室性心動(dòng)過(guò)速消融何時(shí)進(jìn)行？消融？WinKShen課件

WinK.Shen,M.D.ProfessorofMedicineMayoClinicCollegeofMedicineGW-HRSJointSymposium,Beijing2009CP1063458-1室性心動(dòng)過(guò)速的消融：

何時(shí)進(jìn)行？如何消融？?WinK.Shen,M.D.CP1063458-1室性聲明RelevantFinancialRelationship(s)NoneOffLabelUsageNone聲明RelevantFinancialRelations室性心動(dòng)過(guò)速的機(jī)制折返、拖帶、隱匿性拖帶的基本概念穩(wěn)定的，單形性室速不穩(wěn)定或多折返環(huán)室速高級(jí)方法和技術(shù)內(nèi)容室性心動(dòng)過(guò)速的機(jī)制內(nèi)容CP1323528-2室速消融指南建議I類(lèi)適應(yīng)證持續(xù)單形性室速，藥物無(wú)效或不能耐受或患者不愿意長(zhǎng)期服藥，猝死低危患者(C)束支折返室速(C)ICD植入后反復(fù)放電，重新程控、調(diào)整用藥均無(wú)效，或不愿意接受長(zhǎng)期藥物治療的患者，導(dǎo)管消融作為輔助治療(C)Circ2006CP1323528-2室速消融I類(lèi)適應(yīng)證Circ2006室性心律失常CP1206111-1“局灶”“多發(fā)性”流出道分支瓣上RVLV普肯野折返解剖靶點(diǎn)心肌病疤痕二尖瓣電生理策略P.刺激拖帶影像電生理?yè)p傷解剖室性心律失常CP1206111-1“局灶”“多發(fā)性”流出道分室速標(biāo)測(cè)和消融步驟潛在的心臟機(jī)制，病史缺血性心臟病特發(fā)性擴(kuò)心病其它根據(jù)心電圖判斷心動(dòng)過(guò)速的起源程序性刺激，方法重整拖帶隱匿性拖帶高級(jí)標(biāo)測(cè)技術(shù)電壓標(biāo)測(cè)電解剖標(biāo)測(cè)影像心外膜標(biāo)測(cè)其它室速標(biāo)測(cè)和消融步驟潛在的心臟機(jī)制，病史標(biāo)測(cè)的概念折返性室速雙電位疤痕Scars0.5mV2mV潛在折返環(huán)CP1176527-5標(biāo)測(cè)的概念折返性室速雙電位疤痕Scars0.5mV2mVCP1233975-13ECGECGQRS起始共同通路(CP)CP

入口內(nèi)環(huán)疤痕外環(huán)疤痕通道盲端CP出口折返環(huán)和相關(guān)術(shù)語(yǔ)CP1233975-13ECGECGQRS起始共同通路(CP該室速折返環(huán)出口位置可能是:A.LV/前壁/基底部/側(cè)壁B.LV/后壁/心尖/側(cè)壁C.LV/后壁中部/間隔部D.LV/后壁/心尖/間隔部該室速折返環(huán)出口位置可能是:標(biāo)測(cè)示意圖橫斷面基地部心尖長(zhǎng)軸切面間隔側(cè)壁12693前壁后壁CP1060083-4ABCDE標(biāo)測(cè)示意圖橫斷面基地部心尖長(zhǎng)軸切面間隔側(cè)壁12693前壁后壁QRS形態(tài)提示室速的出口位置V4基底部心尖AVRCP1060083-1AVRV4QRS形態(tài)提示室速的出口位置V4基底部心尖AVRCP1060II,III,aVFQRS形態(tài)提示室速的出口CP1060083-2前壁后壁II,III,aVFII,III,aVFQRS形態(tài)提示室速的出口CP106QRS形態(tài)提示室速的出口I,aVL間隔部側(cè)壁II,III,aVFCP1060083-3QRS形態(tài)提示室速的出口I,aVL間隔部側(cè)壁II,III該室速的折返環(huán)出口位置可能是:A.LV/前壁/基底部/側(cè)壁B.LV/后壁/心尖/側(cè)壁C.LV/后壁/中部/間隔部D.LV/后壁/心尖l/間隔**該室速的折返環(huán)出口位置可能是:**CP1233975-13折返環(huán)路與拖帶A,B,C拖帶，隱匿融合PPI=VTCLS-QRS=EGM-QRSS-QRS<70%VTCLD,E*拖帶，隱匿融合PPI>VTCLS-QRS>EGM-QRSF拖帶，顯性融合PPI=VTCLS-QRS=EGM-QRSG拖帶，顯性融合PPI≠VTCLS-QRS≠

EGM-QRSABCDE*FGCP1233975-13折返環(huán)路與拖帶A,B,CABCD起搏部位:緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無(wú)奪獲ABCD哪個(gè)位置起搏與折返環(huán)有關(guān)?起搏部位:ABCD哪個(gè)位置起搏與折返環(huán)有關(guān)?起搏部位緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無(wú)奪獲*起搏部位*起搏部位：緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無(wú)奪獲ABCD起搏部位：ABCD起搏部位緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無(wú)奪獲*起搏部位*起搏部位:緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無(wú)奪獲PPITCLABCDPPI=395S-QRS=265VTCL=395E-QRS=265起搏部位:PPITCLABCDPPI=395S-QRS起搏部位:緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無(wú)奪獲PPITCL*PPI=395S-QRS=265VTCL=395E-QRS=265起搏部位:PPITCL*PPI=395S-QRS=2室速終止CP1201033-1%0-10n=4611-30n=1831-60n=24>60n=64PPI-VTCL(msec)室速終止CP1201033-1%0-10n=4611-30nCP1270284-4VT#5VT1VT2VT3VT3CP1270284-4VT#5VT1VT2VT3VTCP1270284-17電壓標(biāo)測(cè)指導(dǎo)的室速消融CP1270284-17電壓標(biāo)測(cè)指導(dǎo)的室速消融男性，55歲，擴(kuò)張型心肌病,EF27%

ICD頻繁放電，既往消融失敗男性，55歲，擴(kuò)張型心肌病,EF27%

ICD頻繁放電左心室輔助裝置Low-speedcentrifugalcontinuousflowpumpLowbloodsurfaceareacontact21FrLeftatrialcannula19FrfemoralarterialcannulaUpto4L/minFlowThieleetalCirc2001左心室輔助裝置Low-speedcentrifugalc左心室支持下誘發(fā)室速左心室支持下誘發(fā)室速左心室輔助支持下心內(nèi)膜及心外膜標(biāo)測(cè)LAALACannulaEndoEpi左心室輔助支持下心內(nèi)膜及心外膜標(biāo)測(cè)LAALAEndoEpi經(jīng)心外膜途徑消融Schweikertetal.Circulation.2003;108:1329-1335.EduardoSosa,JACC2000室速合并冠心病的患者經(jīng)心外膜消融是可行的.53例中發(fā)生了4例右心室穿孔及心臟壓塞

對(duì)其它心律失常亦有效(VT伴或不伴SHD,WPW,RVOTVT,AT)

，尤其是經(jīng)心內(nèi)膜消融失敗的患者無(wú)并發(fā)癥報(bào)道經(jīng)心外膜途徑消融Schweikertetal.Circ左心室心內(nèi)膜和心內(nèi)膜消融MitralValve左心室心內(nèi)膜和心內(nèi)膜消融MitralValve多數(shù)情況下為折返機(jī)制根據(jù)拖帶的反應(yīng)識(shí)別傳導(dǎo)的關(guān)鍵區(qū)域多形性室速和多環(huán)路折返較常見(jiàn)通常需要電壓/把橫標(biāo)測(cè)部分病人可能需要心外膜標(biāo)測(cè)為防止ICD反復(fù)放電，多數(shù)患者應(yīng)接受姑息性VT消融疤痕依賴(lài)基質(zhì)的室速消融多數(shù)情況下為折返機(jī)制疤痕依賴(lài)基質(zhì)的室速消融GW-ICCHRSJointSymposiumBeijingOct.11,2009GW-ICCHRSJointSymposiumBeijWinK.Shen,M.D.ProfessorofMedicineMayoClinicCollegeofMedicineGW-HRSJointSymposium,Beijing2009CP1063458-1VentricularTachycardiaAblation

WhenandHow?WinK.Shen,M.D.CP1063458-1VeDISCLOSURERelevantFinancialRelationship(s)NoneOffLabelUsageNoneDISCLOSURERelevantFinancialRSpectrumofVTmechanismsBasicconceptofreentry,entrainment,andconcealedentrainmentStable,monomorphicVTUnstableVTormultiplecircuitsAdvancedtechnologyandtechniquesObjectivesSpectrumofVTmechanismsObjecCP1323528-2VTAblationRecommendationsClassIAblationisindicatedinpatientswhoareotherwiseatlowriskforSCDandhavesustainedpredominantlymonomorphicVTthatisdrugresistant,whoaredrugintolerant,orwhodonotwishlong-termdrugtherapy(levelofevidence:C)Ablationisindicatedinpatientswithbundle-branchreentrantVT(levelofevidence:C)AblationisindicatedasadjunctivetherapyinpatientswithanICDwhoarereceivingmultipleshocksasaresultofsustainedVTthatisnotmanageablebyreprogrammingorchangingdrugtherapyorwhodonotwishlong-termdrugtherapy(levelofevidence:C)Circ2006CP1323528-2VTAblationClassICVentricularArrhythmiasCP1206111-1“Focal”“Diffuse”O(jiān)utflowtractFascicularSupra-valvularRVLVPurkinjeReentryAnatomictargetMyopathicScarsMitralvalveEPmaneuversP.StimulationEntrainmentImagingElectrophysiologyLesioncreationAnatomyVentricularArrhythmiasCP12061StepsinMappingandAblatingVTUnderlyingcardiacsubstrate,historyIschemicheartdiseaseIdiopathicdilatedcardiomyopathyOthersECGrecognitionoftachycardiaoriginProgrammedstimulation,maneuversResetEntrainmentConcealedentrainmentAdvancedmappingVoltagemappingElectro-anatomicalcorrelationImagingEpicardialapproachOthersStepsinMappingandAblatingConceptsofMappingReentrantVentricularTachycardiaDoublepotentialsScarsScars0.5mV2mVPotentialcircuitsCP1176527-5ConceptsofMappingReentrantVCP1233975-13ECGECGQRSonsetCommonpathway(CP)CP

entranceInnerloopScarOuterloopScarDead-endpathwayCPexitReentrantCircuitandTerminologyCP1233975-13ECGECGQRSCommonpaThisVTcircuitexitsiteislikely:A.LV/anterior/basal/lateralB.LV/posterior/apical/lateralC.LV/posterior/mid/septalD.LV/posterior/apical/septalThisVTcircuitexitsiteislMappingSchemeCrossSectionBaseApexLongitudinalSectionSeptalLateral12693AnteriorPosteriorCP1060083-4ABCDEMappingSchemeCrossSectionBasQRSMorphologyCluestoVTExitSiteV4BaseApexAVRCP1060083-1AVRV4QRSMorphologyCluestoVTExiII,III,aVFQRSMorphologyCluestoVTExitSiteCP1060083-2AnteriorPosteriorII,III,aVFII,III,aVFQRSMorphologyCluQRSMorphologyCluestoVTExitSiteI,aVLSeptalLateralII,III,aVFCP1060083-3QRSMorphologyCluestoVTExiThisVTcircuitexitsiteislikely:A.LV/anterior/basal/lateralB.LV/posterior/apical/lateralC.LV/posterior/mid/septalD.LV/posterior/apical/septal**ThisVTcircuitexitsiteislCP1233975-13ReentrantCircuitandEntrainmentA,B,CEntrainmentwithconcealedfusionPPI=VTCLS-QRS=EGM-QRSS-QRS<70%VTCLD,E*EntrainmentwithconcealedfusionPPI>VTCLS-QRS>EGM-QRSFEntrainmentwithmanifestedfusionPPI=VTCLS-QRS=EGM-QRSGEntrainmentwithmanifestedfusionPPI≠VTCLS-QRS≠

EGM-QRSABCDE*FGCP1233975-13ReentrantCircuitPacingatthissiteismostconsistentwith:PacinginacriticalzoneofslowconductionPacingina“deadendalley”P(pán)acinginanouterloopPacingoutsideofthecircuitNoncaptureABCDWherewasthepacingsiteinrelationshiptothecircuit?PacingatthissiteismostcoPacingatthissiteismostconsistentwith:PacinginacriticalzoneofslowconductionPacingina“deadendalley”P(pán)acinginanouterloopPacingoutsideofthecircuitNoncapture*PacingatthissiteismostcoPacingatthissiteismostconsistentwith:PacinginacriticalzoneofslowconductionPacingina“deadendalley”P(pán)acinginanouterloopPacingoutsideofthecircuitNoncaptureABCDPacingatthissiteismostcoPacingatthissiteismostconsistentwith:PacinginacriticalzoneofslowconductionPacingina“deadendalley”P(pán)acinginanouterloopPacingoutsideofthecircuitNoncapture*PacingatthissiteismostcoPacingatthissiteismostconsistentwith:PacinginacriticalzoneofslowconductionPacingina“deadendalley”P(pán)acinginanouterloopPacingoutsideofthecircuitNoncapturePPITCLABCDPPI=395S-QRS=265VTCL=395E-QRS=265PacingatthissiteismostcoPacingatthissiteismostconsistentwith:PacinginacriticalzoneofslowconductionPacingina“deadendalley”P(pán)acinginanouterloopPacingoutsideofthecircuitNoncapturePPITCL*PPI=395S-QRS=265VTCL=395E-QRS=265PacingatthissiteismostcoTerminationofVTCP1201033-1%0-10n=4611-30n=1831-60n=24>60n=64PPI-VTCL(msec)TerminationofVTCP1201033-1%0CP1270284-4VT#5VT1VT2VT3VT3CP1270284-4VT#5VT1VT2VT3VTCP1270284-17VoltageMapGuidedVTAblationCP1270284-17VoltageMapGuided55year-oldmanwithDCM,EF27%

FrequentICDshocks,failedpreviousablation55year-oldmanwithDCM,EF2LeftVentricularSupportLow-speedcentrifugalcontinuousflowpumpLowbloodsurfaceareacontact21FrLeftatrialcannula19FrfemoralarterialcannulaUpto4L/minFlowThieleetalCirc2001LeftVentricularSupportLow-spInductionofVTonLVSupportInductionofVTonLVSupportEndocardialandEpicardialMappingwithLeftVentricularSupportLAALACannulaEndoEpiEndocardialandEpicardialMapEpicardial

ApproachSchweikertetal.Circulation.2003;108:1329-1335.EduardoSosa,JACC2000EpicardialapproachshowntobefeasibleforVTablationinpatientswithCAD.Complicationseenin4/53patientsinformofRVperforationandtamponade.

Alsoeffectiveforotherarrhythmias(VTwith&withoutSHD,WPW,RVOTVT,AT)especiallywhenendocardialablationunsuccessful.NocomplicationsreportedEpicardial

ApproachSchweikertEndocardialandEpicardialLVAblationMitralValveEndocardialandEpicardialLVReentrymechanismismostcommonResponsetoentrainmentmaneuversdeterminesthecriticalzoneofconductionMultipleVTsandcircuitsarefrequentlypresentVoltage/scarmappingisoftenrequiredEpicardialapproachmayberequiredinselectedpatientsMostpatientsundergo“palliative”VTablationforrecurrentICDshocksVTAblationinScarDependentSubstrateReentrymechanismismostcommGW-ICCHRSJointSymposiumBeijingOct.11,2009GW-ICCHRSJointSymposiumBeijWinK.Shen,M.D.ProfessorofMedicineMayoClinicCollegeofMedicineGW-HRSJointSymposium,Beijing2009CP1063458-1室性心動(dòng)過(guò)速的消融：

何時(shí)進(jìn)行？如何消融？?WinK.Shen,M.D.CP1063458-1室性聲明RelevantFinancialRelationship(s)NoneOffLabelUsageNone聲明RelevantFinancialRelations室性心動(dòng)過(guò)速的機(jī)制折返、拖帶、隱匿性拖帶的基本概念穩(wěn)定的，單形性室速不穩(wěn)定或多折返環(huán)室速高級(jí)方法和技術(shù)內(nèi)容室性心動(dòng)過(guò)速的機(jī)制內(nèi)容CP1323528-2室速消融指南建議I類(lèi)適應(yīng)證持續(xù)單形性室速，藥物無(wú)效或不能耐受或患者不愿意長(zhǎng)期服藥，猝死低?；颊?C)束支折返室速(C)ICD植入后反復(fù)放電，重新程控、調(diào)整用藥均無(wú)效，或不愿意接受長(zhǎng)期藥物治療的患者，導(dǎo)管消融作為輔助治療(C)Circ2006CP1323528-2室速消融I類(lèi)適應(yīng)證Circ2006室性心律失常CP1206111-1“局灶”“多發(fā)性”流出道分支瓣上RVLV普肯野折返解剖靶點(diǎn)心肌病疤痕二尖瓣電生理策略P.刺激拖帶影像電生理?yè)p傷解剖室性心律失常CP1206111-1“局灶”“多發(fā)性”流出道分室速標(biāo)測(cè)和消融步驟潛在的心臟機(jī)制，病史缺血性心臟病特發(fā)性擴(kuò)心病其它根據(jù)心電圖判斷心動(dòng)過(guò)速的起源程序性刺激，方法重整拖帶隱匿性拖帶高級(jí)標(biāo)測(cè)技術(shù)電壓標(biāo)測(cè)電解剖標(biāo)測(cè)影像心外膜標(biāo)測(cè)其它室速標(biāo)測(cè)和消融步驟潛在的心臟機(jī)制，病史標(biāo)測(cè)的概念折返性室速雙電位疤痕Scars0.5mV2mV潛在折返環(huán)CP1176527-5標(biāo)測(cè)的概念折返性室速雙電位疤痕Scars0.5mV2mVCP1233975-13ECGECGQRS起始共同通路(CP)CP

入口內(nèi)環(huán)疤痕外環(huán)疤痕通道盲端CP出口折返環(huán)和相關(guān)術(shù)語(yǔ)CP1233975-13ECGECGQRS起始共同通路(CP該室速折返環(huán)出口位置可能是:A.LV/前壁/基底部/側(cè)壁B.LV/后壁/心尖/側(cè)壁C.LV/后壁中部/間隔部D.LV/后壁/心尖/間隔部該室速折返環(huán)出口位置可能是:標(biāo)測(cè)示意圖橫斷面基地部心尖長(zhǎng)軸切面間隔側(cè)壁12693前壁后壁CP1060083-4ABCDE標(biāo)測(cè)示意圖橫斷面基地部心尖長(zhǎng)軸切面間隔側(cè)壁12693前壁后壁QRS形態(tài)提示室速的出口位置V4基底部心尖AVRCP1060083-1AVRV4QRS形態(tài)提示室速的出口位置V4基底部心尖AVRCP1060II,III,aVFQRS形態(tài)提示室速的出口CP1060083-2前壁后壁II,III,aVFII,III,aVFQRS形態(tài)提示室速的出口CP106QRS形態(tài)提示室速的出口I,aVL間隔部側(cè)壁II,III,aVFCP1060083-3QRS形態(tài)提示室速的出口I,aVL間隔部側(cè)壁II,III該室速的折返環(huán)出口位置可能是:A.LV/前壁/基底部/側(cè)壁B.LV/后壁/心尖/側(cè)壁C.LV/后壁/中部/間隔部D.LV/后壁/心尖l/間隔**該室速的折返環(huán)出口位置可能是:**CP1233975-13折返環(huán)路與拖帶A,B,C拖帶，隱匿融合PPI=VTCLS-QRS=EGM-QRSS-QRS<70%VTCLD,E*拖帶，隱匿融合PPI>VTCLS-QRS>EGM-QRSF拖帶，顯性融合PPI=VTCLS-QRS=EGM-QRSG拖帶，顯性融合PPI≠VTCLS-QRS≠

EGM-QRSABCDE*FGCP1233975-13折返環(huán)路與拖帶A,B,CABCD起搏部位:緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無(wú)奪獲ABCD哪個(gè)位置起搏與折返環(huán)有關(guān)?起搏部位:ABCD哪個(gè)位置起搏與折返環(huán)有關(guān)?起搏部位緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無(wú)奪獲*起搏部位*起搏部位：緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無(wú)奪獲ABCD起搏部位：ABCD起搏部位緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無(wú)奪獲*起搏部位*起搏部位:緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無(wú)奪獲PPITCLABCDPPI=395S-QRS=265VTCL=395E-QRS=265起搏部位:PPITCLABCDPPI=395S-QRS起搏部位:緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無(wú)奪獲PPITCL*PPI=395S-QRS=265VTCL=395E-QRS=265起搏部位:PPITCL*PPI=395S-QRS=2室速終止CP1201033-1%0-10n=4611-30n=1831-60n=24>60n=64PPI-VTCL(msec)室速終止CP1201033-1%0-10n=4611-30nCP1270284-4VT#5VT1VT2VT3VT3CP1270284-4VT#5VT1VT2VT3VTCP1270284-17電壓標(biāo)測(cè)指導(dǎo)的室速消融CP1270284-17電壓標(biāo)測(cè)指導(dǎo)的室速消融男性，55歲，擴(kuò)張型心肌病,EF27%

ICD頻繁放電，既往消融失敗男性，55歲，擴(kuò)張型心肌病,EF27%

ICD頻繁放電左心室輔助裝置Low-speedcentrifugalcontinuousflowpumpLowbloodsurfaceareacontact21FrLeftatrialcannula19FrfemoralarterialcannulaUpto4L/minFlowThieleetalCirc2001左心室輔助裝置Low-speedcentrifugalc左心室支持下誘發(fā)室速左心室支持下誘發(fā)室速左心室輔助支持下心內(nèi)膜及心外膜標(biāo)測(cè)LAALACannulaEndoEpi左心室輔助支持下心內(nèi)膜及心外膜標(biāo)測(cè)LAALAEndoEpi經(jīng)心外膜途徑消融Schweikertetal.Circulation.2003;108:1329-1335.EduardoSosa,JACC2000室速合并冠心病的患者經(jīng)心外膜消融是可行的.53例中發(fā)生了4例右心室穿孔及心臟壓塞

對(duì)其它心律失常亦有效(VT伴或不伴SHD,WPW,RVOTVT,AT)

，尤其是經(jīng)心內(nèi)膜消融失敗的患者無(wú)并發(fā)癥報(bào)道經(jīng)心外膜途徑消融Schweikertetal.Circ左心室心內(nèi)膜和心內(nèi)膜消融MitralValve左心室心內(nèi)膜和心內(nèi)膜消融MitralValve多數(shù)情況下為折返機(jī)制根據(jù)拖帶的反應(yīng)識(shí)別傳導(dǎo)的關(guān)鍵區(qū)域多形性室速和多環(huán)路折返較常見(jiàn)通常需要電壓/把橫標(biāo)測(cè)部分病人可能需要心外膜標(biāo)測(cè)為防止ICD反復(fù)放電，多數(shù)患者應(yīng)接受姑息性VT消融疤痕依賴(lài)基質(zhì)的室速消融多數(shù)情況下為折返機(jī)制疤痕依賴(lài)基質(zhì)的室速消融GW-ICCHRSJointSymposiumBeijingOct.11,2009GW-ICCHRSJointSymposiumBeijWinK.Shen,M.D.ProfessorofMedicineMayoClinicCollegeofMedicineGW-HRSJointSymposium,Beijing2009CP1063458-1VentricularTachycardiaAblation

WhenandHow?WinK.Shen,M.D.CP1063458-1VeDISCLOSURERelevantFinancialRelationship(s)NoneOffLabelUsageNoneDISCLOSURERelevantFinancialRSpectrumofVTmechanismsBasicconceptofreentry,entrainment,andconcealedentrainmentStable,monomorphicVTUnstableVTormultiplecircuitsAdvancedtechnologyandtechniquesObjectivesSpectrumofVTmechanismsObjecCP1323528-2VTAblationRecommendationsClassIAblationisindicatedinpatientswhoareotherwiseatlowriskforSCDandhavesustainedpredominantlymonomorphicVTthatisdrugresistant,whoaredrugintolerant,orwhodonotwishlong-termdrugtherapy(levelofevidence:C)Ablationisindicatedinpatientswithbundle-branchreentrantVT(levelofevidence:C)AblationisindicatedasadjunctivetherapyinpatientswithanICDwhoarereceivingmultipleshocksasaresultofsustainedVTthatisnotmanageablebyreprogrammingorchangingdrugtherapyorwhodonotwishlong-termdrugtherapy(levelofevidence:C)Circ2006CP1323528-2VTAblationClassICVentricularArrhythmiasCP1206111-1“Focal”“Diffuse”O(jiān)utflowtractFascicularSupra-valvularRVLVPurkinjeReentryAnatomictargetMyopathicScarsMitralvalveEPmaneuversP.StimulationEntrainmentImagingElectrophysiologyLesioncreationAnatomyVentricularArrhythmiasCP12061StepsinMappingandAblatingVTUnderlyingcardiacsubstrate,historyIschemicheartdiseaseIdiopathicdilatedcardiomyopathyOthersECGrecognitionoftachycardiaoriginProgrammedstimulation,maneuversResetEntrainmentConcealedentrainmentAdvancedmappingVoltagemappingElectro-anatomicalcorrelationImagingEpicardialapproachOthersStepsinMappingandAblatingConceptsofMappingReentrantVentricularTachycardiaDoublepotentialsScarsScars0.5mV2mVPotentialcircuitsCP1176527-5ConceptsofMappingReentrantVCP1233975-13ECGECGQRSonsetCommonpathway(CP)CP

entranceInnerloopScarOuterloopScarDead-endpathwayCPexitReentrantCircuitandTerminologyCP1233975-13ECGECGQRSCommonpaThisVTcircuitexitsiteislikely:A.LV/anterior/basal/lateralB.LV/posterior/apical/lateralC.LV/posterior/mid/septalD.LV/posterior/apical/septalThisVTcircuitexitsiteislMappingSchemeCrossSectionBaseApexLongitudinalSectionSeptalLateral12693AnteriorPosteriorCP1060083-4ABCDEMappingSchemeCrossSectionBasQRSMorphologyCluestoVTExitSiteV4BaseApexAVRCP1060083-1AVRV4QRSMorphologyCluestoVTExiII,III,aVFQRSMorphologyCluestoVTExitSiteCP1060083-2AnteriorPosteriorII,III,aVFII,III,aVFQRSMorphologyCluQRSMorphologyCluestoVTExitSiteI,aVLSeptalLateralII,III,aVFCP1060083-3QRSMorphologyCluestoVTExiThisVTcircuitexitsiteislikely:A.LV/anterior/basal/lateralB.LV/posterior/apical/lateralC.LV/posterior/mid/septalD.LV/posterior/apical/septal**ThisVTcircuitexitsiteislCP1233975-13ReentrantCircuitandEntrainmentA,B,CEntrainmentwithconcealedfusionPPI=VTCLS-QRS=EGM-QRSS-QRS<70%VTCLD,E*EntrainmentwithconcealedfusionPPI>VTCLS-QRS>EGM-QRSFEntrainmentwithmanifestedfusionPPI=VTCLS-QRS=EGM-QRSGEntrainmentwithmanifestedfusionPPI≠VTCLS-QRS≠

EGM-QRSABCDE*FGCP1233975-13ReentrantCircuitPacingatthissiteismostconsistentwith:PacinginacriticalzoneofslowconductionPacingina“deadendalley”P(pán)acinginanouterloopPacingoutsideofthecircuitNoncaptureABCDWherewasthepacingsiteinrelationshiptothecircuit?PacingatthissiteismostcoPacingatthissiteismostconsistentwith:PacinginacriticalzoneofslowconductionPacingina“deadendalley”P(pán)acinginanouterloopPacingoutsideofthecircuitNoncapture*PacingatthissiteismostcoPacingatthissiteismostconsistentwith:PacinginacriticalzoneofslowconductionPacingina“deadendalley”P(pán)acinginanouterloopPacingoutsideofthecircuitNoncaptureABCDPacingatthissiteismostcoPacingatthissiteismostconsistentwith:PacinginacriticalzoneofslowconductionPacingina“deadendalley”P(pán)acinginanouterloopPacingoutsideofthecircuitNoncapture*PacingatthissiteismostcoPacingatthissiteismostconsistentwith:PacinginacriticalzoneofslowconductionPacingina“deadendalley”P(pán)acinginanouterloopPacingoutsideofthecircuitNoncapturePPITCLABCDPPI=395S-QRS=265VTCL=395E-QRS=265Pacing