首都医科大学附属北京朝阳医院心脏中心刘小青.ppt

首都医科大学附属 北京朝阳医院心脏中心 刘小青,三维指导下无X线消融心律失常,“可怕”的辐射,介入医生的心声,“除了经常感到疲劳以外，最近的体检结果显示晶状体出现浑浊，白细胞下降。还有比他更严重的，一位年轻的同行出现了染色体异常。” “上手术台医生大都会挂上X射线计量仪，看看累计吃了多少射线，但是我就不愿意挂，了解多了，心里自然会很担心，病人来了又不能见死不救，还不如难得糊涂。” 摘自丁香园,辐射有哪些危害,最常见是皮肤损害及脱发,A：冠心病介入术后； B、C：电生理消融术后放射性皮炎及坏死,白内障：放射线导致的白内障出现一般是非常慢性的过程，急性照射几乎不会发生，至少在接触射线1年以上出现。 致命性肿瘤：发生机率在百万分之一之万分之一之间，是十分微乎其微的。 生育畸形：这是大家最关心的问题，目前为止没有客观证据证实长期从事介入工作会增加生育畸形发生，已有的关于辐射对于生育的影响都是日本受到原子弹爆炸后，统计接受辐射的人群得出的，结果无显著性增加。,新的成像系统用于减少X光,目前应用的电解剖标测系统有CARTO、非接触球囊标测系统EnSite Array和EnSite NavX。在射频消融治疗室上速、房扑、房颤以及室速等过程中，这些系统可以极大的降低X射线照射时间，有的甚至可以做到零透视。,三维标测系统 CARTO,CARTO系统目前是诊断和治疗复杂心律失常的重要的手术平台之一。工作原理是采用GPRS卫星定位原理将标测导管头端采集的磁场信号转换为电信号，与同时采集的心内电信号一起处理后输入到工作站中形成三维的电解剖标测图,三维标测系统 Ensite Array,非接触球囊标测系统EnSite Array系采用非接触式电极测量空间电场技术，能在每一瞬间撷取心腔壁上3360点的电位并用等电位图表现出来，以确定心律失常的机制，并引导消融导管到达正确位置。但球囊的到位过程需要借助于X线，因此也无法做到零透视。,三维标测系统 Ensite NavX,Ensite NavX系统是另一个解决复杂心律失常的重要平台。其工作的原理同样也是利用空间电场技术来定位电极导管以及重建心脏电解剖模型。NavX是能真正做到不借助于X线，精确导引导管到达所需的部位，这对于电生理标测以及消融治疗意味着一种革命。,新的成像系统用于减少X光,心内超声ICE + Ensite NavX,13,NavX系统辅助SVT消融,此系统是目前所有三维系统中，对于X射线依赖程度最低的； 国内外已有多种导管消融手术借助Ensite 系统成功地在零曝光下完成； 目前研究的趋势，全三维指导室上速射频消融，既安全且有效，不仅最大化保护了医务人员及患者避免X线损害，而且在某些疑难病例中更具优势。,Creation of Vascular Pathway（Point-Cloud Angiography）,We choose left femoral vein as the access. A deflectable decapolar catheter is set as active enguide catheter for geometry creation. System reference is chosen. As we can see, the decapolar catheter could leave the trail of green points. that is the vascular pathway.,16,Identify the Orifice of IVC and SVC,IVC,SVC,When electrograms have been recorded at the distal polar CS1-2, we know this place is the orifice of inferior vena cava. If we advance catheter forward, the electrograms on the distal polar CS1-2 will disappear, the orifice of superior vena cava can be identifed,Placement of CS Catheter through IVC Approach,Before the placement of Coronary sinus catheter, we firstly identify the location of his bundle and make a marker. As a reference, we find the coronary sinus ostium.,His/RVA catheter is sent along the vascular pathway. We can see the right and left femoral vein join together at common iliac vein.,Left femoral v.,Right femoral v.,Common Iliac v.,Right femoral v.,AP,PA,Placement of Other Catheters,Sometime the catheter will enter the branches of IVC, such as hepatic vein and renal veins. They can be displayed by green points.,IVC,Hepatic V.,IVC,Position of All the Catheters for Diagnosis (1),This figure shows the right atrium geometry and all the diagnostic catheters. The purple part is coronary sinus geometry.,IVC,SVC,RA,CS,SVC,IVC,RA,His,CS,RV,His,CS,RV,After all the diagnostic catheters are positioned, the EP examination will be performed. In this picture, we set the geometry totally transparent.,Position of All the Catheters for Diagnosis (2),CASE-1: AVRT-Left Accessory Pathway,Pacing at the right ventricular, we map the retrograde A wave. In this figure, the earliest site is located at the distal of the CS.,26,CASE-1: Geometry of Right Atrium and Aorta,Left accessory pathway was diagnosed. We choosed transaortic approach and used the ablation catheter to create the pathway of aorta. The geometry created by NavX system is displayed in a three dimensional way.,CASE-1: Aortic Coronary Cusps,During the creation of aorta, the three aortic coronary cusps could be seen clearly. So it is important when the ablation catheter across the aortic valves.,29,CASE-1: Successful Ablation,The ablation catheter arrive at the distal CS. The electrogram of catheter has shown the fusion of A and V waves. It is target site. After the first radiofrequency delivery, A and V wave were separated, small A and big V, meant under the mitral valve. Meanwhile the preexcitation of QRS disappeared.,A,B,Figure A : inferior annulus approach, small A and big V on ablation catheter.,Inferior and Superior Mitral Annulus Approach (1),Figure B : superior annulus approach, big A and small V on ablation catheter.,His,RV,CS,His,CS,RV,Ablation from inferior mitral valve to superior mitral valve. The Green tags meant failure site. The red tag meant the success site.,Inferior and Superior Mitral Annulus Approach (2),32,CASE-2: AVRT-Right Accessory Pathway,Mapping during sinus rhythm, localize the shortest AV conduction or the ventricular insertion site. We moved the catheter around the tricuspid annulus. There are two earlier site, the one is His bundle , the other is the site of accessory pathway .,33,CASE-2: AVRT-Right Accessory Pathway,During RV pacing, mapping the earliest atrial activation site around the tricuspid annulus.,34,The target site located at 5 oclock. Almost at the moment of RF delivery (672ms), the preexcitation disappeared. AP was eliminated.,CASE-2: Ablation at the Target Site,35,Preablation,CASE-2: Retrograde Atrial Activation,Postablation,Before ablation, the earliest retrograde atrial activation localized at 5 oclock. After ablation, the earliest site was located at 1 oclock which was site of His bundle.,36,Compared with guided by the conventional fluoroscopy , the advantage of 3D mapping system is making a marker at the target site or ablation site. When the catheter moved away from the target site, it could return back easily and precisely than fluoroscopy.,CASE-2: Mark the Target Site,37,After the position of the catheters and EP examination, AVNRT was diagnosed. The His bundle area must be marked using an ablation catheter. When the ABL reached the area of slow pathway, RF was delivered. The His area was highlighted for avoid damage.,CASE-3: Atrioventricular Nodal Reentry Tachycardia,CASE-3: Atrioventricular Nodal Reentry Tachycardia,The ablation began at the lower site, but junction reaction was not satisfactory. We loosed the curve of the catheter very slowly, the tip get higher, but always below the Hi