室性心动过速的消融何时进行如何消融PPT课件

1、声明声明Relevant Financial Relationship(s)NoneOff Label UsageNone第1页/共64页 室性心动过速的机制 折返、拖带、隐匿性拖带的基本概念 稳定的，单形性室速 不稳定或多折返环室速 高级方法和技术内容内容第2页/共64页CP1323528-2室速消融室速消融指南建议指南建议I类适应证类适应证持续单形性室速，药物无效或不能耐受或患者不愿意长期服药，持续单形性室速，药物无效或不能耐受或患者不愿意长期服药，猝死低危患者猝死低危患者(C)束支折返室速束支折返室速 (C)ICD植入后反复放电，重新程控、调整用药均无效，或不愿意接植入后反复放电，重新程

2、控、调整用药均无效，或不愿意接受长期药物治疗的患者，导管消融作为辅助治疗受长期药物治疗的患者，导管消融作为辅助治疗 (C)Circ 2006第3页/共64页室性心律失常室性心律失常CP1206111-1“局灶局灶”“多发性多发性”流出道流出道分支分支瓣上瓣上RVLV普肯野普肯野折返折返解剖靶点解剖靶点心肌病心肌病疤痕疤痕二尖瓣二尖瓣电生理策略电生理策略P. 刺激刺激拖带拖带影像影像电生理电生理损伤损伤解剖解剖第4页/共64页室速标测和消融步骤室速标测和消融步骤潜在的心脏机制，病史 缺血性心脏病 特发性扩心病 其它根据心电图判断心动过速的起源程序性刺激，方法 重整 拖带 隐匿性拖带高级标测技术

3、电压标测 电解剖标测 影像 心外膜标测 其它第5页/共64页双电位双电位疤痕疤痕Scars0.5 mV2 mV潜在折返环潜在折返环CP1176527-5第6页/共64页CP1233975-13第7页/共64页该室速折返环出口位置可能是: A. LV/前壁/基底部/侧壁 B. LV/后壁/心尖/侧壁 C. LV/后壁中部/间隔部 D. LV/后壁/心尖/间隔部第8页/共64页标测示意图标测示意图横断面横断面基地部基地部心尖心尖长轴切面长轴切面间隔间隔侧壁侧壁12693前壁前壁后壁后壁CP1060083-4ABCDE第9页/共64页QRS形态提示室速的出口位置形态提示室速的出口位置V4基底部基底部

4、心尖心尖AVRCP1060083-1AVRV4第10页/共64页II, III, aVFQRS 形态提示室速的出口形态提示室速的出口CP1060083-2前壁前壁后壁后壁II, III, aVF第11页/共64页QRS形态提示室速的出口形态提示室速的出口I, aVL间隔部间隔部侧壁侧壁II, III, aVFCP1060083-3第12页/共64页该室速的折返环出口位置可能是: A. LV/前壁/基底部/侧壁 B. LV/后壁/心尖/侧壁 C. LV/后壁/中部/间隔部 D. LV/后壁/心尖l/间隔*第13页/共64页CP1233975-13A, B, C拖带，隐匿融合拖带，隐匿融合 PPI

5、 = VTCL S-QRS = EGM-QRS S-QRS VTCL S-QRS EGM-QRSF拖带，显性融合拖带，显性融合 PPI = VTCL S-QRS = EGM-QRSG拖带，显性融合拖带，显性融合 PPI VTCL S-QRS EGM-QRSABCDE*FG第14页/共64页起搏部位起搏部位:A. 缓慢传导的关键部位起搏缓慢传导的关键部位起搏B. 在通道盲端起搏在通道盲端起搏C. 在外环起搏在外环起搏D. 环外起搏环外起搏E. 无夺获无夺获ABCD哪个位置起搏与折返环有关哪个位置起搏与折返环有关?第15页/共64页起搏部位起搏部位A. 缓慢传导的关键部位起搏缓慢传导的关键部位起搏

6、B. 在通道盲端起搏在通道盲端起搏C. 在外环起搏在外环起搏D. 环外起搏环外起搏E. 无夺获无夺获*第16页/共64页起搏部位：起搏部位：A. 缓慢传导的关键部位起搏缓慢传导的关键部位起搏B. 在通道盲端起搏在通道盲端起搏C. 在外环起搏在外环起搏D. 环外起搏环外起搏E. 无夺获无夺获ABCD第17页/共64页起搏部位起搏部位A. 缓慢传导的关键部位起搏缓慢传导的关键部位起搏B. 在通道盲端起搏在通道盲端起搏C. 在外环起搏在外环起搏D. 环外起搏环外起搏E. 无夺获无夺获*第18页/共64页起搏部位起搏部位:A. 缓慢传导的关键部位起搏缓慢传导的关键部位起搏B. 在通道盲端起搏在通道盲端

7、起搏C. 在外环起搏在外环起搏D. 环外起搏环外起搏E. 无夺获无夺获PPITCLABCDPPI = 395S-QRS = 265VTCL = 395E-QRS = 265第19页/共64页起搏部位起搏部位:A. 缓慢传导的关键部位起搏缓慢传导的关键部位起搏B. 在通道盲端起搏在通道盲端起搏C. 在外环起搏在外环起搏D. 环外起搏环外起搏E. 无夺获无夺获PPITCL*PPI = 395S-QRS = 265VTCL = 395E-QRS = 265第20页/共64页室速终止室速终止CP1201033-1第21页/共64页CP1270284-4VT 1VT 2VT 3VT 3第22页/共64页

8、CP1270284-17电压标测指导的室速消融电压标测指导的室速消融第23页/共64页男性，男性，55 岁，扩张型心肌病岁，扩张型心肌病, EF 27%ICD频繁放电，既往消融失败频繁放电，既往消融失败第24页/共64页左心室辅助装置左心室辅助装置 Low-speed centrifugal continuous flow pump Low blood surface area contact 21 Fr Left atrial cannula 19 Fr femoral arterial cannula Up to 4L/min FlowThiele et al Circ 2001第25页/

9、共64页左心室支持下诱发室速左心室支持下诱发室速第26页/共64页左心室辅助支持下心内膜及心外膜标测左心室辅助支持下心内膜及心外膜标测LAALACannulaEndoEpi第27页/共64页Schweikert et al. Circulation. 2003;108:1329-1335.Eduardo Sosa, JACC 2000第28页/共64页左心室心内膜和心内膜消融左心室心内膜和心内膜消融Mitral Valve第29页/共64页 多数情况下为折返机制 根据拖带的反应识别传导的关键区域 多形性室速和多环路折返较常见 通常需要电压/把横标测 部分病人可能需要心外膜标测 为防止ICD反复

10、放电，多数患者应接受姑息性VT消融疤痕依赖基质的室速消融疤痕依赖基质的室速消融第30页/共64页第31页/共64页CP1063458-1Ventricular Tachycardia Ablation When and How?第32页/共64页DISCLOSURERelevant Financial Relationship(s)NoneOff Label UsageNone第33页/共64页 Spectrum of VT mechanisms Basic concept of reentry, entrainment, and concealed entrainment Stable, m

11、onomorphic VT Unstable VT or multiple circuits Advanced technology and techniquesObjectives第34页/共64页CP1323528-2VT AblationRecommendationsClass IAblation is indicated in patients who are otherwise at low risk for SCD and have sustained predominantly monomorphic VT that is drug resistant, who are drug

12、 intolerant, or who do not wish long-term drug therapy (level of evidence: C)Ablation is indicated in patients with bundle-branch reentrant VT (level of evidence: C)Ablation is indicated as adjunctive therapy in patients with an ICD who are receiving multiple shocks as a result of sustained VT that

13、is not manageable by reprogramming or changing drug therapy or who do not wish long-term drug therapy (level of evidence: C)Circ 2006第35页/共64页Ventricular ArrhythmiasCP1206111-1“Focal”“Diffuse”Outflow tractFascicularSupra-valvularRVLVPurkinjeReentryAnatomic targetMyopathicScarsMitral valveEP maneuver

14、sP. StimulationEntrainmentImagingElectrophysiologyLesion creationAnatomy第36页/共64页Steps in Mapping and Ablating VT Underlying cardiac substrate, history Ischemic heart disease Idiopathic dilated cardiomyopathy OthersECG recognition of tachycardia originProgrammed stimulation, maneuvers Reset Entrainm

15、ent Concealed entrainmentAdvanced mapping Voltage mapping Electro-anatomical correlation Imaging Epicardial approach Others第37页/共64页Concepts of MappingReentrant Ventricular TachycardiaDoublepotentialsScarsScars0.5 mV2 mVPotentialcircuitsCP1176527-5第38页/共64页CP1233975-13第39页/共64页This VT circuit exit s

16、ite is likely: A. LV/anterior/basal/lateral B. LV/posterior/apical/lateral C. LV/posterior/mid/septal D. LV/posterior/apical/septal第40页/共64页Mapping SchemeCross SectionBaseApexLongitudinal SectionSeptalLateral12693AnteriorPosteriorCP1060083-4ABCDE第41页/共64页QRS Morphology Clues to VT Exit SiteV4BaseApe

17、xAVRCP1060083-1AVRV4第42页/共64页II, III, aVFQRS Morphology Clues to VT Exit SiteCP1060083-2AnteriorPosteriorII, III, aVF第43页/共64页QRS Morphology Clues to VT Exit SiteI, aVLSeptalLateralII, III, aVFCP1060083-3第44页/共64页This VT circuit exit site is likely: A. LV/anterior/basal/lateral B. LV/posterior/apica

18、l/lateral C. LV/posterior/mid/septal D. LV/posterior/apical/septal*第45页/共64页CP1233975-13A, B, CEntrainment with concealed fusion PPI = VTCL S-QRS = EGM-QRS S-QRS VTCL S-QRS EGM-QRSFEntrainment with manifested fusion PPI = VTCL S-QRS = EGM-QRSGEntrainment with manifested fusion PPI VTCL S-QRS EGM-QRS

19、ABCDE*FG第46页/共64页Pacing at this site is most consistent with:A. Pacing in a critical zone of slow conductionB. Pacing in a “dead end alley”C. Pacing in an outer loopD. Pacing outside of the circuitE. Non captureABCDWhere was the pacing site in relationship to the circuit?第47页/共64页Pacing at this site

20、 is most consistent with:A. Pacing in a critical zone of slow conductionB. Pacing in a “dead end alley”C. Pacing in an outer loopD. Pacing outside of the circuitE. Non capture*第48页/共64页Pacing at this site is most consistent with:A. Pacing in a critical zone of slow conductionB. Pacing in a “dead end

21、 alley”C. Pacing in an outer loopD. Pacing outside of the circuitE. Non captureABCD第49页/共64页Pacing at this site is most consistent with:A. Pacing in a critical zone of slow conductionB. Pacing in a “dead end alley”C. Pacing in an outer loopD. Pacing outside of the circuitE. Non capture*第50页/共64页Paci

22、ng at this site is most consistent with:A. Pacing in a critical zone of slow conductionB. Pacing in a “dead end alley”C. Pacing in an outer loopD. Pacing outside of the circuitE. Non capturePPITCLABCDPPI = 395S-QRS = 265VTCL = 395E-QRS = 265第51页/共64页Pacing at this site is most consistent with:A. Pac

23、ing in a critical zone of slow conductionB. Pacing in a “dead end alley”C. Pacing in an outer loopD. Pacing outside of the circuitE. Non capturePPITCL*PPI = 395S-QRS = 265VTCL = 395E-QRS = 265第52页/共64页Termination of VTCP1201033-1第53页/共64页CP1270284-4VT 1VT 2VT 3VT 3第54页/共64页CP1270284-17Voltage Map Gu

24、ided VT Ablation第55页/共64页55 year-old man with DCM, EF 27%Frequent ICD shocks, failed previous ablation第56页/共64页Left Ventricular Support Low-speed centrifugal continuous flow pump Low blood surface area contact 21 Fr Left atrial cannula 19 Fr femoral arterial cannula Up to 4L/min FlowThiele et al Circ 2001第57页/共64页Induction of VT on LV Support第58页/共64页Endocardial and Epicardial Mapping with Left Ventricular SupportLAALACannulaEndoEpi第59页/共64页Epicardial ApproachSchweikert et al. Circulation. 2003;108:1329-1335.Eduar