心內(nèi)超聲和心電生理-英文課件

1、 Intracardiac Echocardiography and ElectrophysiologySteven C. Hao, MDDirector of ElectrophysiologyNorthern California Heart CareSan Francisco, CADisclosures Biosense Webster- consultant, investigator Acuson/Siemens- consultantCurrent Clinical Applications for Intracardiac Echocardiography (ICE)Elect

2、rophysiology Transseptal puncture VT ablation Aortic Cusp and RVOT Ablation LV Ablations Complex left-sided procedures Atrial flutter ablation Placement and removal of pacing leads Bi-Ventricular pacing for cardiac resynchronizationICE Imaging - Transseptal左邊影象證明了房間隔穿刺后的tenting現(xiàn)象，請注意tenting在肺靜脈平面是最大

3、的，以利于在肺靜脈、肺靜脈前庭以及左房后壁的控制。右圖證明了正確的房間隔穿刺。Using ICE to Guide Transseptal Puncture在ICE的幫助下，可以避免不恰當?shù)姆块g隔穿刺左側(cè)影像表明穿刺針/鞘位置靠前，幾乎從左房前部穿出右側(cè)影像表明在嘗試穿房間隔時穿刺針從右房穿入主動脈根部Aortic Cusp VT Ablation這些圖象演示了在標測一個局部VT消融時，從動脈瓣膜看動脈根部的影像。利用多普勒影像能通過直接的可視化圖形確認冠狀動脈開口。這可以幫助指導在這個區(qū)域的安全的消融。LV Ablation這些圖片顯示的是合并巨大基底動脈瘤的左室影像。注意導管的位置在動脈瘤

4、邊緣。右上圖顯示在射頻消融因局部過熱產(chǎn)生的微泡這個CT圖演示了三個左肺靜脈。ICE可以形象化的演示異常左肺靜脈，減少了肺靜脈消融的危險性。這是一個很罕見的左房，常見的低位開口。ICE證實后位開口（上圖）及巨大的左上肺靜脈（下圖）。 ICE能直接的顯示這類復雜解剖病例的病變部位畸形左房。左肺靜脈共前庭，右上肺靜脈靠前，右下肺靜脈靠后，左房頂部正中有一單獨肺靜脈。3D CT圖象掃描和ICE能對這種復雜的解剖結構的標測和消融有幫助。EsophagusInsert barium swallowICE放置右房能顯示食道，通過上圖能顯示左右肺靜脈和消融導管。Right Pulmonary Veins右側(cè)肺

5、靜脈的橫切面（左圖）及縱切面（右圖）可通過房間隔后斜進入而顯示該患者有三支右肺靜脈，有一束組織從右上及右中肺靜脈之間的突起處延伸至后壁直接顯示肺靜脈及該束組織能指導Lasso及消融導管在該部位的操作Intra-procedural early detection of complicationsACT 350s以防止在標測及消融導管上的血栓形成。低于該標準的抗凝則需要房間隔穿刺以及心內(nèi)導管的操作很精確。如果血栓形成則在ICE能看見并能回縮至鞘內(nèi)或者直接拉回右房Intra-procedural detection of Potential Complications 過熱能導致過度的心內(nèi)膜損傷（

6、左圖），導致內(nèi)膜下基質(zhì)暴露，從而形成血栓在左房和心室消融中，過熱能產(chǎn)生結痂形成和導致中風的潛在原因，在適當?shù)哪芰亢屠湎趯Ч苣芊乐菇Y痂（左圖顯示在LASSO上和右圖顯示大頭）% patientsUltrasound 33 ptsTemperature control482 ptsICE + Bubbles 270 ptsp = 0.029p = 0.2Embolic complications過去的一項研究表明通過ICE監(jiān)測微泡的形成以防止過熱能顯著減少在復雜左房消融中腦卒中的風險Monitor for Pericardial EffusionCardiac Tamponade在這個圖片中IC

7、E導管能早期監(jiān)控和診斷心包滲出。Evaluate Pulmonary Venous FlowLeft Inferior and Superior Pulmonary Veins功能顯像能證實在左房消融前后通過肺靜脈血流是否正常Results - Severe PV Stenosisn=75 n=25 n=102 n=100 n=310 20.0%2.9%2.0%0%15.5%通過確認適當?shù)姆戊o脈前庭損傷，而不是深部肺靜脈的損傷，ICE已經(jīng)被顯示防止肺靜脈狹窄。Visually Assists with Anatomical MapUnusual anatomical variants vert

8、ical or horizontal hearts congenital anomalies any post-operative heart Common left ostium Rapid branching of either vessel Multiple branches of right veinsCARTO and Ultrasound與精確標測系統(tǒng)的三維圖像融合能直觀地顯示復雜解剖結構在CT殼下顯示導管位置能準確地顯示病變位置及導管穩(wěn)定性，從而減少放射線暴露LUPVICE能幫助CT圖象重構選擇位點。Landmark Registration在復雜的左房消融時，我們通常在左房內(nèi)標

9、記三點（左上肺靜脈的后上，左下肺靜脈后下及右上肺靜脈的后上）Left Atrium and Pulmonary VeinsCARTOMERGE形象化的提供在復雜解剖結構中動態(tài)的多種工具。CARTOSOUNDOverview of the CARTOSOUND Image Integration Module and the SOUNDSTAR 3D CatheterCARTOSOUND Module FeaturesAccuracyBeam OrientationCARTOSOUND Module MapsTip to Tissue Contact VisualizationCARTOMERG

10、E Module SynergyCARTOSOUNDBeam Orientation Displaying the real-time ultrasound beam in 3D space improves ease of use and allows for easier interpretation of ICECARTOSOUNDBeam OrientationDisplaying the real-time ultrasound beam in 3D space improves ease of use and allows for easier interpretation of

11、ICECARTOSOUND CARTOSOUND Module Maps Allows for faster and more accurate maps Safely create left sided maps from the right sideCARTOSOUND Tip to Tissue Contact Improves physician confidence with real-time tip to tissue visualization在實時的ICE圖象和重建的3D ICE圖象能顯示導管位置在上圖中。CARTOSOUNDCARTOMERGE Module Synergy

12、First ICE & 3D mapping integration Enhancing safety & ease of use Two years of proven accuracy & experience Full anatomical details of pre- acquired registration綜和ICE和3D系統(tǒng)能實時顯示大頭、解剖、3D重建圖和三維標測系統(tǒng)。Conclusions ICE provides real-time 2D and functional imaging to help guide catheter manipulation in difficult anatomy, monitor lesion formation, prevent and/or monitor for complication