心律失常发生机制及导管消融适应症.ppt

心律失常发生机制及导管消融适应症（ElectrophysiologicalMechanismsofCardiacArrhythmiasandIndicationofRadiofrequencyCatheterAblation),吉林大学第二医院心内科李树岩,IndicationsforRadiofrequencyCatheterAblation,Wolff-Parkinson-WhiteSyndrome(WPW)AtrioventricularNodalReentrantTachycardia(AVNRT)AtrialFlutterAtrialFibrillation(AF)VentricularTachycardia(VT)AtrialTachycardia(AT)Others,RisksandComplicationsWithRFAblation,Hypotension-secondarytodrugsorvagalreactionVascularinjuryIschemia/InfarctionVenous/ArterialThrombosisCardiacperforationDamagetotheAVconductionsystemLifethreateningarrhythmias,ArrhythmiaMechanisms,AutomaticityTriggeredActivityReentry,Automatictachycardia(AT,VT,AF)isidentifiedbythepresenceofthefollowingcharacteristics:CanbeinitiatedbyanisoproterenolinfusionPEScannotinitiateorterminatethetachycradiaCanbegraduallysupressedwithoverdrivepacing,butthenresumeswithagradualincreaseintherateCanbeterminatedbypropranololTheseepisodeshavea“warmup”and/or“cooldownphenomenonCannotbeterminatedbyadenosine,buttransientlyslowsorsuppresses,especiallywhenitcanbeinducedwithisoproterenol,(ZipesDP,JalifeJ.CardiacElectrophysiology:Fromcelltobedside,4thedition.2019;pg.500-501),ArrhythmiaMechanisms,Triggeredactivity(AT,VT,AF)isidentifiedbythepresenceofthefollowingcharacteristics:TriggeredarrhythmiascanbeinitiatedwithrapidpacingorexstrastimulidependantonreachingacertainrangeofpacingcyclelengthsNoentrainmentisobserved,butoverdrivesuppressionorterminationoccursDelayedafterdepolarizationscanberecordedneartheoriginusingamonophasicactionpotentialcatheterbeforetheonset,butnotatsitesremotefromthetachycardiaIsterminatedbyadenosineRarelyrequiresisoproterenoltoinduceitIsterminatedbydipyridamole,propranolol,verapamil,edrophonium,Valsavamaneuversandcarotidsinuspressure,(ZipesDP,JalifeJ.CardiacElectrophysiology:Fromcelltobedside,4thedition.2019;pg.500-501),ArrhythmiaMechanisms,Microreentry(AT,AVNRT,VT)/Macroreentry(AT,AVRT,AtrialFlutter)isidentifiedbythepresenceofthefollowingcharacteristics:CanbereproduciblyinitiatedandterminatedbypacingandextrastimuliNodelayedafterdepolarizationscanberecordedusingamonophasicactionpotentialcatheterManifestandconcealedentrainmentobservedwhilepacingduringthetachycardiaFrequentlyterminatedbyverapamilandadenosine,butadenosineusuallyhasnoeffectTheintervalbetweentheinitiatingprematurebeatandfirstbeatoftheATareinverselyrelated,(ZipesDP,JalifeJ.CardiacElectrophysiology:Fromcelltobedside,4thedition.2019;pg.500-501),ArrhythmiaMechanisms,SequenceoftheFlowinaTypicalEPStudy,PreparationofthePatientInsertionofsheathsandElectrodecathetersBasicEPSstudytogetthebasicdataInductionoftheArrhythmiaDiagnosisoftheArrhythmiaAblationoftheArrhythmia(ifindicated)ConfirmationofTherapySuccess,WPW,Occurrenceofdysrhythmias1,2,2Fitzgerald,etal.,JElectrocardiol.,Vol.29,No.1,Jan.2019,p.1-10.,1Fogoros,ElectrophysiologicTesting,2nded.2019,p104-107,ANTI10%,ORTHO90%,WPWtachycardiacircuits,OrthodromicTachycardia,Thesetermsareonlyapplicablewhenthepatientisintheirtachycardia,i.e.duringtheintrinsicrhythmthispatientmaybemanifestorconcealed,butduringthetachycardiawedefinethispatientaseitherantidromicororthodromic.Antidromicmeansantegradeconduction(fromtheatriumtoventricle)occursdowntheAPandretrogradeconduction(fromtheventricletotheatrium)upthenormalconductionsystem(AVnode).OrthodromicmeansantegradeconductionoccursdownthenormalconductionsystemandretrogradeconductionuptheAP.,AntidromicTachycardia,BypassTractLocations,Anywhereexcepthere(fibroustrigone),BypassTractLocations,TypesofAccessoryPathways,A=atriofascicularB=nodofascicularC=nodoventricular*D=fasciculoventricularE=atrioventricular*firstdescribedbyMahaim,TypesofAccessoryPathways,PreexcitationSyndromes,Wolff-Parkinson-White“Mahaim”Fibers-nowseparatedinto:AtriofascicularNodoventricularNodofascicularFasciculoventricular,Wolff,ParkinsonandWhite,andtheirSyndrome,PublishedinAmericanHeartJournalinAugust,1930findingson11patientswithasyndromeofsignsandsymptomsClinicalsignificanceMayconfusephysiciansDeltaWavemaybeinterpretedasaninfarctMarkedpreexcitationinatrialtachycardiasmaylooklikeVTPthasparoxysmsofSVTMaybypasstheprotectivenatureoftheAVnodeandexposetheventriclestoextremelyhighheartrates.,Kastor,Arrhythmias,2nded.,2000,p.12,Fogoros,ElectrophysiologicTesting,2nded.2019,p132,DiagnosisandLocalization,SurfaceleadevaluationUnderstandingBundleBranchBlock“Patterns”asappliedtointerpretingDeltaWavepolarityDeltaWavePolarityinterpretationTheuseofalgorithmsforevaluatingpreexcited12leadsFunctionalBundlebranchblockduringORTElectrophysiologystudyCathetermapping,DeltaWavePolarity,Usethefirst20-40mSecoftheDeltawavetodeterminepolarityTheQRSusuallyfollowsthepolarityoftheDeltawaveUsealgorithmstolocatetheAPOfprimaryconcern-isthepathwayrightorleftsided?(Transseptalprocedureornot?)DetermineDeltawavepolarityinV1-V1positive=leftsidedV1negative=rightsided,Thedeltawave,ClinicalmanualofelectrophysiologySingerandCoopersmithch9pg125,DeltaWavePolarity,Fitzpatrick,etal.,JACC,Vol.23,No.1,Jan.1994,p.110,Pre-excitation,FusionoftheQRSoccursbecausethereissimultaneousconductiondowntheAVnodeandaccessorypathway,WPWBaseline,Notethepre-excitationasevidencedbythedeltawave,resultinginashortPRinterval,DeltaWave,ShortPRInterval,NormalECGwithnodeltawaveandanormalPRintervalandQRS,Evaluatingapreexcited12lead,LeadsIandaVLIndicatesimpulsetravelasrighttoleft(positive)orlefttoright(negative)LeadsII,III,andaVFIndicateimpulsetravelassuperiortoinferior(positive)orinferiortosuperior(negative)TheQRSaxiswillbedirectedawayfromtheventriclebeingpreexcitedVLeadtransitionHelpsdifferentiateseptalorlateralsites.,Algorithm-Arruda(a),Arruda,et.al.,JCEVol9#1Jan2019,pp.2-12,Algorithm-Arruda(b),Arruda,et.al.,JCEVol9#1Jan2019,pp.2-12,Moreexamples,Electrophysiologystudy,GoalsoftheEPstudyIdentifythefunctionandthreatoftheAPLocatetheAPtodetermineapproachforablationMethodsAtrialPacingVentricularPacingCathetermappingAdditionalManeuversPara-HisianpacingPharmacologicconductionblock,Atrialpacing,InitiatedafterbaselinerecordingsOftenusedwithisoproteronoltoinducetachycardiaandshortenrefractoryperiodsProgressiveAVnodedelayencouragesconductionovertheaccessorypathwayLookfordeltawavetobecomemorenoticeableFindtheantegradeandretrograderefractoryperiodsoftheAVNandAP,VentricularPacing,LookfortheearliestretrogradeA“Advance”theatriaduringtachycardiaDifferentiatebetweenAVRT,AVNRTandatrialtachycardias.,PacedPVCDuringHisRefractoryPeriod,Para-Hisianpacing-RetroAVNconduction;noBPT,NarrowQRS,WideQRS,HisandVcapture,Vcaptureonly,VariableStim-A,Zipescommon;usual;slow-fastAtypical;uncommon;unusual;fast-slowSlow-slow,DistributionofTypesofAVNRT,KuckKH,CappatoR.CatheterAblationintheYear2000.CurrentOpinioninCardiology2000;15:29-40.,AVNRTCircuit,ThereentrantcircuitinvolvestheFastPathway(FP),whichentersthecompactAVnodefromtheanteriorseptalregionclosetothecompactAVnode,andtheSlowPathway(SP),whichislocatedintheposteriorseptalregion.Thereare3typesofAVNRT.IncommontypeAVNRTantegradeconductionisdowntheSPandretrogradeuptheFP.Intheuncommontype,antegradeconductionisdowntheFPandretrogradeuptheSP.Intheslowslowtype,antegradeconductionisdownoneSP(acertainbundleoffibers)andretrogradeupanotherSP(adifferentbundleoffibers).ForallthreetypesablationisperformedbyablatingtheSP,becauseFPablationhastheriskofcompleteAVblocknecessitatingpacemakerimplantationduetoitscloseproximitytothecompactAVnode.,-Dualpathwayphysiology;onefastandoneslow-Typical(common)AVNRT:antegradeslow,retrogradefast-AtypicalAVNRT(uncommon):antegradefast,retrogradeslow-SlowslowAVNRT:antegradecertainslowfibers,retrogradeotherslowfibers-JumpinAHinterval50msecduringa10msecdecrementinextrastimulustesting,Common(Typical)AVNRT,IncommonAVNRT,antegradeconductionisdowntheslowpathwayandretrogradeupthefastpathway.Theearliestatrialactivationwouldberecordedintheanteroseptalregionwherethefastpathwayislocated.Alsosinceconductiontotheventricleisdowntheslowpathway,theAHintervalwillbeprolonged.,Uncommon(Atypical)AVNRT,InuncommonAVNRT,antegradeconductionisdownthefastpathwayandretrogradeuptheslowpathway.Theearliestatrialactivationwouldberecordedintheposteroseptalregionwheretheslowpathwayislocated.Alsosinceconductiontotheventricleisdownthefastpathway,theAHintervalwillbenormal.,SlowSlowAVNRT,InSlowSlowAVNRT,antegradeconductionisdownsomeslowpathwayfibersandretrogradeupotherslowpathwayfibers.Theearliestatrialactivationwouldberecordedintheposteroseptalregionwheretheslowpathwayislocated.Alsosinceconductiontotheventricleandbacktotheatriumisviatheslowpathway,boththeAHduringatrialextra-stimulustestingastheextra-stimulusisintroduced(decremented).,SinusRhythmwithDominantFastPathwayConduction,SinusRhythmwithDominantSlowPathwayConduction,CriteriaforA-VNodalSVTcont.,TypicalA-VNodalReentryRetrogradeatrialactivationcaudocephalicwithelectrogramintheA-VJunctionearliest(V-A-42to+70msec)RetrogradePwavewithintheQRSwithdistortionofterminalportionoftheQRS.Atrium,Hisbundle,andventriclenotrequiredVagalmanueversslowandthenterminateSVT.,ClinicalCardiacElectrophysiology:techniquesandinterpretations,2nd.Ed.LeaandFebiger,1993.page224,DifferentiateAVNRTfrom:AVRTAVNRTAtrialtachycardiasPJRT,DifferentialDiagnosis,DifferentialDiagnosis,PVCwhenHisbundleisrefractoryPara-HisianPacingAdenosineAdministrationA-VWenckebachperiodicityorDissociationV-AWenckebachperiodicityordissociation,PVCsontheHis,PerformedduringtachycardiaPaceRVwhenAVnodeisrefractoryLookforretrogradeatrialconductionV-AconductionwhiletheAVNodeisrefractoryisdiagnosticof