左房解剖及房间隔穿刺技巧

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,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,右心房、上腔静脉、右心耳、右上肺静脉、窦房结,左右心房之间的连接,Bachmann,TA,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,左右心房的相对位置关系,房间隔穿刺左右心房的关系,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,RAO45,定位穿刺点和穿刺方向,AP,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,卵圆窝的滑动征（1）,卵圆窝的滑动征（2）,卵圆窝的滑动征（3）,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,a b c d,针尖入左房后逆钟向旋转的解剖基础,RAO 45,His,SVC,Aorta,房 间 隔 穿 刺,LA0 45,LA0 45,Anatomic Variability,LA0 45,RA0 30,Anatomic Variability,Anatomic Variability,Anatomic Variability,LA0 45,LA0 45,LA0 45,RA0 30,LA0 45,LA0 45,肺静脉的变异及其临床意义,L C P, et al. J Clin Diagn Res. 2014 Feb;8(2):10-1.,2 PVs on either side: -68% 2 left and 3 right PVs: -12%2 left and 1 right PVs: -14% 1 left and 2 right PVs: -4% 1 left and 4 right PVs: -2%,肺静脉的变异及其临床意义,Tekbas G, et al. Wien Klin Wochenschr. 2012 Jan;124(1-2):3-10.,In the majority of cases, two PVs drain into the LA on each side. 18 and 8 variations were found in the right and left sides, respectively. Most frequent combined variations were 2R-4L (32.3%) and 4L was the more frequent single variation type (76%). In addition to that one Situs inversus totalis （完全性内脏逆位）(0.12%), two partial anomalous pulmonary venous returns (0.25%) and one scimitar syndrome（弯刀综合征）(0.12%) were found,肺静脉CT成像,Ernst S, Berns E. Europace. 2009;11(8):1118-1119.,A complete situs inversus and dextrocardia,肺静脉的变异及其临床意义,Marom EM, et al. Radiol.2004;230:824-9.,肺静脉CT成像,肺静脉的变异及其临床意义,Marom EM, et al. Radiol.2004;230:824-9.,肺静脉CT成像,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。Scimitar syndrome, or pulmonary venolobar syndrome (肺静脉叶综合征), is a rarecongenital heart defect characterized by anomalous venous return from the right lung (to the systemic venous drainage, rather than directly to the LA).This anomalous PVs return can be either partial (PAPVR) or total (TAPVR). The syndrome associated with PAPVR is more commonly known asScimitar syndromeafter the curvilinear pattern created on a chest radiograph by the PVs that drain to the IVC.,弯刀综合征（scimitarsyndrome）,肺静脉的变异及其临床意义,Chest x-ray of a five-year-old girl with Scimitar syndrome. The heart (blue outline) is shifted into the right half of the chest, and the anomalous pulmonary venous return (red) has a shape reminiscent of aScimitar.,弯刀综合征（scimitarsyndrome）,左肺静脉与左心耳之间的脊,Muscle sleeve andPV potential formation,Myocardial muscle extensions to coving the outside of PVMuscle sleeve is thickest at the proximal end of vein(1-1.5 mm)Myocardial muscle fibers extend from LA to PV at length of 1-3 cmUsually the sleeve is thickest at the inferior wall of the superior PVs and at the superior wall of the inferior PVs,心脏大静脉肌袖解剖,远端,近端,心脏大静脉肌袖解剖,左肺静脉与左心耳之间的脊,LAO,LAO,RAO,RAO,LSPV,LIPV,LAAP,LAAP,LAAP,LAAP,LSPV,LSPV,左心耳和左上肺静脉,左上腔静脉永存,AP,PA,LAO,左上腔静脉永存,左心房憩室Left Atrial Diverticula,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。 -Wilson L, et al. 2014 HRS,左心房憩室Left Atrial Diverticula,LA,LA,Nagai 2011,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 - Peng 20122. 血栓,左