrasystole.,No dobutamine gradients (Drugs),(,There is no information that reduce the LVOT pressure to reduce sudden death, but the LVOT 30mmHg and increased risk of death directly related to,New Eng l J Med 2003; 348:295-303),PTSMA indication (2)Hemodynam,13,Hypertrophic Cardiomyopathy,Survival According to Outflow Tract Gradient,BJ Maron et al; JAMA 281:650-655, 1999,Hypertrophic Cardiomyopathy S,14,PTSMA,indication,(3),Morophologic indication,Echocariography,Subaorrtic SAM-associated gradient,Mid-cavitary gradient,Caution: papillary muscle involvement:,MCE,No prolonged mitral leaflets,Coronary angiography,suitable septal branch.,PTSMA indication (3)Moropholog,15,Outflow tract obstruction sign in Echocardiograph,M-mode echocardiogram in obstructive hypertrophic cardiomyopathy showing systolic anterior motion of the mitral valve (SAM) (arrows indicating septum and mitral valve leaflet contact),Outflow tract obstruction sign,16,Morphologic,of HOCM,New classfication of HOCM Methods: they were classified into 4 types according to the echocardiographic results:,Type I,:local subaortic obstruction of HOCM;,Type II,: predominant in midventicular obstruction;,Type III,: diffuse septal hypertrophic obstruction in outflow tract and midventicular obstruction;,Type IV,: multiposition hypertrophic obtruction.,1.asymmetrical septal hypertrophy,(ASH),2.Idiopathic hypertrophic subaortic stenosis,(IHSS),3.Apical or,Japanese HCM,. In this form of nonobstructive HCM, the thickest part of the left ventricle is at the tip or apex of the pump .4. the obstruction is not in the outflow tract but in the middle of the ventricle. A tunnel leads into a dilated apical portion, called an aneurysm, which has thin walls.,Morphologic of HOCM,17,Our classfication in PTSMA,Our typing in the,I-type,and,Maron,in the,I-typing,was the same as suitable for PTSMA treatment and Marons,II-type,includes the,type II,and,type,III,of our model, it is suitable PTSMA treatment. Therefore, our,IV-type,classification is the first made by ultrasound imaging features of HOCM, according to its characteristics in line with PTSMA treatment.,Our classfication in PTSMA O,18,Arrhythmia and sudden death,Clinical indication,Septal Ablation in HOCMAcute Results / Ablation Technique,Pathophysiologic and clinical characteristics of HOCM,Characteristics,(post-PTSMA 6months),The vessel can not thorough or incomplete ablation (remaining smaller branches), self-revascularization.,Septal thickness,Characteristics,Transitory trifascicular blocks occurred at a rate of 52.,(PG=80mmHg),Diltiazem,The vessel can not thorough or incomplete ablation (remaining smaller branches), self-revascularization.,Results of PTSMA,Septal thickness,Hypertrophic Cardiomyopathy Survival According to Outflow Tract Gradient,Increase the heart before and after load and myocardial contractility often cause noticeable clinical symptoms.,Complications in our patients,asymmetrical septal hypertrophy (ASH), 2.,Merge other needs surgery heart disease Mitral valve abnormalities and their own form of papillary muscles involved in the formation of pressure gradient, or mitral valve prolapse and regurgitation.,PTSMA contraindications,Target,vessel,Select ablation of regional importance, particularly in the target vessel is not clear who the septal branchThe first septal branch of the size and distribution are great variation,20%,of patients first branch was supplied the free wall of right ventricle,40%,of patients with,subaortic,of septal is not completely supported by the first septal branch,5%,of patients can not determine the target vessel of the region,Arrhythmia and sudden deathTar,19,Contrast echocardiography method in the target vesse,choice,Injection of,a small amount of dye,(1-2ml) through the guidewire lumen of the inflated balloon catheter angiographically,Prior to alcohol injection,1-2ml of echo contrast,medium is administered through the central lumen of the balloon catheter under UCG. determines the supply area of the target septal branch. Ensure that no areas involving non-obstructive, such as the papillary muscles and ventricular free wall and other parts.,Contrast echocardiography meth,20,Myocardial - Contrast - Echo,in HOCM,Avoid LAD ballooning,Exclude LAD leakage,Myocardial - Contrast - Echo i,21,Septal Ablation in HOCM,Myocardial - Contrast - Echo,Levovist,In the interval of contrast agent injected into the branch to observe the distribution of vascular contr,Alcohol,Shadow ,Septal Ablation in HOCMMyocar,22,Levovist shadow,Levovist shadow,23,Echo sequence: Subaortic septum as targetbregion in typical SAM-associated, subaortic obstraction, ( D dotted line) ,E test injection of the echo contrast agent in balloon of the the first setal branch of a forward branch of position highlighting be basal half of septum plus a RV papillary muscle (white arrows) .,After super-selective balloon of other branch of first septal branch. Correct opacification.,Echo sequence: Subaortic septu,24,MCE,N=222,No MCE,n=30,P,Septal branches (n),1.00.1,1.30.2,0.0001,Alcohol (ml),2.90.9,3.92.4,0.0001,Balloon size (mm),1.90.4,2.40.2,0.0001,CK max (U/l),534248,745420,0.001,CK-MB max (U/l),6230,9662,0.0001,H. Seggewiss et al, 49th Scientific Sessions ACC, 2000,Septal Ablation in HOCM,Acute Results / Ablation Technique,MCENo MCEPSeptal branches (n)1,25,H. Seggewiss et al, 49th Scientific Sessions ACC, 2000,Septal Ablation in HOCM,Acute Results / Ablation Technique,p0.05,p 30mmHg and increased risk of death directly related to, New Eng l J Med 2003; 348:295-303),Functional class III or IV,determines the supply area of the target septal branch.,DDD-pacemaker :2-10%,Results of PTSMA,Complications in our patients,Apical or Japanese HCM.,Characteristics,The vessel can not thorough or incomplete ablation (remaining smaller branches), self-revascularization.,Morophologic indication,Systolic function is normal or supranormal in HCOM,The more cardiac hypertrophy, the higher the pressure gradient, the greater the risk of sudden death.,Hypertrophic Cardiomyopathy Survival According to Outflow Tract Gradient,Clinical indication,Must be inserted temporary pacemaker (to prevent the conduction block).,(pre-PTSMA),A 51-year-old womans LVOT gradient was monitored continuously just before the balloon occlusion . (PG=80mmHg),LV,AO,(pre-PTSMA)Contrast echocardig,29,Her LVOT gradient 10 minutes after septal ablation,（,PG=12mmHg,）,LV,AO,Her LVOT gradient 10 minutes a,30,A 36-year-old mans LVOT gradient tested by Doppler echocardiography before PTSMA (PG=219mmHg),A 36-year-old mans LVOT gradi,31,His LVOT gradient 6 months after PTSMA (,PG=15mmHg),His LVOT gradient 6 months aft,32,经皮间隔支化学消融治疗肥厚梗阻性心肌病英文课件(模板),33,经皮间隔支化学消融治疗肥厚梗阻性心肌病英文课件(模板),34,经皮间隔支化学消融治疗肥厚梗阻性心肌病英文课件(模板),35,PG120mmHg before procedure,PG120mmHg before procedure,36,PG=40mmHg after injection of 4.8 ml alchohol,PG=40mmHg after injection of 4,37,Great attention,Echocardiography showed ventricular septal hypertrophy over,30 mm,in HOCM, necessary to performeing PTSMA should be very cautious and careful. May be there were,a,thick,septal branch, and control,wide, and,collateral-rich,septal branch of support, treatment had a,higher risk,and improve the clinical symptoms and hemodynamics have difficulties, so surgery mytomce may be a better choice.,Great attention Echocardiog,38,It is very big septal branch 2.5mm and too long. There is quite danger to PTMSA,It is very big septal branch ,39,PTSMA contraindications,No significant pressure gradient in hypertrophic cardiomyopathy or very diffuse obstructive.,Merge other needs surgery heart disease,Mitral valve abnormalities and their own form of papillary muscles involved in the formation of pressure gradient, or mitral valve,prolapse and,regurgitation.,Contrast echocardiography,can not determine target vessel or the obstruction of regional no suitable target vessel.,Target vessel supply to non-obstruction other regions such as: papillary muscle, free wall, etc.,Not suitable,Over-the-wire balloon.,PTSMA contraindications No sig,40,PTSMA complications (1),Hospital mortality rate,:1-2%,DDD-pacemaker :,2-10%,Myocardial infarction,Reason:,alcohol,leakage,into the parts of inappropriate,collateral,branch opening , alcohol into the inappropriate parts cause no-reflow, LAD / LM / RCA injury,Emergency surgery,Reason:,coronary artery injury, acute mitral regurgitation (papillary muscle rupture ),Bundle branch block: about,50%,and RBBB-based,PTSMA complications (1) Hosp,41,PTSMA complications (2),Height or III -AVB,Factors:,whether,the method of application of myocardial contrast echocardiography.,Dose,of alcohol and,speed,.,Left anterior descending artery dissection, coronary thrombosis, ventricular fibrillation and ventricular tachycardia, acute mitral regurgitation, right ventricular infarction, left ventricular free wall infarction.,PTSMA complications (2) Heig,42,PTSMA shortcomings,Injury of the left coronary artery required emergency bypass or stent,Can not enter the target septal branch,Can not determine the target branch of support,For mitral and papillary muscle anomalies and abnormal septal hypertrophy the best choice the surgery,Mitral valve injury required emergency surgery .,Permanent conduction block occurs treatment should be PM,PTSMA shortcomings Injury of t,43,The septal branch with good collateral circulation.,Diastolic dysfunction,Beta-blockers,The vast majority of patients with no symptoms,PTSMA complications (2),(post-PTSMA 3days),PTSMA indication (3),Echocardiographic observations plays an important role in that will help to finalize define the choice of septal ablation and the ablation efficacy and reduce risks and Long-term follow-up of treatment efficacy .,Complications in our patients,PG120mmHg before procedure,Functional class II with objective limitation or risk factors,Clinical indication,Patients (n=171),Echocariography,Generally considered: more severe hypertrophy, outflow tract obstruction near the LVOT sit, the more higher the obstructive pressure gradient were the more obvious clinical symptoms and the greater the potential threat.,Diltiazem,HOCM Myectomy,For mitral and papillary muscle anomalies and abnormal septal hypertrophy the bes