心律失常發(fā)生機制及導(dǎo)管消融適應(yīng)癥英文

心律失常發(fā)生機制及導(dǎo)管消融適應(yīng)癥英文第1頁/共65頁心律失常發(fā)生機制及導(dǎo)管消融適應(yīng)癥

（ElectrophysiologicalMechanismsofCardiacArrhythmias

andIndicationofRadiofrequencyCatheterAblation)第2頁/共65頁IndicationsforRadiofrequencyCatheterAblationWolff-Parkinson-WhiteSyndrome(WPW)AtrioventricularNodalReentrantTachycardia(AVNRT)AtrialFlutterAtrialFibrillation(AF)VentricularTachycardia(VT)AtrialTachycardia(AT)Others第3頁/共65頁RisksandComplicationsWithRFAblationHypotension-secondarytodrugsorvagalreactionVascularinjuryIschemia/InfarctionVenous/ArterialThrombosisCardiacperforationDamagetotheAVconductionsystemLifethreateningarrhythmias第4頁/共65頁ArrhythmiaMechanismsAutomaticityTriggeredActivityReentry第5頁/共65頁

Automatictachycardia(AT,VT,AF)isidentifiedbythe presenceofthefollowingcharacteristics:CanbeinitiatedbyanisoproterenolinfusionPEScannotinitiateorterminatethetachycradiaCanbegraduallysupressedwithoverdrivepacing,butthen resumeswithagradualincreaseintherateCanbeterminatedbypropranololTheseepisodeshavea“warmup”and/or“cooldown phenomenonCannotbeterminatedbyadenosine,buttransientlyslowsor suppresses,especiallywhenitcanbeinducedwith isoproterenol

(ZipesDP,JalifeJ.CardiacElectrophysiology:Fromcelltobedside,4thedition.2004;pg.500-501)ArrhythmiaMechanisms

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Triggeredactivity(AT,VT,AF)isidentifiedbythe presenceofthefollowingcharacteristics:Triggeredarrhythmiascanbeinitiatedwithrapidpacingor exstrastimulidependantonreachingacertainrangeofpacing cyclelengthsNoentrainmentisobserved,butoverdrivesuppressionor terminationoccursDelayedafterdepolarizationscanberecordedneartheorigin usingamonophasicactionpotentialcatheterbeforetheonset, butnotatsitesremotefromthetachycardiaIsterminatedbyadenosineRarelyrequiresisoproterenoltoinduceitIsterminatedbydipyridamole,propranolol,verapamil, edrophonium,Valsavamaneuversandcarotidsinuspressure

(ZipesDP,JalifeJ.CardiacElectrophysiology:Fromcelltobedside,4thedition.2004;pg.500-501)ArrhythmiaMechanisms

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Microreentry(AT,AVNRT,VT)/Macroreentry (AT,AVRT,AtrialFlutter)isidentifiedbythe presenceofthefollowingcharacteristics:Canbereproduciblyinitiatedandterminatedby pacingandextrastimuliNodelayedafterdepolarizationscanberecordedusing amonophasicactionpotentialcatheterManifestandconcealedentrainmentobservedwhile pacingduringthetachycardiaFrequentlyterminatedbyverapamilandadenosine, butadenosineusuallyhasnoeffectTheintervalbetweentheinitiatingprematurebeatand firstbeatoftheATareinverselyrelated(ZipesDP,JalifeJ.CardiacElectrophysiology:Fromcelltobedside,4thedition.2004;pg.500-501)ArrhythmiaMechanisms

第8頁/共65頁SequenceoftheFlowinaTypicalEPStudyPreparationofthePatientInsertionofsheathsandElectrodecathetersBasicEPSstudytogetthebasicdataInductionoftheArrhythmiaDiagnosisoftheArrhythmiaAblationoftheArrhythmia(ifindicated)ConfirmationofTherapySuccess第9頁/共65頁WPW第10頁/共65頁Occurrenceofdysrhythmias1,2TYPICAL90%ATYPICAL10%AVNRT50%LFW40%RFW30%SEPTAL30%WPW30%CC90%CW10%TYPICAL90%ATYPICAL10%AFLUTTER10%OTHER10%PTS.PRESENTINGWITHSVT2Fitzgerald,etal.,JElectrocardiol.,Vol.29,No.1,Jan.1996,p.1-10.1Fogoros,ElectrophysiologicTesting,2nded.1995,p104-107ANTI10%ORTHO90%第11頁/共65頁WPWtachycardiacircuitsOrthodromicTachycardiaThesetermsareonlyapplicablewhenthepatientisintheirtachycardia,i.e.duringtheintrinsicrhythmthispatientmaybemanifestorconcealed,butduringthetachycardiawedefinethispatientaseitherantidromicororthodromic.Antidromicmeansantegradeconduction(fromtheatriumtoventricle)occursdowntheAPandretrogradeconduction(fromtheventricletotheatrium)upthenormalconductionsystem(AVnode).OrthodromicmeansantegradeconductionoccursdownthenormalconductionsystemandretrogradeconductionuptheAP.AntidromicTachycardia第12頁/共65頁BypassTractLocationsAnywhereexcepthere(fibroustrigone)第13頁/共65頁BypassTractLocations第14頁/共65頁TypesofAccessoryPathwaysA=atriofascicularB=nodofascicularC=nodoventricular*D=fasciculoventricularE=atrioventricular*firstdescribedbyMahaim第15頁/共65頁TypesofAccessoryPathways第16頁/共65頁PreexcitationSyndromesWolff-Parkinson-White“Mahaim”Fibers-nowseparatedinto:AtriofascicularNodoventricularNodofascicularFasciculoventricular第17頁/共65頁Wolff,ParkinsonandWhite,

andtheirSyndromePublishedinAmericanHeartJournalinAugust,1930findingson11patientswithasyndromeofsignsandsymptomsClinicalsignificanceMayconfusephysiciansDeltaWavemaybeinterpretedasaninfarctMarkedpreexcitationinatrialtachycardiasmaylooklikeVTPthasparoxysmsofSVTMaybypasstheprotectivenatureoftheAVnodeandexposetheventriclestoextremelyhighheartrates.Kastor,Arrhythmias,2nded.,2000,p.12Fogoros,ElectrophysiologicTesting,2nded.1995,p132第18頁/共65頁DiagnosisandLocalizationSurfaceleadevaluationUnderstandingBundleBranchBlock“Patterns”asappliedtointerpretingDeltaWavepolarityDeltaWavePolarityinterpretationTheuseofalgorithmsforevaluatingpreexcited12leadsFunctionalBundlebranchblockduringORTElectrophysiologystudyCathetermapping第19頁/共65頁DeltaWavePolarityUsethefirst20-40mSecoftheDeltawavetodeterminepolarityTheQRSusuallyfollowsthepolarityoftheDeltawaveUsealgorithmstolocatetheAPOfprimaryconcern-isthepathwayrightorleftsided?(Transseptalprocedureornot?)DetermineDeltawavepolarityinV1-V1positive=leftsidedV1negative=rightsided第20頁/共65頁ThedeltawaveClinicalmanualofelectrophysiologySingerandCoopersmithch9pg125第21頁/共65頁DeltaWavePolarityFitzpatrick,etal.,JACC,Vol.23,No.1,Jan.1994,p.110第22頁/共65頁Pre-excitationFusionoftheQRSoccursbecausethereissimultaneousconductiondowntheAVnodeandaccessorypathway第23頁/共65頁WPWBaselineNotethepre-excitationasevidencedbythedeltawave,resultinginashortPRintervalDeltaWaveShortPRIntervalNormalECGwithnodeltawaveandanormalPRintervalandQRS第24頁/共65頁Evaluatingapreexcited12lead

LeadsIandaVLIndicatesimpulsetravelasrighttoleft(positive)orlefttoright(negative)LeadsII,III,andaVFIndicateimpulsetravelassuperiortoinferior(positive)orinferiortosuperior(negative)TheQRSaxiswillbedirectedawayfromtheventriclebeingpreexcitedVLeadtransitionHelpsdifferentiateseptalorlateralsites.第25頁/共65頁Algorithm-Arruda(a)Arruda,et.al.,JCEVol9#1Jan1998,pp.2-12第26頁/共65頁Algorithm-Arruda(b)Arruda,et.al.,JCEVol9#1Jan1998,pp.2-12Moreexamples第27頁/共65頁ElectrophysiologystudyGoalsoftheEPstudyIdentifythefunctionandthreatoftheAPLocatetheAPtodetermineapproachforablationMethodsAtrialPacingVentricularPacingCathetermappingAdditionalManeuversPara-HisianpacingPharmacologicconductionblock第28頁/共65頁AtrialpacingInitiatedafterbaselinerecordingsOftenusedwithisoproteronoltoinducetachycardiaandshortenrefractoryperiodsProgressiveAVnodedelayencouragesconductionovertheaccessorypathwayLookfordeltawavetobecomemorenoticeableFindtheantegradeandretrograderefractoryperiodsoftheAVNandAP第29頁/共65頁VentricularPacingLookfortheearliestretrogradeA“Advance”theatriaduringtachycardiaDifferentiatebetweenAVRT,AVNRTandatrialtachycardias.第30頁/共65頁PacedPVCDuring

HisRefractoryPeriod第31頁/共65頁Para-Hisianpacing-

RetroAVNconduction;noBPTNarrowQRSWideQRSHisandVcaptureVcaptureonlyVariableStim-AZipes&Jalife,CardiacElectrophysiology:FromCelltoBedside,2nded,.1995,p.623第32頁/共65頁Para-Hisianpacing-

RetroconductionthroughBPTNarrowQRSWideQRSHisandVcaptureVcaptureonlyFixedStim-AZipes&Jalife,CardiacElectrophysiology:FromCelltoBedside,2nded,.1995,p.623第33頁/共65頁PharmacologicBlockBlockAVnodeconductionwithadenosineorverapamil.ShouldshowcontinuedV-AconductionduringVpacing.Adenosinecanbreaksomenon-WPWtachycardiasAdenosinedoesnotworkineverypatient..第34頁/共65頁房室折返性心動過速（AVRT）適應(yīng)證明確適應(yīng)證：

?反復(fù)發(fā)生AVRT首選射頻消融

?房顫或其他房性心律失常伴旁道前傳所致快速心室率相對適應(yīng)證：

?無關(guān)旁道

第35頁/共65頁AblationObjectives-EliminatetheabnormalconductionPreservethenormalconductionIndicatorsofsuccess-DisappearanceofDeltaWave(inWPWonly)IncreaseinV-AconductiontimeduringVpacing(WPWorconcealedAPs)TachycardianotinducibleCaveats“bumping”thepathwaybeforeablationComplications(A-VblockduringRFofanteroseptalpathways,transseptalrisks,perforation,vascularablation,others)第36頁/共65頁AblationRickerd,TheNewEPTech’sBook,3rded.,

2002,p.102-103Moreexamples第37頁/共65頁AVNRT第38頁/共65頁BasicsofAVNRTMostcommonformofSVTtreatedbyablationMorecommoninfemalesthanmalesOtherwisehealthyindividualsUsuallyadolescenttomid-30's,butcanoccuratanyage,includinginfancy第39頁/共65頁TypesofAVNRTThreeMainTypesTypical;common;usual;slow-fastAtypical;uncommon;unusual;fast-slowSlow-slow

第40頁/共65頁DistributionofTypesofAVNRTKuckKH,CappatoR.CatheterAblationintheYear2000.CurrentOpinioninCardiology2000;15:29-40.第41頁/共65頁AVNRTCircuitThereentrantcircuitinvolvestheFastPathway(FP),whichentersthecompactAVnodefromtheanteriorseptalregionclosetothecompactAVnode,andtheSlowPathway(SP),whichislocatedintheposteriorseptalregion.Thereare3typesofAVNRT.IncommontypeAVNRTantegradeconductionisdowntheSPandretrogradeuptheFP.Intheuncommontype,antegradeconductionisdowntheFPandretrogradeuptheSP.Intheslowslowtype,antegradeconductionisdownoneSP(acertainbundleoffibers)andretrogradeupanotherSP(adifferentbundleoffibers).ForallthreetypesablationisperformedbyablatingtheSP,becauseFPablationhastheriskofcompleteAVblocknecessitatingpacemakerimplantationduetoitscloseproximitytothecompactAVnode.-Dualpathwayphysiology;onefastandoneslow-Typical(common)AVNRT:antegradeslow,retrogradefast-AtypicalAVNRT(uncommon):antegradefast,retrogradeslow-SlowslowAVNRT:antegradecertainslowfibers,retrogradeotherslowfibers-JumpinAHinterval>50msecduringa10msecdecrementinextrastimulustesting第42頁/共65頁Common(Typical)AVNRTIncommonAVNRT,antegradeconductionisdowntheslowpathwayandretrogradeupthefastpathway.Theearliestatrialactivationwouldberecordedintheanteroseptalregionwherethefastpathwayislocated.Alsosinceconductiontotheventricleisdowntheslowpathway,theAHintervalwillbeprolonged.第43頁/共65頁Uncommon(Atypical)AVNRTInuncommonAVNRT,antegradeconductionisdownthefastpathwayandretrogradeuptheslowpathway.Theearliestatrialactivationwouldberecordedintheposteroseptalregionwheretheslowpathwayislocated.Alsosinceconductiontotheventricleisdownthefastpathway,theAHintervalwillbenormal.第44頁/共65頁SlowSlowAVNRTInSlowSlowAVNRT,antegradeconductionisdownsomeslowpathwayfibersandretrogradeupotherslowpathwayfibers.Theearliestatrialactivationwouldberecordedintheposteroseptalregionwheretheslowpathwayislocated.Alsosinceconductiontotheventricleandbacktotheatriumisviatheslowpathway,boththeAH&HAintervalswillbeprolonged.第45頁/共65頁

DualAVNodalPhysiologyPatientswithAVNRTusuallydemonstratedual-nodalphysiology.第46頁/共65頁

DualAVNodalPhysiology

con’tComplexstructureofAVNDisplaysdiscontinuousConductionPropertiesPeri-nodaltissuebehavesfunctionallyastwoparallelpathwaysDifferentiatedbyelectrophysiologicpropertiesExhibitsnon-uniformanisotropicpropertiesBothCapableofAntegradeandretrogradeconductionExhibitslongitudinaldissociationResultsinReentryaround,orwithin,theAVN第47頁/共65頁SlowandFastPathwaysSlowPathwayPerinodaltissuepossessingconductionpropertiesofslowdepolarizationandrelativelyrapidrepolarizationFastPathwayPerinodaltissuepossessingtheconductionpropertiesofrelativelyrapiddepolarizationandrelativelyslowrepolarization第48頁/共65頁

DualAVNodalPhysiology

con’tDualAVnodalphysiology-a“jump”intheA-Hintervalofgreaterthan,orequalto,50msecinresponsetoa10msecdecrementintheS1S2interval;duringatrialextra-stimulustestingastheextra-stimulusisintroduced(decremented).

第49頁/共65頁SinusRhythmwithDominantFastPathwayConduction第50頁/共65頁SinusRhythmwithDominantSlowPathwayConduction第51頁/共65頁CriteriaforA-VNodalSVTcont.TypicalA-VNodalReentryRetrogradeatrialactivationcaudocephalicwithelectrogramintheA-VJunctionearliest(V-A-42to+70msec)RetrogradePwavewithintheQRSwithdistortionofterminalportionoftheQRS.Atrium,Hisbundle,andventriclenotrequiredVagalmanueversslowandthenterminateSVT.

ClinicalCardiacElectrophysiology:techniquesandinterpretations,2nd.Ed..LeaandFebiger,1993.page224第52頁/共65頁

DifferentiateAVNRTfrom:AVRTAVNRTAtrialtachycardiasPJRT

DifferentialDiagnosis第53頁/共65頁DifferentialDiagnosisPVCwhenHisbundleisrefractoryPara-HisianPacingAdenosineAdministrationA-VWenckebachperiodicityorDissociationV-AWenckebachperiodicityordissociation第54頁/共65