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1、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 recurrentSVT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
2、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 ca
3、pable 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 conductionIncreased 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
4、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 electrophysio
5、logy 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,Cour
6、tesy 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，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 Atrium左心房后面观,R. s
7、uperior pulmonary vein,R. inferior pulmonary vein,Coronary sinus,L. inferior pulmonary vein,L. atrium,L. superior pulmonary vein,L. auricle,L. pulmonary artery,R. pulmonary artery,Netter F. Atlas of Human Anatomy. 1989;Plate 202.,A型预激心电图,A型预激窦性心律时心内图,A型预激心动过速时心电图,心内图,左侧旁路靶点图,成功后靶点图,A型预激,心室起搏诱发心动过速,窦
8、性心律靶点图,B型预激,心动过速时心内图,B型预激,Orthodromic Reciprocating Tachycardia 顺向型,Kay NG. Am J of Med. 1996;10:344-356.,旁路形成的心律失常,旁路逆传，房室结前传:顺向型心动过速旁路前传:房扑房颤时旁路前传导致：室速/室颤；阵发性心动过速时旁路前传：逆向型心动过速,顺向型AVRT形成机制,逆向型房室折返性心动过速形成机制,B型预激心内图,心动过速,另一种形态心动过速,左侧旁路参与,第3种形态,所有旁路消融后心电图,旁路的性质,Kent束：全和无 普通旁路、慢旁路 ATP无影响Mahim纤维：无逆传 只有前
9、向递减性传导,房室旁路解剖示意图,Catheter Placement for Ablation of Left Free-Wall Accessory Pathway 左侧旁路导管放置,Morady F. N Engl J of Med. 1999;340:534-544.,Accessory AV Pathways,Location:Right free-wall 右游离壁 部位Septal accessory pathways间隔部Left free-wall左游离壁Approach:Venous, transseptal or retrograde aortic途径 静脉,穿间隔,主动
10、脉逆行Efficacy89-99%疗效Highest left-sided pathways 左侧旁路高Lower septal and right-sided pathways 右侧旁路低Recurrence 3-9%复发率,Morady F. N Engl J of Med. 1999;340:534-544.,旁路的标测,旁路前传时:V波最早旁路逆传时:A波最早,房室旁路的射频消融(右侧),左侧旁路的旁路电位,隐匿性旁路的旁路电位,不同部位旁路的特点,左前旁路:靠近左心耳，导管难以到位靶点AV之比1:1左后间隔旁路:A波变化大，导管容易移位，靠近房室结右后间隔旁路：注意心中静脉的可能性；左侧消融右游离壁旁路：导管贴靠的问题右前间隔旁路：靠近希氏束；不要轻易放电；能量滴定；小功率长时间。,间隔部旁路、房速、双径路的鉴别诊断,临床表现心电图表现电生理检查心动过速心内图表现ATP反应标测,
