器質(zhì)性心臟病室速的消融終點(diǎn)課件

1、器質(zhì)性心臟病室速的消融終點(diǎn)Campus 1Campus 2Campus 3室速的標(biāo)測(cè)心電圖-定位12-導(dǎo)聯(lián)心電圖特點(diǎn)：束支阻滯形態(tài)，電軸，移行部位起搏標(biāo)測(cè):同形態(tài) 定出口激動(dòng)標(biāo)測(cè):定位最早激動(dòng)點(diǎn)/起源點(diǎn)拖帶標(biāo)測(cè):評(píng)價(jià)折返環(huán)激動(dòng)的相互作用與反應(yīng)確定是否位于折返環(huán)內(nèi)基質(zhì)標(biāo)測(cè):定位瘢痕傳導(dǎo)的關(guān)鍵部位與通路器質(zhì)性疤痕相關(guān)VT基質(zhì)標(biāo)測(cè)和消融方法心室程序電刺激誘發(fā)VT/證實(shí)診斷確定疤痕電壓標(biāo)測(cè)電壓標(biāo)測(cè)(0.5-1.5mV)局部電位標(biāo)測(cè)，如晚電位、碎裂電位，消融起搏標(biāo)測(cè)VT出口電不激動(dòng)瘢痕緩慢傳導(dǎo)誘發(fā)VTRV/LV心室程序電刺激驗(yàn)證消融結(jié)果不穩(wěn)定VT可能時(shí)拖帶標(biāo)測(cè)嘗試消融終止竇律時(shí)標(biāo)測(cè)穩(wěn)定VT拖帶標(biāo)測(cè)局部電

2、圖VT時(shí)消融峽部/出口竇律時(shí)消融峽部/出口/電位線性消融Pacing LatencyAblation Through and BetweenLow Voltage AreasPace Mapping at Scar Border to Identify VT Exit Sites and Ablation Just Inside ScarICE GuidanceLVScarScar“Channel Mapping”，LPLBBpossible？ 消融終點(diǎn)：所有的異常電位消融？ 局部異常電位的識(shí)別和消融IIIIIIAVRAVLAVFV1AbldV2V3V4V5V6AblpRVAdStimHisp

3、HisdRVAp171 msAH203 msSinus RhythmRV Pacing 700 msec213 msRV Pacing 600 msecLP的其他特點(diǎn)遞減傳導(dǎo) IIIIIIAVRAVLAVFV1AbldV2V3V4V5V6AblpRVAdStimHispHisdRVApLP的其他特點(diǎn)遞減傳導(dǎo) IIIIIIAVRAVLAVFV1AbldV2V3V4V5V6AblpRVAdStimHispHisdRVApLP的其他特點(diǎn)文氏現(xiàn)象 IIIIIIAVRAVLAVFV1AbldV2V3V4V5V6AblpTimeHispHisdRVAp431 ms431 ms142 ms138 msLP的

4、其他特點(diǎn)局部可進(jìn)行拖帶 技術(shù)與器械進(jìn)步，手段越來越多Jas P et al. Circulation. 2012;125:2184-2196基質(zhì)可以被完全消除？ 消融終點(diǎn)：誘發(fā)？不誘發(fā)？ 誘發(fā)的目的和意義 誘發(fā)方式不完全統(tǒng)一誘發(fā)的臨床室速與非臨床室速意義不同誘發(fā)的室速不一定可以完全消除部分患者無法達(dá)到此消融終點(diǎn)誘發(fā)室速的血流動(dòng)力學(xué)風(fēng)險(xiǎn)室速的電風(fēng)暴風(fēng)險(xiǎn)誘發(fā)為終點(diǎn)存在的問題After ablation was performed in the region of the targeted VT, programmed stimulation was repeated with ventricula

5、r extrastimulus testing at drive cycles of 600 and 400 ms, with decrement by 10 ms until refractoriness or 200 ms, up to 4 extrastimuli at a minimum of 2 sites. If an inducible VT had the same morphology as one seen during the case or was tolerated, it was retargeted.Programmed RV stimulation was re

6、peated after completion of ablation. As before, up to 3 extrastimuli at 2 different RV sites were used to induce VT. If VT was still inducible, additional ablation was performed using the strategy described previously. If the ablated VTs or other sustained monomorphic VT could not be induced even wi

7、th intravenous isoproterenol infusion (up to 10 g/min), the procedure was considered successful.誘發(fā)方式不完全統(tǒng)一Clinical VTs are defined as having a rate within 20 ms and QRS morphology agreeing in bundle-branch block configuration in V1, frontal plane axis, and transition with a spontaneously documented V

8、T. Presumptive clinical VTs had a cycle length within 20 ms of a spontaneous VT, without available complete 12-lead ECGs to compare spontaneous QRS morphology. VTs of shorter cycle lengths were targeted at the discretion of the investigator.重復(fù)誘發(fā)臨床室速定義仍存在不確定性心功能的影響 其他消融終點(diǎn)仍需繼續(xù)探索器質(zhì)性心臟病室速的消融終點(diǎn)誘發(fā)作為消融終點(diǎn)具有極為重要的作用，但是仍然存在