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1、起源于心外膜心律失常 的识别与消融,中国医科大学盛京医院 孙英贤,起源于 心外膜 心律失 常包括 哪些？,心外膜旁路 起源于心外膜的室速,Tricuspid Annulus,LAO Projection,Mitral Annulus,LA Connections,RA Connections,LV Connection,LV Connection,Ideal Ablation Site,Epicardial Posteroseptal and Left Posterior Accessory Pathways: Connections Between the CS Myocardial Coa
2、t and the Atria and Left Ventricle,Posterior Coronary Vein,Middle Cardiac Vein,Ideal Ablation site,MCV,Ventricular Connection,Mitral Annulus,Tricuspid Annulus,CS Myocardial Coat,Epicardial Posteroseptal and Left Posterior Accessory Pathways,L A O,R A O,RAA,CS,MCV,PV,LV Map,HB,A,B,HB,LV Map,CS,RAA,MC
3、V,1.2cm,PV,C,CS,RAA,HB,MCV,RV,A,B,RAA,HB,MCV,RV,LAO,RAO,CS,C,Epicardial Accessory Pathways,171 Patients,9,99,1,11,15 (9%),3,18,120 (70%),36 (21%),3,27,Diverticula,Narrow Neck,Wide Neck,Septal to MCV(5/27),Lateral to MCV(22/27),CS,CS,CS,CS,MCV,D,D,D,D,MCV,CS,MCV,SCV,Enlargement of SCV, MCV and CS,15/
4、171 (9%) Pts,Bulbous Enlargement of MCV or CS (3 Patients),Fosiform Enlargement of SCV or MCV (12 pts ),LAO,Atrial Diastole Atrial systole,CS,MCV,PV,Posterior Descending Coronary Artery,Right Coronary Artery,Fig 2,Tricuspid Annulus,Mitral Annulus,LA Connection,RA Connection,Ideal Ablation site,Middl
5、e Cardiac Vein,Location of the Distal Right Coronary Artery Relative to Ideal Ablation Site,Posterior Coronary Vein,Ideal Ablation site,CS Angiography (LAO),RCA Angiography (LAO),LCA Angiography (RAO),CS,D,Ablation,Ablation,A. Before Ablation,B. After Ablation,左前斜位,行选择性冠状动脉造影，该处未见相邻冠状动脉，,心外膜旁路 起源于心外
6、膜的室速,心外膜室速的心电图特征,Pseudo delta wave34ms Intrinsicoid deflection time85ms RS complex duration121msec QRS198ms,Circulation 109:1842-1847,2004.,心外膜室速与基础心脏病,特发性室性心动过速 伴缺血性心脏病 伴扩张性心肌病,心外膜室速的心内电图特征,心内膜标测不到最早激动 心内膜的最早激动分布范围较广 心内膜起搏标测不理想 心内膜处消融不成功,心外膜消融,冠状窦 心外膜 其他(主动脉,心内膜等),心外膜室速的消融方法,后室间静脉内标测电极,心内膜消融电极,心外膜标
7、测电极处隐匿拖带,经冠状静脉系统标测指导心内膜消融,Heart 79:59-63,1998,心外膜消融的激动标测,JICE 2004,10:281-288,心外膜室速的拖带标测,PACE 1999.22:128-130,心外膜消融,冠状窦 心外膜 其他(主动脉,心内膜等),心外膜室速的消融方法,经剑下穿刺心包内标测消融,心外膜拖带标测,JCE 16:449-452,2005,经剑下心外穿刺消融的注意事项,避免冠状动脉操作: 常规行冠脉造影 心外膜脂肪垫影响消融效果: 应用灌注消融 术后合并心包炎: 对症抗炎镇痛 合并膈神经损伤: 消融前高能量起搏,心外膜消融,冠状窦 心外膜 其他(主动脉,心内膜等),小结,心外膜室速多伴有冠脉病变或扩张性心肌病 体表心电图及心内电图的一些特征可以提示存在心外膜室速 经心包途径是消融心外膜室速的最佳方法 心外膜消融前应常规行冠状动脉造影 必要时可行盐水灌注消融,