房室旁路的射频消融要点.pptVIP

房室旁路的射频消融 中国协和医科大学阜外心血管病医院 临床电生理研究室 楚建民 如何判定左右侧旁路 心律失常的形成机制 旁路的解剖基础 旁路的标测和消融技术 Accessory AV Pathways Symptoms: Range from asymptomatic to sudden cardiac death 症状:无症状到猝死 SVT may be frequent or recurrent SVT频繁发作,表现为心慌、胸闷。 Up to 40% of patients remain asymptomatic 40%无症状 Orthodromic reciprocating tachycardia顺向型 (30% of PSVTs) clinical presentation: Antegrade conduction over AV node房室结前传 Retrograde conduction over accessory pathway旁路逆传 Kay GN. Am J Med. 1996;100:344-345. Wolff-Parkinson-White Syndrome心电图表现 The electrocardiogram may show pre-excitation (delta wave)心电图QRS起始部粗钝形成预激波 If accessory pathway not capable of anterograde conduction, the ECG may not show pre-excitation (concealed pathway) ECG无预激(隐匿性旁路) If accessory pathway capable of rapid antegrade conduction Increased risk to develop VF from rapid conduction of AF房扑发展为室颤 Pre-excitation预激体表心电图 Kay NG. Am J of Med. 1996;10:344-356. WPW: Case Study 病例 18 year old male basketball player 篮球运动员 Presented to ER with: 症状 Multiple episodes of near-syncope 先兆晕厥 Adenosine 12 mg accelerated the heart rate 12mg腺苷心室率加快 Emergency cardioversion performed 紧急电复律 WPW: Case Study ECG旁路前传 Courtesy of Dr. Brian Olshansky. WPW: Case Study Studied in the electrophysiology laboratory 电生理检查 Induced AF ? VF 诱发房扑演化为室扑 Mapping: two pathways双旁路 Posterior septal后间隔 Left lateral accessory pathway游离壁 Ablation of both pathways 消融2条旁路 No additional therapy needed无需药物治疗 AF with Multiple Accessory Pathways房扑 Courtesy of Dr. Brian Olshansky. AF with Multiple Accessory Pathways房扑 Courtesy of Dr. Brian Olshansky. AF ? VF 房扑转为室扑 Courtesy of Dr. Brian Olshansky. 心动过速时的心电图表现 顺向型心动过速心电图特点：QRS后可见P波，RPPR,RP70ms。P波与T波融合，导致T波僵硬、畸形。 逆向型心动过速心电图：宽大QRS心动过速，形态与窦性心律时一致。 左右侧旁路的判定 A型预激：V1预激波和QRS主波向上，旁路位于左心房和左心室之间，即二尖瓣环上。 B型预激：V1预激波和QRS主波向下，旁路位于右心房和右心室之间，即三尖瓣环上。 Posterior Basal View – Left A