张澍电生理捡查

心脏电生理检查,心律失常诊治中心张澍,内容,电生理捡查目的电生理捡查方法及原理电生理捡查在心律失常中应用术前准备及术后护理,电生理检查目的,明确心律失常诊断了解心律失常机制明确心律失常起源检验药物抗心律失常效果选择射频消融适应证起搏器及ICD适应证晕厥原因捡查,电生理捡查方法及原理,心电图(ECG)及心内电图(EGM)记录技术心脏程序电刺激技术,刺激+记录,体外除颤器,Hard wiredpulse timer,Softwarepulse timer,脉冲刺激器,示波器,计算机,Preamplifiersat the table,病 人,记录器,放大器,Typical Catheter Placement,(H)RA,前后位,侧位,右前斜 (RAO),左前斜 (LAO),导 管,电活动,Recording 1-2,Recording 3-4,双极:激动时间,4,3,2,1,记录纸速,50-100mm/s,I,V1,HRA,His,CS,CS,CS,RV,滤波,ECG (0.05-2500 Hz),(30-100 Hz),EGM (30-500 Hz),(0.05-2500 Hz),Effect of filtering on the signals and interpretation,Burst,Ramp,50Hz,Pacing,程序电刺激,递增刺激,扫描刺激,程序早搏刺激,St= StimulusR= Response,S 2,S 2,S 1,S 1,S 1,S 1,S 1,S 1,S 2,S t,R,S t,R,S t,R,S t,R,S t,R,S 1,S 1,S 1,S 1,S 1,S 1,S 2,S t,R,基础刺激S1,早搏刺激S2, S3,P,V,V,HRA,CS,HBE,A,H,激动顺序传导时间不应期折返,RA,DCS,PCS,HB,I,AVF,V1,A,A,V,A,A,V,A,V,A,V,A,V,H,A,V,H,750,PA=50AH=80HV=45,HRA,His,LV,P,R,T,I,不同部位记录,EGM HRA,EGM septum,EGM CS,P-wave,Timing relationship of the activation of different sites,激动顺序,激动顺序,I,aVr,aVf,V1,HRA,AVJ,CSp,CSm,CSd,SN,A,AVN,BH,ECG,最小值,最大值,50,100,55,P,QRS,P-A:,A-H:,H-V:,25,50,35,A,H,V,正常传导间期,正常 HV间期,ECG-V1,HRA,His,RV,HV 50ms,A H,V,V,HV延长,HRA,AH,AVJ,AVJ,HV=90 ms,AH,V,V,HV阻滞,心房起搏 (350 ms),HRA,AVJ,AVJ,S,S,S,S,S,A,H,A,H,V,A,H,V,A,H,VA逆传,不应期,S,S,REFRACTORY,REFRACTORY,REFRACTORY,刺激阈值,引起心肌细胞兴奋的最小能量全或无概念,阈值,夺获,不夺获,心房不应期,心室不应期,260,270,S1,S1,S1,S2,S1,S1,S1,S2,不夺获,夺获,房室结特性,正常情况下心房递增刺激时房室结(AH)传导时间会相应延长，房内传导及室内传导时间不变,ECG-V1,HR1,His,RV,Cycle length: 450,Cycle length: 360,S,S,S,S,A,A,H,V,V,90,65,50,20,90,90,50,A,H,V,V,20,A,A,aVf,aVr,V1,V5,HRA,AVJ,RV,I,AVJ,S1,S1,S1,S2,300,400,A,A,AH,AH,HV,HV,激动传导,心房:稳定心室:稳定AV结:随心率加快传导减慢,电生理捡查在心律失常中应用,过缓型心律失常SSSAV阻滞室内阻滞过速型心律失常SVTVT晕厥待查选择心律失常治疗适应证,病态窦房结综合征(SSS)窦律下记录窦房结恢复时间窦房传导时间窦房结电图,心房,窦房结,房室传导阻滞体表心电图希氏束电图心房程序电刺激,定位诊断定量诊断,ECG,Minimum,values,Maximum,values,50,100,55,P,QRS,P-A:,A-H:,H-V:,25,50,35,A,H,V,心室内传导阻滞体表心电图希氏束电图心房程序电刺激,阻滞数量阻滞部位预后评价,ECG,Minimum,values,Maximum,values,50,100,55,P,QRS,P-A:,A-H:,H-V:,25,50,35,A,H,V,心动过速,大多为折返性室上性心动过速阵发性室上性心动过速窦性、房性、房室结、旁道房扑、房颤室性心动过速HPS分支折返,(a),(b),(c),(d) AVNRT,正路前传型AVRT,旁路前传型AVRT,双旁路AVRT,AVN,I型,II型,III型,Wolff-Parkinson-White Syndrome,房室旁道 一种快传导纤维束(随心率加快不减慢)心室预激波 delta波构成折返途经慢径房室结 (AV-node)快径旁道 (Kent bundle)触发因素: 早搏 诱发+终止,隐匿性旁道房室旁道无前传良好逆传构成心动过速,I,aVr,aVf,V1,HRA,AVJ,CSp,CSm,CSd,RV,左侧旁路折返SVT,A,A,A,A,A,诱发 SVT,S,S,S,S,SVT 200 bpm,I,aVr,aVf,V1,HRA,AVJ,CSp,CSm,CSd,RV,心室刺激终止 SVT,S,S,S,S,S,S,S,SVT,Ventricular pacing,NSR,房室结双径路,房室结的一种电生理特性见于10%的人群形成心动过速的基础，购成约一半的PSVT电生理特征心电图上两种PR间期心房刺激时A-H间期出现跳跃(50ms)能诱发PSVT,B,A,心房刺激周期缩短10ms，A-H增加超过50ms，(B-A50ms),心动过速,室性心动过速HPS分支折返电药理学,a,b,c,d,A,B,1,2,4,3,诱发 VT,S1,S1,S2,S1,S1,S2,I,aVf,aVr,V1,V5,HRA,AVJ,AVJ,RV,I,II,III,aVr,V5,V1,HRA,RV,S1,S1,S1,S1,S2,S3,S1,S1,S1,S1,S2,S3,Induction of VT,早搏刺激终止 VT,aVf,I,aVr,V1,V5,HRA,RV,320,190,S,快速终止 VT,aVf,aVr,V1,V5,HRA,RVOT,RVA,270,S,S,S,S,S,S,S,S,S,S,190,晕厥待查,机械电生理,过缓过速,晕厥待查,测定窦房结功能测定房室结功能测定室内传导功能测定旁道不应期-诱发房颤观察心室反应诱发室性心动过速观察血流动力学,选择心律失常治疗适应证,进一步明确病窦-植入起搏