房室旁路的射频消融 严选课件

房室旁路的射频消融,中国协和医科大学阜外心血管病医院临床电生理研究室楚建民,1,参考材料,如何判定左右侧旁路心律失常的形成机制旁路的解剖基础旁路的标测和消融技术,2,参考材料,AccessoryAVPathways,Symptoms:Rangefromasymptomatictosuddencardiacdeath症状:无症状到猝死SVTmaybefrequentorrecurrentSVT频繁发作,表现为心慌、胸闷。Upto40%ofpatientsremainasymptomatic40%无症状Orthodromicreciprocatingtachycardia顺向型(30%ofPSVTs)clinicalpresentation:AntegradeconductionoverAVnode房室结前传Retrogradeconductionoveraccessorypathway旁路逆传,KayGN.AmJMed.1996;100:344-345.,3,参考材料,Wolff-Parkinson-WhiteSyndrome心电图表现,Theelectrocardiogrammayshowpre-excitation(deltawave)心电图QRS起始部粗钝形成预激波Ifaccessorypathwaynotcapableofanterogradeconduction,theECGmaynotshowpre-excitation(concealedpathway)ECG无预激(隐匿性旁路)IfaccessorypathwaycapableofrapidantegradeconductionIncreasedrisktodevelopVFfromrapidconductionofAF房扑发展为室颤,4,参考材料,Pre-excitation预激体表心电图,KayNG.AmJofMed.1996;10:344-356.,5,参考材料,WPW:CaseStudy病例,18yearoldmalebasketballplayer篮球运动员PresentedtoERwith:症状Multipleepisodesofnear-syncope先兆晕厥Adenosine12mgacceleratedtheheartrate12mg腺苷心室率加快Emergencycardioversionperformed紧急电复律,6,参考材料,WPW:CaseStudyECG旁路前传,CourtesyofDr.BrianOlshansky.,7,参考材料,WPW:CaseStudy,Studiedintheelectrophysiologylaboratory电生理检查InducedAFVF诱发房扑演化为室扑Mapping:twopathways双旁路Posteriorseptal后间隔Leftlateralaccessorypathway游离壁Ablationofbothpathways消融2条旁路Noadditionaltherapyneeded无需药物治疗,8,参考材料,AFwithMultipleAccessoryPathways房扑,CourtesyofDr.BrianOlshansky.,9,参考材料,AFwithMultipleAccessoryPathways房扑,CourtesyofDr.BrianOlshansky.,10,参考材料,AFVF房扑转为室扑,CourtesyofDr.BrianOlshansky.,11,参考材料,心动过速时的心电图表现,顺向型心动过速心电图特点：QRS后可见P波，RP70ms。P波与T波融合，导致T波僵硬、畸形。逆向型心动过速心电图：宽大QRS心动过速，形态与窦性心律时一致。,12,参考材料,左右侧旁路的判定,A型预激：V1预激波和QRS主波向上，旁路位于左心房和左心室之间，即二尖瓣环上。B型预激：V1预激波和QRS主波向下，旁路位于右心房和右心室之间，即三尖瓣环上。,13,参考材料,PosteriorBasalViewLeftAtrium左心房后面观,R.superiorpulmonaryvein,R.inferiorpulmonaryvein,Coronarysinus,L.inferiorpulmonaryvein,L.atrium,L.superiorpulmonaryvein,L.auricle,L.pulmonaryartery,R.pulmonaryartery,NetterF.AtlasofHumanAnatomy.1989;Plate202.,14,参考材料,A型预激心电图,15,参考材料,A型预激窦性心律时心内图,16,参考材料,A型预激心动过速时心电图,17,参考材料,心内图,18,参考材料,左侧旁路靶点图,19,参考材料,成功后靶点图,20,参考材料,21,参考材料,A型预激,22,参考材料,23,参考材料,心室起搏诱发心动过速,24,参考材料,窦性心律靶点图,25,参考材料,B型预激,26,参考材料,心动过速时心内图,27,参考材料,B型预激,28,参考材料,OrthodromicReciprocatingTachycardia顺向型,KayNG.AmJofMed.1996;10:344-356.,29,参考材料,旁路形成的心律失常,旁路逆传，房室结前传:顺向型心动过速旁路前传:房扑房颤时旁路前传导致：室速/室颤；阵发性心动过速时旁路前传：逆向型心动过速,30,参考材料,顺向型AVRT形成机制,31,参考材料,逆向型房室折返性心动过速形成机制,32,参考材料,B型预激心内图,33,参考材料,心动过速,34,参考材料,另一种形态心动过速,35,参考材料,左侧旁路参与,36,参考材料,第3种形态,37,参考材料,38,参考材料,所有旁路消融后心电图,39,参考材料,旁路的性质,Kent束：全和无普通旁路、慢旁路ATP无影响Mahim纤维：无逆传只有前向递减性传导,40,参考材料,房室旁路解剖示意图,41,参考材料,CatheterPlacementforAblationofLeftFree-WallAccessoryPathway左侧旁路导管放置,MoradyF.NEnglJofMed.1999;340:534-544.,42,参考材料,AccessoryAVPathways,Location:Rightfree-wall右游离壁部位Septalaccessorypathways间隔部Leftfree-wall左游离壁Approach:Venous,transseptalorretrogradeaortic途径静脉,穿间隔,主动脉逆行Efficacy89-99%疗效Highestleft-sidedpathways左侧旁路高Lowerseptalandright-sidedpathways右侧旁路低Recurrence3-9%复发率,MoradyF.NEnglJofMed.1999;340:534-544.,43,参考材料,旁路的标测,旁路前传时:V波最早旁路逆传时:A波最早,44,参考材料,房室旁路的射频消融(右侧),45,参考材料,左侧旁路的旁路电位,46,参考材料,隐匿性旁路的旁路电位,47,参考材料,不同部位旁路的特点,左前旁路:靠近左心耳，导管难以到位靶点AV之比1