冠状静脉解剖、造影及CRT心电图、左室电极影像

冠状静脉解剖、造影及CRT心电图、左室电极影像,武汉亚洲心脏病医院韩宏伟2012.7,心脏再同步化治疗益处-Cardiac Resynchronization Therapy（CRT）,左室机械收缩效率的提高使血流动力学得到急性改善改善室内的不同步改善左右室的不同步改善“室壁”不同阶段的不同步,逆转左室重构逆转左房重构减少二尖瓣反流使神经体液因素恢复正常改善心血管自主神经的调节,房室、室间、室内不同步是部分患者心衰产生、进展、恶化的重要原因！,熟练掌握冠状静脉解剖及影像特征的重要性,对术者重要性1.手术难易及成败2.手术疗效对管床医生重要性1.术前谈话、预判手术难易2.观察术后主要并发症-电极移位脱位对影像科医生重要性1.协助筛选合适病人2.术后为临床尽早预警电极移位脱位3.协助临床优化参数、改善疗效,心脏再同步化治疗三腔起搏器电极常见植入部位,右心房电极：右心耳尖部及基底部、右房侧壁、右房间隔右心室电极：右室心尖部、右室基底部、右室流出道左心室电极：左室侧静脉、左室后侧静脉、左室前侧静脉、心大静脉、心中静脉、心外膜左室侧壁或前侧壁,冠状静脉解剖结构,冠状窦开口,心中静脉,心后静脉,后侧静脉,心大静脉,侧静脉,前侧静脉,冠状静脉MSCT三维重建,Standard multidetector computed tomography angiogram (Brilliance16P scanner) delineating the coronary venous branches in closeproximity to the coronary arteries. No appreciable posterior or posterolateral vein. The lateral marginal vein seems to be diminutive. Conventional branches are labeled as follows: LV lateral marginal vein; MV middle cardiac vein; CS coronary sinus; PDA posterior descending coronary artery.,冠状静脉造影,Rotational venous angiogram, with still frames in anteroposterior (A) and left anterior oblique 30 (B). PV posterior vein; MV middle cardiacvein; GV great cardiac vein; AV, anterior cardiac vein. Alongside are three-dimensional reconstructed images of the coronary venous tree, facilitatingsegmental visualization of the coronary venous anatomy. The coronary venous ring is divisible into three segments: posterior (C), lateral (B), and anterior(A), in both views. (B) The mid-ventricular position of a lateral segmental branch (1), closely corresponding to the second-order lateral tributary from ananterior segmental branch, extending over the mid-ventricular region (2).,冠状静脉造影,各种不同左室电极,各种不同左室电极的X-ray-常用左室电极4193,各种不同左室电极的X-ray-常用左室电极4194,各种不同左室电极的X-ray-左室主动电极,各种不同左室电极的X-ray-左室心外膜电极4965,各种不同左室电极的X-ray-St.Jude左室电极,特殊病例-左室电极内保留导丝,不同部位左室电极影像-左室前侧静脉,不同部位左室电极影像-左室侧静脉,不同部位左室电极影像-左室后侧静脉,不同部位左室电极影像-左室后静脉,不同部位左室电极影像-心中静脉,特殊影像（左室心中静脉逆行+导丝断裂）,病例介绍CRT超反应者胸片变化,LV 7.3cmEF 18%LVESV 149ml,病例介绍CRT超反应者术前心脏三维超声（2011.05.26）,LV 5.8cmEF 28%LVESV 100ml,病例介绍CRT超反应者术后心脏三维超声（2011.06.07）,术前冠状静脉CT成像与术中造影,CRT术后左室电极脱位-病例1,术中影像AP+LAO,术后3月胸片AP+LAO,CRT术后左室电极移位-病例2,术中影像AP,术中影像LAO,CRT术后左室电极移位-病例2,术后8个月胸片AP+LAO,术后一周胸片AP+LAO,心电图判断左室失夺获,敏感性94%,特异性93%,CRT左室夺获判断,CRT术后左室电极脱位-病例1,术中一周心电图,术后7个月心电图,CRT术后左室电极移位-病例2,术后一周ECG,术后8个月ECG,如何及时发现左室电极脱位？,术毕透视与术中对比术后起搏心电图变化程控测