室性心动过速的消融何时进行？如何消融？WinKShen.ppt

Win K. Shen, M.D. Professor of Medicine Mayo Clinic College of Medicine GW-HRS Joint Symposium, Beijing 2009,CP1063458-1,室性心动过速的消融： 何时进行？如何消融？?,声明,Relevant Financial Relationship(s) None Off Label Usage None,室性心动过速的机制 折返、拖带、隐匿性拖带的基本概念 稳定的，单形性室速 不稳定或多折返环室速 高级方法和技术,内容,CP1323528-2,室速消融 指南建议,I类适应证 持续单形性室速，药物无效或不能耐受或患者不愿意长期服药，猝死低危患者(C) 束支折返室速 (C) ICD植入后反复放电，重新程控、调整用药均无效，或不愿意接受长期药物治疗的患者，导管消融作为辅助治疗 (C),Circ 2006,室性心律失常,CP1206111-1,“局灶”,“多发性”,流出道,分支,瓣上,RV,LV,普肯野,折返,解剖靶点,心肌病,疤痕,二尖瓣,电生理策略,P. 刺激,拖带,室速标测和消融步骤,潜在的心脏机制，病史 缺血性心脏病 特发性扩心病 其它 根据心电图判断心动过速的起源 程序性刺激，方法 重整 拖带 隐匿性拖带 高级标测技术 电压标测 电解剖标测 影像 心外膜标测 其它,标测的概念,折返性室速,双电位,疤痕,Scars,0.5 mV,2 mV,潜在折返环,CP1176527-5,CP1233975-13,ECG,ECG,QRS起始,共同通路(CP),CP 入口,内环,疤痕,外环,疤痕,通道盲端,CP 出口,折返环和相关术语,该室速折返环出口位置可能是: A. LV/前壁/基底部/侧壁 B. LV/后壁/心尖/侧壁 C. LV/后壁中部/间隔部 D. LV/后壁/心尖/间隔部,标测示意图,横断面,基地部,心尖,长轴切面,间隔,侧壁,12,6,9,3,前壁,后壁,CP1060083-4,A,B,C,D,E,QRS形态提示室速的出口位置,V4,基底部,心尖,AVR,CP1060083-1,AVR,V4,II, III, aVF,QRS 形态提示室速的出口,CP1060083-2,前壁,后壁,II, III, aVF,QRS形态提示室速的出口,I, aVL,间隔部,侧壁,II, III, aVF,CP1060083-3,该室速的折返环出口位置可能是: A. LV/前壁/基底部/侧壁 B. LV/后壁/心尖/侧壁 C. LV/后壁/中部/间隔部 D. LV/后壁/心尖l/间隔,*,*,CP1233975-13,折返环路与拖带,A, B, C 拖带，隐匿融合 PPI = VTCL S-QRS = EGM-QRS S-QRS VTCL S-QRS EGM-QRS F 拖带，显性融合 PPI = VTCL S-QRS = EGM-QRS G 拖带，显性融合 PPI VTCL S-QRS EGM-QRS,A,B,C,D,E*,F,G,起搏部位: 缓慢传导的关键部位起搏 在通道盲端起搏 在外环起搏 环外起搏 无夺获,A,B,C,D,哪个位置起搏与折返环有关?,起搏部位 缓慢传导的关键部位起搏 在通道盲端起搏 在外环起搏 环外起搏 无夺获,*,起搏部位： 缓慢传导的关键部位起搏 在通道盲端起搏 在外环起搏 环外起搏 无夺获,A,B,C,D,起搏部位 缓慢传导的关键部位起搏 在通道盲端起搏 在外环起搏 环外起搏 无夺获,*,起搏部位: 缓慢传导的关键部位起搏 在通道盲端起搏 在外环起搏 环外起搏 无夺获,PPI,TCL,A,B,C,D,起搏部位: 缓慢传导的关键部位起搏 在通道盲端起搏 在外环起搏 环外起搏 无夺获,PPI,TCL,*,室速终止,CP1201033-1,%,0-10,n=46,11-30,n=18,31-60,n=24,60,n=64,PPI-VTCL (msec),CP1270284-4,VT #5,VT 1,VT 2,VT 3,VT 3,CP1270284-17,电压标测指导的室速消融,男性，55 岁，扩张型心肌病, EF 27% ICD频繁放电，既往消融失败,左心室辅助装置,Low-speed centrifugal continuous flow pump Low blood surface area contact 21 Fr Left atrial cannula 19 Fr femoral arterial cannula Up to 4L/min Flow,Thiele et al Circ 2001,左心室支持下诱发室速,左心室辅助支持下心内膜及心外膜标测,LAA,LA Cannula,经心外膜途径消融,Schweikert et al. Circulation. 2003;108:1329-1335.,Eduardo Sosa, JACC 2000,室速合并冠心病的患者经心外膜消融是可行的. 53例中发生了4例右心室穿孔及心脏压塞 对其它心律失常亦有效(VT 伴或不伴SHD, WPW, RVOT VT, AT) ，尤其是经心内膜消融失败的患者 无并发症报道,左心室心内膜和心内膜消融,Mitral Valve,多数情况下为折返机制 根据拖带的反应识别传导的关键区域 多形性室速和多环路折返较常见 通常需要电压/把横标测 部分病人可能需要心外膜标测 为防止ICD反复放电，多数患者应接受姑息性VT消融,疤痕依赖基质的室速消融,Win K. Shen, M.D. Professor of Medicine Mayo Clinic College of Medicine GW-HRS Joint Symposium, Beijing 2009,CP1063458-1,Ventricular Tachycardia Ablation When and How?,DISCLOSURE,Relevant Financial Relationship(s) None Off Label Usage None,Spectrum of VT mechanisms Basic concept of reentry, entrainment, and concealed entrainment Stable, monomorphic VT Unstable VT or multiple circuits Advanced technology and techniques,Objectives,CP1323528-2,VT Ablation Recommendations,Class I Ablation is indicated in patients who are otherwise at low risk for SCD and have sustained predominantly monomorphic VT that is drug resistant, who are drug intolerant, or who do not wish long-term drug therapy (level of evidence: C) Ablation is indicated in patients with bundle-branch reentrant VT (level of evidence: C) Ablation is indicated as adjunctive therapy in patients with an ICD who are receiving multiple shocks as a result of sustained VT that is not manageable by reprogramming or changing drug therapy or who do not wish long-term drug therapy (level of evidence: C),Circ 2006,Ventricular Arrhythmias,CP1206111-1,“Focal”,“Diffuse”,Outflow tract,Fascicular,Supra-valvular,RV,LV,Purkinje,Reentry,Anatomic target,Myopathic,Scars,Mitral valve,EP maneuvers,P. Stimulation,Entrainment,Steps in Mapping and Ablating VT,Underlying cardiac substrate, history Ischemic heart disease Idiopathic dilated cardiomyopathy Others ECG recognition of tachycardia origin Programmed stimulation, maneuvers Reset Entrainment Concealed entrainment Advanced mapping Voltage mapping Electro-anatomical correlation Imaging Epicardial approach Others,Concepts of Mapping,Reentrant Ventricular Tachycardia,Double potentials,Scars,Scars,0.5 mV,2 mV,Potential circuits,CP1176527-5,CP1233975-13,ECG,ECG,QRS onset,Common pathway (CP),CP entrance,Inner loop,Scar,Outer loop,Scar,Dead-end pathway,CP exit,Reentrant Circuit and Terminology,This VT circuit exit site is likely: A. LV/anterior/basal/lateral B. LV/posterior/apical/lateral C. LV/posterior/mid/septal D. LV/posterior/apical/septal,Mapping Scheme,Cross Section,Base,Apex,Longitudinal Section,Septal,Lateral,12,6,9,3,Anterior,Posterior,CP1060083-4,A,B,C,D,E,QRS Morphology Clues to VT Exit Site,V4,Base,Apex,AVR,CP1060083-1,AVR,V4,II, III, aVF,QRS Morphology Clues to VT Exit Site,CP1060083-2,Anterior,Posterior,II, III, aVF,QRS Morphology Clues to VT Exit Site,I, aVL,Septal,Lateral,II, III, aVF,CP1060083-3,This VT circuit exit site is likely: A. LV/anterior/basal/lateral B. LV/posterior/apical/lateral C. LV/posterior/mid/septal D. LV/posterior/apical/septal,*,*,CP1233975-13,Reentrant Circuit and Entrainment,A, B, C Entrainment with concealed fusion PPI = VTCL S-QRS = EGM-QRS S-QRS VTCL S-QRS EGM-QRS F Entrainment with manifested fusion PPI = VTCL S-QRS = EGM-QRS G Entrainment with manifested fusion PPI VTCL S-QRS EGM-QRS,A,B,C,D,E*,F,G,Pacing at this site is most consistent with: Pacing in a critical zone of slow conduction Pacing in a “dead end alley” Pacing in an outer loop Pacing outside of the circuit Non capture,A,B,C,D,Where was the pacing site in relationship to the circuit?,Pacing at this site is most consistent with: Pacing in a critical zone of slow conduction Pacing in a “dead end alley” Pacing in an outer loop Pacing outside of the circuit Non capture,*,Pacing at this site is most consistent with: Pacing in a critical zone of slow conduction Pacing in a “dead end alley” Pacing in an outer loop Pacing outside of the circuit Non capture,A,B,C,D,Pacing at this site is most consistent with: Pacing in a critical zone of slow conduction Pacing in a “dead end alley” Pacing in an outer loop Pacing outside of the circuit Non capture,*,Pacing at this site is most consistent with: Pacing in a critical zone of slow conduction Pacing in a “dead end alley” Pacing in an outer loop Pacing outside of the circuit Non capture,PPI,TCL,A,B,C,D,Pacing at this site is most consistent with: Pacing in a critical zone of slow conduction Pacing in a “dead end alley” Pacing in an outer loop Pacing outside of the circuit Non capture,PPI,TCL,*,Termination of VT,CP1201033-1,%,0-10,n=46,11-30,n=18,31-60,n=24,60,n=64,PPI-VTCL (msec),CP1270284-4,VT #5,VT 1,VT 2,VT 3,VT 3,CP1270284-17,Voltage Map Guided VT Ablation,55 year-old man with DCM, EF 27% Frequent ICD shocks, failed previous ablation,Left Ventricular Support,Low-speed centrifugal continuous flow pump Low blood surface area contact 21 Fr Left atrial cannula 19 Fr femoral arterial cannula Up to 4L/min Flow,Thiele et al Circ 2001,Induction of VT on LV Support,Endocardial and Epicardial Mapping with Left Ventricular Support,LAA,LA Cannula,Epicardial Approach,Schweikert et al. Circulatio