房室旁路的射频消融课件

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1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如何判定左右侧旁路2AccessoryAVPathwaysSymptoms:Rangefromasymptomaticto

suddencardiacdeath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.AccessoryAVPathwaysSymptoms:3Wolff-Parkinson-WhiteSyndrome

心电图表现Theelectrocardiogrammayshow

pre-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)IfaccessorypathwaycapableofrapidantegradeconductionIncreasedrisktodevelopVFfromrapid

conductionofAF房扑发展为室颤Wolff-Parkinson-WhiteSyndrome4Pre-excitation预激体表心电图KayNG.AmJofMed.1996;10:344-356.Pre-excitation预激体表心电图KayNG.A5WPW: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WPW:CaseStudy病例18yearo6WPW:CaseStudyECG旁路前传CourtesyofDr.BrianOlshansky.WPW:CaseStudyECG旁路前传Courtes7WPW:CaseStudyStudiedintheelectrophysiologylaboratory电生理检查InducedAF®VF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WPW:CaseStudyStudiedinthe8AFwithMultiple

AccessoryPathways房扑CourtesyofDr.BrianOlshansky.AFwithMultiple

AccessoryPa9AFwithMultiple

AccessoryPathways房扑CourtesyofDr.BrianOlshansky.AFwithMultiple

AccessoryPa10AF®VF房扑转为室扑CourtesyofDr.BrianOlshansky.AF®VF房扑转为室扑CourtesyofD11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，RP<PR,RP>70ms。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。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12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。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13PosteriorBasalView–

LeftAtrium左心房后面观R.superiorpulmonaryveinR.inferior

pulmonaryveinCoronarysinusL.inferiorpulmonaryveinL.atriumL.superiorpulmonaryveinL.auricleL.pulmonaryarteryR.pulmonaryarteryNetterF.AtlasofHumanAnatomy.1989;Plate202.PosteriorBasalView–

LeftA14A型预激心电图A型预激心电图15A型预激窦性心律时心内图A型预激窦性心律时心内图16A型预激心动过速时心电图A型预激心动过速时心电图17心内图心内图18左侧旁路靶点图左侧旁路靶点图19成功后靶点图成功后靶点图20房室旁路的射频消融课件21A型预激A型预激22房室旁路的射频消融课件23心室起搏诱发心动过速心室起搏诱发心动过速24窦性心律靶点图窦性心律靶点图25B型预激B型预激26心动过速时心内图心动过速时心内图27B型预激B型预激28OrthodromicReciprocatingTachycardia顺向型KayNG.AmJofMed.1996;10:344-356.OrthodromicReciprocatingTach29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30顺向型AVRT形成机制顺向型AVRT形成机制31逆向型房室折返性心动过速

形成机制逆向型房室折返性心动过速

形成机制32B型预激心内图B型预激心内图33心动过速心动过速34另一种形态心动过速另一种形态心动过速35左侧旁路参与左侧旁路参与36第3种形态第3种形态37房室旁路的射频消融课件38所有旁路消融后心电图所有旁路消融后心电图39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旁路的性质Kent束：全和无40房室旁路解剖示意图房室旁路解剖示意图41CatheterPlacementforAblationof

LeftFree-WallAccessoryPathway左侧旁路导管放置MoradyF.NEnglJofMed.1999;340:534-544.CatheterPlacementforAblatio42AccessoryAVPathwaysLocation: 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Efficacy 89-99%

疗效 Highestleft-sidedpathways左侧旁路高

Lowerseptalandright-sidedpathways右侧旁路低Recurrence 3-9%复发率MoradyF.NEnglJofMed.1999;340:534-544.AccessoryAVPathwaysLocation:43旁路的标测旁路前传时:V波最早旁路逆传时:A波最早旁路的标测44房室旁路的射频消融(右侧)房室旁路的射频消融(右侧)45左侧旁路的旁路电位左侧旁路的旁路电位46隐匿性旁路的旁路电位隐匿性旁路的旁路电位47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1:1左后间隔旁路:A波变化大，导管容易移位，靠近房室结右后间隔旁路：注意心中静脉的可能性；左侧消融右游离壁旁路：导管贴靠的问题右前间隔旁路：靠近希氏束；不要轻易放电；能量滴定；小功率长时间。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AV48间隔部旁路、房速、双径路

的鉴别诊断临床表现心电图表现电生理检查心动过速心内图表现ATP反应标测间隔部旁路、房速、双径路

的鉴别诊断临床表现49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50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如何判定左右侧旁路51AccessoryAVPathwaysSymptoms:Rangefromasymptomaticto

suddencardiacdeath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.AccessoryAVPathwaysSymptoms:52Wolff-Parkinson-WhiteSyndrome

心电图表现Theelectrocardiogrammayshow

pre-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)IfaccessorypathwaycapableofrapidantegradeconductionIncreasedrisktodevelopVFfromrapid

conductionofAF房扑发展为室颤Wolff-Parkinson-WhiteSyndrome53Pre-excitation预激体表心电图KayNG.AmJofMed.1996;10:344-356.Pre-excitation预激体表心电图KayNG.A54WPW: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WPW:CaseStudy病例18yearo55WPW:CaseStudyECG旁路前传CourtesyofDr.BrianOlshansky.WPW:CaseStudyECG旁路前传Courtes56WPW:CaseStudyStudiedintheelectrophysiologylaboratory电生理检查InducedAF®VF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WPW:CaseStudyStudiedinthe57AFwithMultiple

AccessoryPathways房扑CourtesyofDr.BrianOlshansky.AFwithMultiple

AccessoryPa58AFwithMultiple

AccessoryPathways房扑CourtesyofDr.BrianOlshansky.AFwithMultiple

AccessoryPa59AF®VF房扑转为室扑CourtesyofDr.BrianOlshansky.AF®VF房扑转为室扑CourtesyofD60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，RP<PR,RP>70ms。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。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61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。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62PosteriorBasalView–

LeftAtrium左心房后面观R.superiorpulmonaryveinR.inferior

pulmonaryveinCoronarysinusL.inferiorpulmonaryveinL.atriumL.superiorpulmonaryveinL.auricleL.pulmonaryarteryR.pulmonaryarteryNetterF.AtlasofHumanAnatomy.1989;Plate202.PosteriorBasalView–

LeftA63A型预激心电图A型预激心电图64A型预激窦性心律时心内图A型预激窦性心律时心内图65A型预激心动过速时心电图A型预激心动过速时心电图66心内图心内图67左侧旁路靶点图左侧旁路靶点图68成功后靶点图成功后靶点图69房室旁路的射频消融课件70A型预激A型预激71房室旁路的射频消融课件72心室起搏诱发心动过速心室起搏诱发心动过速73窦性心律靶点图窦性心律靶点图74B型预激B型预激75心动过速时心内图心动过速时心内图76B型预激B型预激77OrthodromicReciprocatingTachycardia顺向型KayNG.AmJofMed.1996;10:344-356.OrthodromicReciprocatingTach78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79顺向型AVRT形成机制顺向型AVRT形成机制80逆向型房室折返性心动过速

形成机制逆向型房室折返性心动过速

形成机制81B型预激心内图B型预激心内图82心动过速心动过速83另一种形态心动过速另一种形态心动过速84左侧旁路参与左侧旁路参与85第3种形态第3种形态86房室旁路的射频消融课件87所有旁路消融后心电图所有旁路消融后心电图88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旁路的性质Kent束：全和无89房室旁路解剖示意图房室旁路解剖示意图90CatheterPlacementforAblationof

LeftFree-WallAccessoryPathway左侧旁路导管放置MoradyF.N