（医学课件）左房解剖及房间隔穿刺技巧.ppt

刘少稳,左房解剖及房间隔穿刺技巧,上海市第一人民医院上海交通大学附属第一人民医院,心内科,1,右心房、上腔静脉、右心耳、右上肺静脉、窦房结,AP,RAA,SVC,TA,MA,CS,RAA,SVC,2,右心房、上腔静脉、右心耳、右上肺静脉、窦房结,3,4,左右心房之间的连接,Bachmann,TA,5,右房激动标测和右侧狭部起搏拖带均提示为典型房扑，在右侧狭部线性消融中房扑终止。窦律下起搏评价发现右侧狭部阻滞。,TA,6,左右心房的相对位置关系,7,房间隔穿刺左右心房的关系,8,RAO45透视指导房间隔穿刺,穿刺针与鞘管的关系：穿刺针、扩张鞘和外鞘管同轴，穿刺针是否出了扩张鞘？穿刺点定位PA位：定高低（头足方向定位），左房影下缘上1个椎体RAO45：定方向，使垂直于房间隔面，位于左心影后缘与房室沟影中点或偏脊柱侧穿刺针方向垂直于房间隔，穿刺针远段呈直线状,9,RAO45,定位穿刺点和穿刺方向,AP,10,1.导管放置,3.肺静脉造影,2.房间隔穿刺,不能太靠后不能太高,回撤时两次跳跃穿刺针在房间隔部：波动和摆动,2.房间隔穿刺,房间隔穿刺,11,卵圆窝的滑动征（1）,12,卵圆窝的滑动征（2）,13,卵圆窝的滑动征（3）,14,左心房下缘、心影后缘、房室沟,LA下缘,CS电极=LA下缘,RAO45心影后缘由左房构成，房室沟CSLA影,15,16,17,abcd,18,针尖入左房后逆钟向旋转的解剖基础,19,RAO45,His,SVC,Aorta,20,房间隔穿刺,21,LA045,LA045,AnatomicVariability,22,LA045,RA030,AnatomicVariability,23,AnatomicVariability,24,AnatomicVariability,LA045,LA045,LA045,RA030,LA045,LA045,25,肺静脉的变异及其临床意义,LCP,etal.JClinDiagnRes.2014Feb;8(2):10-1.,2PVsoneitherside:-68%2leftand3rightPVs:-12%2leftand1rightPVs:-14%1leftand2rightPVs:-4%1leftand4rightPVs:-2%,26,肺静脉的变异及其临床意义,TekbasG,etal.WienKlinWochenschr.2012Jan;124(1-2):3-10.,Inthemajorityofcases,twoPVsdrainintotheLAoneachside.18and8variationswerefoundintherightandleftsides,respectively.Mostfrequentcombinedvariationswere2R-4L(32.3%)and4Lwasthemorefrequentsinglevariationtype(76%).InadditiontothatoneSitusinversustotalis（完全性内脏逆位）(0.12%),twopartialanomalouspulmonaryvenousreturns(0.25%)andonescimitarsyndrome（弯刀综合征）(0.12%)werefound,肺静脉CT成像,27,ErnstS,BernsE.Europace.2009;11(8):1118-1119.,Acompletesitusinversusanddextrocardia,28,肺静脉的变异及其临床意义,MaromEM,etal.Radiol.2004;230:824-9.,肺静脉CT成像,29,肺静脉的变异及其临床意义,MaromEM,etal.Radiol.2004;230:824-9.,肺静脉CT成像,30,肺静脉的变异及其临床意义,为PV引流异常而致的先天性多发性心肺病,是由于右肺静脉开口于下腔静脉,部分PV回流异常而导致的一组病征。Scimitarsyndrome,orpulmonaryvenolobarsyndrome(肺静脉叶综合征),isararecongenitalheartdefectcharacterizedbyanomalousvenousreturnfromtherightlung(tothesystemicvenousdrainage,ratherthandirectlytotheLA).ThisanomalousPVsreturncanbeeitherpartial(PAPVR)ortotal(TAPVR).ThesyndromeassociatedwithPAPVRismorecommonlyknownasScimitarsyndromeafterthecurvilinearpatterncreatedonachestradiographbythePVsthatdraintotheIVC.,弯刀综合征（scimitarsyndrome）,31,肺静脉的变异及其临床意义,Chestx-rayofafive-year-oldgirlwithScimitarsyndrome.Theheart(blueoutline)isshiftedintotherighthalfofthechest,andtheanomalouspulmonaryvenousreturn(red)hasashapereminiscentofaScimitar.,弯刀综合征（scimitarsyndrome）,32,左肺静脉与左心耳之间的脊,33,MusclesleeveandPVpotentialformation,MyocardialmuscleextensionstocovingtheoutsideofPVMusclesleeveisthickestattheproximalendofvein(1-1.5mm)MyocardialmusclefibersextendfromLAtoPVatlengthof1-3cmUsuallythesleeveisthickestattheinferiorwallofthesuperiorPVsandatthesuperiorwalloftheinferiorPVs,35,心脏大静脉肌袖解剖,远端,近端,36,心脏大静脉肌袖解剖,37,左肺静脉与左心耳之间的脊,38,LAO,LAO,RAO,RAO,LSPV,LIPV,LAAP,LAAP,LAAP,LAAP,LSPV,LSPV,左心耳和左上肺静脉,39,40,左上腔静脉永存,AP,PA,LAO,41,左上腔静脉永存,42,左心房憩室LeftAtrialDiverticula,左心房憩室较常见（46%），多呈囊型（cystiform），常见部位为近右上肺静脉左心房前上壁（88%），与性别、年龄、房颤类型和左心房大小无关。-WilsonL,etal.2014HRS,43,左心房憩室LeftAtrialDiverticula,LA,LA,Nagai2011,左心房憩室的临床意义：1.穿孔：平均LAD壁的厚度是：0.9mm，而周围心房组织的厚度是：2.4mm-Peng20122.血栓,44,左