心室顫動和多形性室速消融觸發(fā)灶吳書林

1、會計學(xué)1心室顫動和多形性室速消融觸發(fā)灶吳書心室顫動和多形性室速消融觸發(fā)灶吳書林林自旋波自旋波Wu et al. Circulation 2002;100:1859-1866快速快速,電恢復(fù)曲線電恢復(fù)曲線1(APD/DI)快速快速,電恢復(fù)曲線電恢復(fù)曲線1 心肌增厚心肌增厚 19% 長長Q-T綜合征綜合征 60% 心肌缺血情況下室性早搏心肌缺血情況下室性早搏 6-25% 擴張性心肌病并心衰擴張性心肌病并心衰 47% 致心律失常性右心室發(fā)育不全致心律失常性右心室發(fā)育不全 29% 不明原因暈厥不明原因暈厥 心臟性猝死的病理生理心臟性猝死的病理生理 結(jié)構(gòu)結(jié)構(gòu) 功能功能心肌梗死心肌梗死 冠狀動脈血流暫時性

2、改變冠狀動脈血流暫時性改變 -缺血缺血 -急性暫性缺血急性暫性缺血 -壞死壞死 -缺血后再灌注缺血后再灌注 -纖維化纖維化 全身性因素全身性因素 -室壁瘤室壁瘤 -血流動力學(xué)異常血流動力學(xué)異常心肌肥厚心肌肥厚 -低氧血癥低氧血癥 -心肌細胞肥大心肌細胞肥大 -酸堿平衡失調(diào)酸堿平衡失調(diào) -心肌細胞排列異常心肌細胞排列異常 室速室速/室顫室顫 -細胞內(nèi)外電解質(zhì)紊亂細胞內(nèi)外電解質(zhì)紊亂 -心肌重構(gòu)心肌重構(gòu) 電電-機械分離機械分離 -血小板聚集異常血小板聚集異常心肌病變心肌病變 心搏停止心搏停止 -極度體力活動極度體力活動 -擴張擴張 神經(jīng)生理性作用神經(jīng)生理性作用 -纖維化纖維化 -傳遞介質(zhì)傳遞介質(zhì) -

3、浸潤浸潤 心臟性猝死心臟性猝死 -受體受體 -炎癥炎癥 -中樞神經(jīng)影響中樞神經(jīng)影響 結(jié)構(gòu)性心電異常結(jié)構(gòu)性心電異常 （精神壓力、卒中等）（精神壓力、卒中等） -WPW綜合征綜合征 -自主神經(jīng)系統(tǒng)功能紊亂自主神經(jīng)系統(tǒng)功能紊亂 -特殊傳導(dǎo)系統(tǒng)病變特殊傳導(dǎo)系統(tǒng)病變 毒性作用毒性作用 -QT延長綜合征延長綜合征 -藥物的致心律失常作用藥物的致心律失常作用 -Brugada綜合征綜合征 -心臟毒性反應(yīng)心臟毒性反應(yīng) 折返機制折返機制PFVPercentage of wave-front activation patterns at different VF durationsCopyright 2003 A

4、merican Heart AssociationHaissaguerre, M. et al. Circulation 2003;108:925-928Haissaguerre, M. et al. Circulation 2003;108:925-9281.Purkinje-triggered1.Purkinje-triggered VF VF A, Twelve-lead ECG showing LQTS (7th QRST complex) and polymorphic ventricular tachycardia demonstrated to be of Purkinje or

5、igin, as shown in the right panel (arrows). B, Endocardial mapping in LQTS demonstrating Purkinje triggers of multiple morphology. Each QRS complex is morphologically different but preceded by a Purkinje potential (arrow) with a varying conduction time. The same activity is also present during sinus

6、 rhythm with a short conduction time.Haissaguerre, M. et al. Circulation 2003;108:925-928Haissaguerre, M. et al. Circulation 2003;108:925-9282.RVOT-triggered VF2.RVOT-triggered VFA, Holter demonstrates LQTS and polymorphic ventricular tachycardia, minutes later followed by VF requiring resuscitation

7、 (not shown because of tracing artifact). B, Defibrillator interrogation demonstrates isolated monomorphic premature beats that subsequently initiate VF in Brugada syndrome. C, Twelve-lead ECG demonstrating features of Brugada syndrome and characteristic RVOT premature beat, subsequently inducing an

8、 arrhythmic storm requiring 11 shocks. 其他：低血鉀所致其他：低血鉀所致VF54歲女性歲女性,腹瀉腹瀉3天天,暈厥暈厥1次次 郭成軍（中華心律失常學(xué)雜志，郭成軍（中華心律失常學(xué)雜志，2002）.4例特發(fā)例特發(fā)VF，消融觸發(fā)消融觸發(fā)VF的的PVC,隨訪隨訪11個月個月3年無暈厥發(fā)作年無暈厥發(fā)作 2929例缺血性心肌病并例缺血性心肌病并VFVF（ICDICD植入且有記植入且有記錄結(jié)果），錄結(jié)果），2121例經(jīng)例經(jīng)AADAAD和抗心衰治療控制和抗心衰治療控制VFVF風(fēng)風(fēng)暴。暴。8 8例行例行CarfoCarfo標(biāo)測和標(biāo)測和RFCARFCA 5 5例頻發(fā)例頻發(fā)PV

9、CsPVCs誘發(fā)誘發(fā)VFVF，標(biāo)測到激動部位位，標(biāo)測到激動部位位于心梗疤痕區(qū)，于心梗疤痕區(qū)，PVCsPVCs前有浦氏電位（前有浦氏電位（PLPPLP）。）。另另3 3例偶發(fā)室早，未標(biāo)測到例偶發(fā)室早，未標(biāo)測到PLPPLP，沿疤痕區(qū)消融。，沿疤痕區(qū)消融。8 8例即時成功例即時成功 隨訪隨訪10106 6個月，個月，1 1例單次例單次VFVF發(fā)作，另發(fā)作，另1 1例出例出現(xiàn)持續(xù)單形性現(xiàn)持續(xù)單形性VTVT。無。無VFVF風(fēng)暴出現(xiàn)風(fēng)暴出現(xiàn)Marrouche NF,et al. JACC.2004;43:1715-20ECG記錄記錄Carto Mapping and RFCAMapping and Abl

10、ation of PolymorphicVentricular Tachycardia After Myocardial Infarction Szumowski L,.Haissagurre M.JACC2004;44:1700-6 5例例MI后后PVT行行RFCA,PVCs時，時，PLP提前于提前于QRS波波20-160ms.RFCA全部成功全部成功Carto Mapping and RFCA靶點靶點PFs電位電位(PLP)領(lǐng)先于領(lǐng)先于V波波(SR or VT) 21歲女性歲女性 心悸心悸10余年余年, 反復(fù)暈厥，近反復(fù)暈厥，近一年半每一年半每2-3月暈厥月暈厥1次次Holter ：271

11、76 VE, 207 nonsustained VT, 425 run, 1597 bigeminyEcho：LVED 55 LVES 37 LVEF 57%Lian yulu2007-6-11 2006年年AHA/ACC/HRS 室性心律失常室性心律失常處理指南處理指南Copyright 2003 American Heart AssociationHaissaguerre, M. et al. Circulation 2003;108:925-928Haissaguerre, M. et al. Circulation 2003;108:925-9281.Purkinje-triggere

12、d1.Purkinje-triggered VF VF A, Twelve-lead ECG showing LQTS (7th QRST complex) and polymorphic ventricular tachycardia demonstrated to be of Purkinje origin, as shown in the right panel (arrows). B, Endocardial mapping in LQTS demonstrating Purkinje triggers of multiple morphology. Each QRS complex is morphologically different but preceded by a Purkinje potential (arrow) with a varying conduction time. The same activity is also present during sinus rhythm with a short conduction