室性心动过速的消融何时进行如何消融WinKShen.pptx

声明声明Relevant Financial Relationship(s)NoneOff Label UsageNone第1页/共64页 室性心动过速的机制室性心动过速的机制 折返、拖带、隐匿性拖带的基本概念折返、拖带、隐匿性拖带的基本概念 稳定的，单形性室速稳定的，单形性室速 不稳定或多折返环室速不稳定或多折返环室速 高级方法和技术高级方法和技术内容内容第2页/共64页CP1323528-2室速消融室速消融室速消融室速消融指南建议指南建议指南建议指南建议I I类适应证类适应证类适应证类适应证 持续单形性室速，药物无效或不能耐受或患者不愿意长期服药，持续单形性室速，药物无效或不能耐受或患者不愿意长期服药，持续单形性室速，药物无效或不能耐受或患者不愿意长期服药，持续单形性室速，药物无效或不能耐受或患者不愿意长期服药，猝死低危患者猝死低危患者猝死低危患者猝死低危患者(C)(C)束支折返室速束支折返室速束支折返室速束支折返室速(C)(C)ICDICD植入后反复放电，重新程控、调整用药均无效，或不愿意接植入后反复放电，重新程控、调整用药均无效，或不愿意接植入后反复放电，重新程控、调整用药均无效，或不愿意接植入后反复放电，重新程控、调整用药均无效，或不愿意接受长期药物治疗的患者，导管消融作为辅助治疗受长期药物治疗的患者，导管消融作为辅助治疗受长期药物治疗的患者，导管消融作为辅助治疗受长期药物治疗的患者，导管消融作为辅助治疗(C)(C)Circ 2006第3页/共64页室性心律失常室性心律失常CP1206111-1“局灶局灶局灶局灶”“多发性多发性多发性多发性”流出道流出道流出道流出道分支分支分支分支瓣上瓣上瓣上瓣上RVRVLVLV普肯普肯普肯普肯野野野野折返折返折返折返解剖靶点解剖靶点解剖靶点解剖靶点心肌病心肌病心肌病心肌病疤痕疤痕疤痕疤痕二尖瓣二尖瓣二尖瓣二尖瓣电生理策略电生理策略电生理策略电生理策略P.P.刺激刺激刺激刺激拖带拖带拖带拖带影像影像影像影像电生理电生理电生理电生理损伤损伤损伤损伤解剖解剖解剖解剖第4页/共64页室速标测和消融步骤室速标测和消融步骤潜在的心脏机制，病史潜在的心脏机制，病史潜在的心脏机制，病史潜在的心脏机制，病史缺血性心脏病缺血性心脏病缺血性心脏病缺血性心脏病特发性扩心病特发性扩心病特发性扩心病特发性扩心病其它其它其它其它根据心电图判断心动过速的起源根据心电图判断心动过速的起源根据心电图判断心动过速的起源根据心电图判断心动过速的起源程序性刺激，方法程序性刺激，方法程序性刺激，方法程序性刺激，方法重整重整重整重整拖带拖带拖带拖带隐匿性拖带隐匿性拖带隐匿性拖带隐匿性拖带高级标测技术高级标测技术高级标测技术高级标测技术电压标测电压标测电压标测电压标测电解剖标测电解剖标测电解剖标测电解剖标测影像影像影像影像心外膜标测心外膜标测心外膜标测心外膜标测其它其它其它其它第5页/共64页标测的概念标测的概念折返性室速折返性室速双电位双电位疤痕疤痕Scars0.5 mV2 mV潜在折返环潜在折返环CP1176527-5第6页/共64页CP1233975-13ECGECGECGECGECGECGQRSQRSQRS起始起始起始起始起始起始共同通路共同通路共同通路共同通路共同通路共同通路(CP)(CP)(CP)CPCPCP入口入口入口入口入口入口内环内环内环内环内环内环疤痕疤痕疤痕疤痕疤痕疤痕外环外环外环外环外环外环疤痕疤痕疤痕疤痕疤痕疤痕通道盲端通道盲端通道盲端通道盲端通道盲端通道盲端CP CP CP 出口出口出口出口出口出口折返环和相关术语折返环和相关术语折返环和相关术语折返环和相关术语第7页/共64页该室速折返环出口位置可能是该室速折返环出口位置可能是:A.LV/A.LV/前壁前壁前壁前壁/基底部基底部基底部基底部/侧壁侧壁侧壁侧壁B.LV/B.LV/后壁后壁后壁后壁/心尖心尖心尖心尖/侧壁侧壁侧壁侧壁C.LV/C.LV/后壁中部后壁中部后壁中部后壁中部/间隔部间隔部间隔部间隔部D.LV/D.LV/后壁后壁后壁后壁/心尖心尖心尖心尖/间隔部间隔部间隔部间隔部第8页/共64页标测示意图标测示意图横断面横断面横断面横断面基地部基地部基地部基地部心尖心尖心尖心尖长轴切面长轴切面长轴切面长轴切面间隔间隔间隔间隔侧壁侧壁侧壁侧壁12126 69 93 3前壁前壁前壁前壁后壁后壁后壁后壁CP1060083-4A AB BC CD DE E第9页/共64页QRS形态提示室速的出口位置形态提示室速的出口位置V4V4基底部基底部基底部基底部心尖心尖心尖心尖AVRAVRCP1060083-1AVRV4第10页/共64页II,III,aVFII,III,aVFQRS 形态提示室速的出口形态提示室速的出口CP1060083-2前壁前壁前壁前壁后壁后壁后壁后壁II,III,aVFII,III,aVF第11页/共64页QRS形态提示室速的出口形态提示室速的出口I,aVLI,aVL间隔部间隔部间隔部间隔部侧壁侧壁侧壁侧壁II,III,aVFII,III,aVFCP1060083-3第12页/共64页该室速的折返环出口位置可能是该室速的折返环出口位置可能是:A.LV/A.LV/前壁前壁前壁前壁/基底部基底部基底部基底部/侧壁侧壁侧壁侧壁B.LV/B.LV/后壁后壁后壁后壁/心尖心尖心尖心尖/侧壁侧壁侧壁侧壁C.LV/C.LV/后壁后壁后壁后壁/中部中部中部中部/间隔部间隔部间隔部间隔部D.LV/D.LV/后壁后壁后壁后壁/心尖心尖心尖心尖l/l/间隔间隔间隔间隔*第13页/共64页CP1233975-13折返环路与拖带折返环路与拖带折返环路与拖带折返环路与拖带A,B,C拖带，隐匿融合拖带，隐匿融合 PPI=VTCL S-QRS=EGM-QRS S-QRS VTCL S-QRS EGM-QRSF拖带，显性融合拖带，显性融合 PPI=VTCL S-QRS=EGM-QRSG拖带，显性融合拖带，显性融合 PPI VTCL S-QRS EGM-QRSABCDE*FG第14页/共64页起搏部位起搏部位:A.缓慢传导的关键部位起搏缓慢传导的关键部位起搏B.在通道盲端起搏在通道盲端起搏C.在外环起搏在外环起搏D.环外起搏环外起搏E.无夺获无夺获ABCD哪个位置起搏与折返环有关哪个位置起搏与折返环有关?第15页/共64页起搏部位起搏部位A.缓慢传导的关键部位起搏缓慢传导的关键部位起搏B.在通道盲端起搏在通道盲端起搏C.在外环起搏在外环起搏D.环外起搏环外起搏E.无夺获无夺获*第16页/共64页起搏部位：起搏部位：A.缓慢传导的关键部位起搏缓慢传导的关键部位起搏B.在通道盲端起搏在通道盲端起搏C.在外环起搏在外环起搏D.环外起搏环外起搏E.无夺获无夺获ABCD第17页/共64页起搏部位起搏部位A.缓慢传导的关键部位起搏缓慢传导的关键部位起搏B.在通道盲端起搏在通道盲端起搏C.在外环起搏在外环起搏D.环外起搏环外起搏E.无夺获无夺获*第18页/共64页起搏部位起搏部位:A.缓慢传导的关键部位起搏缓慢传导的关键部位起搏B.在通道盲端起搏在通道盲端起搏C.在外环起搏在外环起搏D.环外起搏环外起搏E.无夺获无夺获PPITCLABCDPPI=395S-QRS=265VTCL=395E-QRS=265第19页/共64页起搏部位起搏部位:A.缓慢传导的关键部位起搏缓慢传导的关键部位起搏B.在通道盲端起搏在通道盲端起搏C.在外环起搏在外环起搏D.环外起搏环外起搏E.无夺获无夺获PPITCL*PPI=395S-QRS=265VTCL=395E-QRS=265第20页/共64页室速终止室速终止CP1201033-1%0-100-100-10n=46n=46n=4611-3011-3011-30n=18n=18n=1831-6031-6031-60n=24n=24n=24606060n=64n=64n=64PPI-VTCL(msec)PPI-VTCL(msec)PPI-VTCL(msec)第21页/共64页CP1270284-4VT#5VT 1VT 2VT 3VT 3第22页/共64页CP1270284-17电压标测指导的室速消融电压标测指导的室速消融第23页/共64页男性，男性，男性，男性，55 55 岁，扩张型心肌病岁，扩张型心肌病岁，扩张型心肌病岁，扩张型心肌病,EF 27%,EF 27%ICDICD频繁放电，既往消融失败频繁放电，既往消融失败频繁放电，既往消融失败频繁放电，既往消融失败第24页/共64页左心室辅助装置左心室辅助装置Low-speed Low-speed centrifugal centrifugal continuous flow continuous flow pump pump Low blood surface Low blood surface area contact area contact 21 Fr Left atrial 21 Fr Left atrial cannulacannula19 Fr femoral 19 Fr femoral arterial cannulaarterial cannulaUp to 4L/min FlowUp to 4L/min FlowThiele et al Circ 2001第25页/共64页左心室支持下诱发室速左心室支持下诱发室速第26页/共64页左心室辅助支持下心内膜及心外膜标测左心室辅助支持下心内膜及心外膜标测LAALACannulaEndoEpi第27页/共64页经心外膜途径消融经心外膜途径消融Schweikert et al.Circulation.2003;108:1329-1335.Eduardo Sosa,JACC 2000 室速合并冠心病的患者经心外膜消融是可行的室速合并冠心病的患者经心外膜消融是可行的室速合并冠心病的患者经心外膜消融是可行的室速合并冠心病的患者经心外膜消融是可行的.5353例中发生了例中发生了例中发生了例中发生了4 4例右心室穿孔及心脏压塞例右心室穿孔及心脏压塞例右心室穿孔及心脏压塞例右心室穿孔及心脏压塞 对其它心律失常亦有效对其它心律失常亦有效对其它心律失常亦有效对其它心律失常亦有效(VT(VT 伴或不伴伴或不伴SHD,WPW,RVOT SHD,WPW,RVOT VT,AT)VT,AT)，尤其是经心内膜消融失败的患者，尤其是经心内膜消融失败的患者，尤其是经心内膜消融失败的患者，尤其是经心内膜消融失败的患者 无并发症报道无并发症报道无并发症报道无并发症报道第28页/共64页左心室心内膜和心内膜消融左心室心内膜和心内膜消融Mitral Valve第29页/共64页 多数情况下为折返机制多数情况下为折返机制 根据拖带的反应识别传导的关键区域根据拖带的反应识别传导的关键区域 多形性室速和多环路折返较常见多形性室速和多环路折返较常见 通常需要电压通常需要电压/把横标测把横标测 部分病人可能需要心外膜标测部分病人可能需要心外膜标测 为防止为防止ICDICD反复放电，多数患者应接受姑息性反复放电，多数患者应接受姑息性VTVT消消融融疤痕依赖基质的室速消融疤痕依赖基质的室速消融第30页/共64页GW-ICC HRS Joint SymposiumBeijingBeijingOct.11,2009Oct.11,2009第31页/共64页Win K.Shen,M.D.Win K.Shen,M.D.Professor of MedicineProfessor of MedicineMayo Clinic College of MedicineMayo Clinic College of MedicineGW-HRS Joint Symposium,Beijing 2009GW-HRS Joint Symposium,Beijing 2009CP1063458-1Ventricular Tachycardia Ablation When and How?第32页/共64页DISCLOSUREDISCLOSURERelevant Financial Relationship(s)Relevant Financial Relationship(s)NoneNoneOff Label UsageOff Label UsageNoneNone第33页/共64页Spectrum of VT mechanismsSpectrum of VT mechanismsBasic concept of reentry,entrainment,and concealed entrainment Basic concept of reentry,entrainment,and concealed entrainment Stable,monomorphic VTStable,monomorphic VTUnstable VT or multiple circuitsUnstable VT or multiple circuitsAdvanced technology and techniquesAdvanced technology and techniquesObjectivesObjectives第34页/共64页CP1323528-2VT AblationVT AblationRecommendationsRecommendationsClass IClass I Ablation is indicated in patients who are otherwise at low Ablation is indicated in patients who are otherwise at low risk for SCD and have sustained predominantly risk for SCD and have sustained predominantly monomorphic VT that is drug resistant,who are drug monomorphic VT that is drug resistant,who are drug intolerant,or who do not wish long-term drug therapy intolerant,or who do not wish long-term drug therapy(level of evidence:C)(level of evidence:C)Ablation is indicated in patients with bundle-branch Ablation is indicated in patients with bundle-branch reentrant VT(level of evidence:C)reentrant VT(level of evidence:C)Ablation is indicated as adjunctive therapy in patients with Ablation is indicated as adjunctive therapy in patients with an ICD who are receiving multiple shocks as a result of an ICD who are receiving multiple shocks as a result of sustained VT that is not manageable by reprogramming or sustained VT that is not manageable by reprogramming or changing drug therapy or who do not wish long-term drug changing drug therapy or who do not wish long-term drug therapy(level of evidence:C)therapy(level of evidence:C)Circ 2006第35页/共64页Ventricular ArrhythmiasVentricular ArrhythmiasCP1206111-1“Focal”Focal”“Diffuse”Diffuse”Outflow tractOutflow tractFascicularFascicularSupra-valvularSupra-valvularRVRVLVLVPurkinjePurkinjeReentryReentryAnatomic targetAnatomic targetMyopathicMyopathicScarsScarsMitral valveMitral valveEP maneuversEP maneuversP.StimulationP.StimulationEntrainmentEntrainmentImagingImagingElectrophysiologyElectrophysiologyLesion creationLesion creationAnatomyAnatomy第36页/共64页Steps in Mapping and Ablating VT Steps in Mapping and Ablating VT Underlying cardiac substrate,historyUnderlying cardiac substrate,historyIschemic heart disease Ischemic heart disease Idiopathic dilated cardiomyopathyIdiopathic dilated cardiomyopathyOthersOthersECG recognition of tachycardia originECG recognition of tachycardia originProgrammed stimulation,maneuversProgrammed stimulation,maneuversResetResetEntrainmentEntrainmentConcealed entrainmentConcealed entrainmentAdvanced mappingAdvanced mappingVoltage mapping Voltage mapping Electro-anatomical correlationElectro-anatomical correlationImagingImagingEpicardial approachEpicardial approachOthersOthers第37页/共64页Concepts of MappingConcepts of MappingReentrant Ventricular TachycardiaDoublepotentialsScarsScars0.5 mV2 mVPotentialcircuitsCP1176527-5第38页/共64页CP1233975-13ECGECGECGECGECGECGQRSQRSQRSonsetonsetonsetCommon pathwayCommon pathwayCommon pathway(CP)(CP)(CP)CPCPCPentranceentranceentranceInner loopInner loopInner loopScarScarScarOuter loopOuter loopOuter loopScarScarScarDead-endDead-endDead-endpathwaypathwaypathwayCP exitCP exitCP exitReentrant Circuit and TerminologyReentrant Circuit and Terminology第39页/共64页This VT circuit exit site is likely:This VT circuit exit site is likely:A.LV/anterior/basal/lateralA.LV/anterior/basal/lateralB.LV/posterior/apical/lateralB.LV/posterior/apical/lateralC.LV/posterior/mid/septalC.LV/posterior/mid/septalD.LV/posterior/apical/septalD.LV/posterior/apical/septal第40页/共64页Mapping SchemeMapping SchemeCross SectionCross SectionBaseBaseApexApexLongitudinal SectionLongitudinal SectionSeptalSeptalLateralLateral12126 69 93 3AnteriorAnteriorPosteriorPosteriorCP1060083-4A AB BC CD DE E第41页/共64页QRS Morphology Clues to VT Exit SiteQRS Morphology Clues to VT Exit SiteV4V4BaseBaseApexApexAVRAVRCP1060083-1AVRV4第42页/共64页II,III,aVFII,III,aVFQRS Morphology Clues to VT Exit SiteQRS Morphology Clues to VT Exit SiteCP1060083-2AnteriorAnteriorPosteriorPosteriorII,III,aVFII,III,aVF第43页/共64页QRS Morphology Clues to VT Exit SiteQRS Morphology Clues to VT Exit SiteI,aVLI,aVLSeptalSeptalLateralLateralII,III,aVFII,III,aVFCP1060083-3第44页/共64页This VT circuit exit site is likely:This VT circuit exit site is likely:A.LV/anterior/basal/lateralA.LV/anterior/basal/lateralB.LV/posterior/apical/lateralB.LV/posterior/apical/lateralC.LV/posterior/mid/septalC.LV/posterior/mid/septalD.LV/posterior/apical/septalD.LV/posterior/apical/septal*第45页/共64页CP1233975-13Reentrant Circuit and EntrainmentReentrant Circuit and EntrainmentA,B,CEntrainment with concealed fusion PPI=VTCL S-QRS=EGM-QRS S-QRS VTCL S-QRS EGM-QRSFEntrainment with manifested fusion PPI=VTCL S-QRS=EGM-QRSGEntrainment with manifested fusion PPI VTCL S-QRS EGM-QRSABCDE*FG第46页/共64页Pacing at this site is most consistent with:A.Pacing in a critical zone of slow conductionB.Pacing in a“dead end alley”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non captureABCDWhere was the pacing site in relationship to the circuit?第47页/共64页Pacing at this site is most consistent with:A.Pacing in a critical zone of slow conductionB.Pacing in a“dead end alley”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non capture*第48页/共64页Pacing at this site is most consistent with:A.Pacing in a critical zone of slow conductionB.Pacing in a“dead end alley”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non captureABCD第49页/共64页Pacing at this site is most consistent with:A.Pacing in a critical zone of slow conductionB.Pacing in a“dead end alley”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non capture*第50页/共64页Pacing at this site is most consistent with:A.Pacing in a critical zone of slow conductionB.Pacing in a“dead end alley”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non capturePPITCLABCDPPI=395S-QRS=265VTCL=395E-QRS=265第51页/共64页Pacing at this site is most consistent with:A.Pacing in a critical zone of slow conductionB.Pacing in a“dead end alley”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non capturePPITCL*PPI=395S-QRS=265VTCL=395E-QRS=265第52页/共64页Termination of VTTermination of VTCP1201033-1%0-100-100-10n=46n=46n=4611-3011-3011-30n=18n=18n=1831-6031-6031-60n=24n=24n=24606060n=64n=64n=64PPI-VTCL(msec)PPI-VTCL(msec)PPI-VTCL(msec)第53页/共64页CP1270284-4VT#5VT 1VT 2VT 3VT 3第54页/共64页CP1270284-17Voltage Map Guided VT Ablation第55页/共64页55 year-old man with DCM,EF 27%55 year-old man with DCM,EF 27%Frequent ICD shocks,failed previous ablationFrequent ICD shocks,failed previous ablation第56页/共64页Left Ventricular SupportLeft Ventricular Support Low-speed Low-speed centrifugal centrifugal continuous flow continuous flow pump pump Low blood Low blood surface area surface area contact contact 21 Fr Left atrial 21 Fr Left atrial cannulacannula 19 Fr femoral 19 Fr femoral arterial cannulaarterial cannula Up to 4L/min Up to 4L/min FlowFlowThiele et al Circ 2001第57页/共64页Induction of VT on LV SupportInduction of VT on LV Support第58页/共64页Endocardial and Epicardial Mapping Endocardial and Epicardial Mapping with Left Ventricular Supportwith Left Ventricular SupportLAALACannulaEndoEpi第59页/共64页Epicardial ApproachSchweikert et al.Circulation.2003;108:1329-1335.Eduardo Sosa,JACC 2000Epicardial approach shown to be feasible for VT ablation in patients with CAD.Complication seen in 4/53 patients in form of RV perforation and tamponade.Also effective for other arrhythmias(VT with&without SHD,WPW,RVOT VT,AT)especially when endocardial ablation unsuccessful.No complications reported第60页/共64页Endocardial and Epicardial LV Endocardial and Epicardial LV AblationAblationMitral Valve第61页/共64页 Reentry mechanism is most commonReentry mechanism is most common Response to entrainment maneuvers Response to entrainment maneuvers determines the critical zone of conductiondetermines the critical zone of conduction Multiple VTs and circuits are frequently presentMultiple VTs and circuits are frequently present Voltage/scar mapping is often required Voltage/scar mapping is often required Epicardial approach may be required in Epicardial approach may be required in selected patientsselected patients Most patients undergo“palliative”VT ablation Most patients undergo“palliative”VT ablation for recurrent ICD shocks for recurrent ICD shocks VT Ablation in Scar Dependent SubstrateVT Ablation in Scar Dependent Substrate第62页/共64页GW-ICC HRS Joint SymposiumBeijingBeijingOct.11,2009Oct.11,2009第63页/共64页感谢您的观看！第64页/共64页