室性心動過速的消融何時進(jìn)行？如何消融？winkshen

1、Win K. Shen, M.D.Professor of MedicineMayo Clinic College of MedicineGW-HRS Joint Symposium, Beijing 2009,CP1063458-1,室性心動過速的消融： 何時進(jìn)行？如何消融？?,聲明,Relevant Financial Relationship(s)NoneOff Label UsageNone,室性心動過速的機(jī)

2、制折返、拖帶、隱匿性拖帶的基本概念穩(wěn)定的，單形性室速不穩(wěn)定或多折返環(huán)室速高級方法和技術(shù),,內(nèi)容,CP1323528-2,室速消融指南建議,I類適應(yīng)證持續(xù)單形性室速，藥物無效或不能耐受或患者不愿意長期服藥，猝死低?；颊?C)束支折返室速 (C)ICD植入后反復(fù)放電，重新程控、調(diào)整用藥均無效，或不愿意接受長期藥物治療的患者，導(dǎo)管消融作為輔助治療 (C),Circ 2006,,,,室性心律失常,CP1206111-1,“局灶”

3、,“多發(fā)性”,流出道,分支,瓣上,RV,LV,普肯野,折返,解剖靶點(diǎn),心肌病,疤痕,二尖瓣,電生理策略,P. 刺激,拖帶,,,,室速標(biāo)測和消融步驟,潛在的心臟機(jī)制，病史缺血性心臟病特發(fā)性擴(kuò)心病其它根據(jù)心電圖判斷心動過速的起源程序性刺激，方法重整拖帶隱匿性拖帶高級標(biāo)測技術(shù)電壓標(biāo)測電解剖標(biāo)測影像心外膜標(biāo)測其它,標(biāo)測的概念,折返性室速,雙電位,,疤痕,,Scars,0.5 mV,2 mV,,,,潛在折返環(huán),,,,,

4、,,,,,,,,,,,,,CP1176527-5,CP1233975-13,ECG,ECG,QRS起始,共同通路(CP),CP入口,內(nèi)環(huán),疤痕,外環(huán),疤痕,通道盲端,,,,CP 出口,折返環(huán)和相關(guān)術(shù)語,,該室速折返環(huán)出口位置可能是:A. LV/前壁/基底部/側(cè)壁B. LV/后壁/心尖/側(cè)壁C. LV/后壁中部/間隔部D. LV/后壁/心尖/間隔部,標(biāo)測示意圖,橫斷面,基地部,心尖,長軸切面,間隔,側(cè)壁,12,6,9,3

5、,前壁,后壁,CP1060083-4,A,,B,,,,,C,D,E,QRS形態(tài)提示室速的出口位置,V4,基底部,心尖,AVR,,CP1060083-1,,AVR,V4,II, III, aVF,QRS 形態(tài)提示室速的出口,CP1060083-2,前壁,后壁,,II, III, aVF,QRS形態(tài)提示室速的出口,I, aVL,間隔部,側(cè)壁,II, III, aVF,CP1060083-3,,,該室速的折返環(huán)出口位置可能是:A. LV/

6、前壁/基底部/側(cè)壁B. LV/后壁/心尖/側(cè)壁C. LV/后壁/中部/間隔部D. LV/后壁/心尖l/間隔,,,,*,*,CP1233975-13,折返環(huán)路與拖帶,A, B, C拖帶，隱匿融合 PPI = VTCL S-QRS = EGM-QRS S-QRS VTCL S-QRS > EG

7、M-QRSF拖帶，顯性融合 PPI = VTCL S-QRS = EGM-QRSG拖帶，顯性融合 PPI ≠ VTCL S-QRS ≠ EGM-QRS,A,B,C,,D,E*,F,G,起搏部位:緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無奪獲,,A,B,C,D,哪個位置起搏與折返環(huán)有關(guān)?,起搏部位

8、緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無奪獲,,*,起搏部位：緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無奪獲,,A,B,C,D,起搏部位緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無奪獲,,*,起搏部位:緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起搏在外環(huán)起搏環(huán)外起搏無奪獲,,,PPI,TCL,A,B,C,D,起搏部位:緩慢傳導(dǎo)的關(guān)鍵部位起搏在通道盲端起

9、搏在外環(huán)起搏環(huán)外起搏無奪獲,,,PPI,TCL,*,室速終止,CP1201033-1,,%,0-10,n=46,11-30,n=18,31-60,n=24,>60,n=64,PPI-VTCL (msec),CP1270284-4,VT #5,,,,VT 1,VT 2,VT 3,VT 3,CP1270284-17,電壓標(biāo)測指導(dǎo)的室速消融,男性，55 歲，擴(kuò)張型心肌病, EF 27%ICD頻繁放電，既往消融失敗,左心室輔助裝置

10、,Low-speed centrifugal continuous flow pump Low blood surface area contact 21 Fr Left atrial cannula19 Fr femoral arterial cannulaUp to 4L/min Flow,Thiele et al Circ 2001,左心室支持下誘發(fā)室速,左心室輔助支持下心內(nèi)膜及心外膜標(biāo)測,LAA,,LACannula,

11、,經(jīng)心外膜途徑消融,Schweikert et al. Circulation. 2003;108:1329-1335.,Eduardo Sosa, JACC 2000,室速合并冠心病的患者經(jīng)心外膜消融是可行的.53例中發(fā)生了4例右心室穿孔及心臟壓塞對其它心律失常亦有效(VT 伴或不伴SHD, WPW, RVOT VT, AT) ，尤其是經(jīng)心內(nèi)膜消融失敗的患者無并發(fā)癥報道,左心室心內(nèi)膜和心內(nèi)膜消融,Mitral Valve,多數(shù)

12、情況下為折返機(jī)制根據(jù)拖帶的反應(yīng)識別傳導(dǎo)的關(guān)鍵區(qū)域多形性室速和多環(huán)路折返較常見通常需要電壓/把橫標(biāo)測部分病人可能需要心外膜標(biāo)測為防止ICD反復(fù)放電，多數(shù)患者應(yīng)接受姑息性VT消融,疤痕依賴基質(zhì)的室速消融,Win K. Shen, M.D.Professor of MedicineMayo Clinic College of MedicineGW-HRS Joint Symposium, Beijing 2009,CP106

13、3458-1,Ventricular Tachycardia Ablation When and How?,DISCLOSURE,Relevant Financial Relationship(s)NoneOff Label UsageNone,Spectrum of VT mechanismsBasic concept of reentry, entrainment, and concealed entrainment

14、Stable, monomorphic VTUnstable VT or multiple circuitsAdvanced technology and techniques,,Objectives,CP1323528-2,VT AblationRecommendations,Class IAblation is indicated in patients who are otherwise at low risk for

15、SCD and have sustained predominantly monomorphic VT that is drug resistant, who are drug intolerant, or who do not wish long-term drug therapy (level of evidence: C)Ablation is indicated in patients with bundle-branch r

16、eentrant VT (level of evidence: C)Ablation is indicated as adjunctive therapy in patients with an ICD who are receiving multiple shocks as a result of sustained VT that is not manageable by reprogramming or changing dru

17、g therapy or who do not wish long-term drug therapy (level of evidence: C),Circ 2006,,,,Ventricular Arrhythmias,CP1206111-1,“Focal”,“Diffuse”,Outflow tract,Fascicular,Supra-valvular,RV,LV,Purkinje,Reentry,Anatomic target

18、,Myopathic,Scars,Mitral valve,EP maneuvers,P. Stimulation,Entrainment,,,,Steps in Mapping and Ablating VT,Underlying cardiac substrate, historyIschemic heart disease Idiopathic dilated cardiomyopathyOthersECG recogn

19、ition of tachycardia originProgrammed stimulation, maneuversResetEntrainmentConcealed entrainmentAdvanced mappingVoltage mapping Electro-anatomical correlationImagingEpicardial approachOthers,Concepts of Mappin

20、g,Reentrant Ventricular Tachycardia,Doublepotentials,,Scars,,Scars,0.5 mV,2 mV,,,,Potentialcircuits,,,,,,,,,,,,,,,,,,CP1176527-5,CP1233975-13,ECG,ECG,QRSonset,Common pathway(CP),CPentrance,Inner loop,Scar,Outer loop

21、,Scar,Dead-endpathway,,,,CP exit,Reentrant Circuit and Terminology,,This VT circuit exit site is likely:A. LV/anterior/basal/lateralB. LV/posterior/apical/lateralC. LV/posterior/mid/septalD. LV/posterior/apical/

22、septal,Mapping Scheme,Cross Section,Base,Apex,Longitudinal Section,Septal,Lateral,12,6,9,3,Anterior,Posterior,CP1060083-4,A,,B,,,,,C,D,E,QRS Morphology Clues to VT Exit Site,V4,Base,Apex,AVR,,CP1060083-1,,AVR,V4,II, III,

23、 aVF,QRS Morphology Clues to VT Exit Site,CP1060083-2,Anterior,Posterior,,II, III, aVF,QRS Morphology Clues to VT Exit Site,I, aVL,Septal,Lateral,II, III, aVF,CP1060083-3,,,This VT circuit exit site is likely:A. LV/ant

24、erior/basal/lateralB. LV/posterior/apical/lateralC. LV/posterior/mid/septalD. LV/posterior/apical/septal,,,,*,*,CP1233975-13,Reentrant Circuit and Entrainment,A, B, CEntrainment with concealed fusion

25、 PPI = VTCL S-QRS = EGM-QRS S-QRS VTCL S-QRS > EGM-QRSFEntrainment with manifested fusion PPI = VTCL S-QRS = EGM-QRSGEntrainment with ma

26、nifested fusion PPI ≠ VTCL S-QRS ≠ EGM-QRS,A,B,C,,D,E*,F,G,Pacing at this site is most consistent with:Pacing in a critical zone of slow conductionPacing in a “dead end alley”Pacing in an

27、 outer loopPacing outside of the circuitNon capture,,A,B,C,D,Where was the pacing site in relationship to the circuit?,Pacing at this site is most consistent with:Pacing in a critical zone of slow conductionPacing i

28、n a “dead end alley”Pacing in an outer loopPacing outside of the circuitNon capture,,*,Pacing at this site is most consistent with:Pacing in a critical zone of slow conductionPacing in a “dead end alley”Pacing in

29、an outer loopPacing outside of the circuitNon capture,,A,B,C,D,Pacing at this site is most consistent with:Pacing in a critical zone of slow conductionPacing in a “dead end alley”Pacing in an outer loopPacing outs

30、ide of the circuitNon capture,,*,Pacing at this site is most consistent with:Pacing in a critical zone of slow conductionPacing in a “dead end alley”Pacing in an outer loopPacing outside of the circuitNon capture,

31、,,PPI,TCL,A,B,C,D,Pacing at this site is most consistent with:Pacing in a critical zone of slow conductionPacing in a “dead end alley”Pacing in an outer loopPacing outside of the circuitNon capture,,,PPI,TCL,*,Term

32、ination of VT,CP1201033-1,%,0-10,n=46,11-30,n=18,31-60,n=24,>60,n=64,PPI-VTCL (msec),CP1270284-4,VT #5,,,,VT 1,VT 2,VT 3,VT 3,CP1270284-17,Voltage Map Guided VT Ablation,55 year-old man with DCM, EF 27%Frequent ICD s

33、hocks, failed previous ablation,Left Ventricular Support,Low-speed centrifugal continuous flow pump Low blood surface area contact 21 Fr Left atrial cannula19 Fr femoral arterial cannulaUp to 4L/min Flow,Thiele et al

34、 Circ 2001,Induction of VT on LV Support,Endocardial and Epicardial Mapping with Left Ventricular Support,LAA,,LACannula,,Epicardial Approach,Schweikert et al. Circulation. 2003;108:1329-1335.,Eduardo Sosa, JACC 2000,E

35、picardial 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,

36、WPW, RVOT VT, AT) especially when endocardial ablation unsuccessful.No complications reported,Endocardial and Epicardial LV Ablation,Mitral Valve,Reentry mechanism is most commonResponse to entrainment maneuvers determ

37、ines the critical zone of conductionMultiple VTs and circuits are frequently presentVoltage/scar mapping is often required Epicardial approach may be required in selected patientsMost patients undergo “palliative” VT