流出道室性心律失常的特点与消融PPT课件

鲁志兵武汉大学人民医院心内科流出道室性心律失常的特点与消融分类右室流出道起源的VAs肺动脉起源的VAs主动脉根部起源的VAs左室流出道起源的VAs左室心外膜起源的VAs流出道的解剖特点IIIIIIavRavLavF典型RVOT-VPB的特点QRS宽下壁导联直立胸导联移行于V3或以后V1导联多呈QS形AnteriorPosteriorFreeWallSeptal13起源于RVOT的VPB的特点123下壁导联顿挫胸导联移行>=V4V2、V3导联S波较深下壁导联无顿挫胸导联移行V3-V4I导联判断前后间隔部游离壁起源部位？RVOT？三尖瓣环起源RVOT起源三尖瓣环vsRVOT三尖瓣环前壁起源的VPB与RVOT-VPB的鉴别相同点：下壁导联直立、胸导联移行区类似鉴别点：I导联在TV直立高大，而在RVOT形态多样并且R低平avL导联在TV大多直立，而在RVOT深倒RVOT-VPB起搏标测激动顺序标测常规标测的缺点激动标测费时、需要标测的范围较广电位较小干扰起搏标测无法夺获，加大电压可夺获，但夺获大片心肌主观性较强三维电激动标测－Carto需要稳定、频发的室早辅助标测－环形标测电极三维电激动标测－Ensite仅需一个早搏即可完成标测起源部位？PA起源的室性早搏的特点与RVOT-VPB难于区分PA起源的室性早搏消融前消融后PVC1：起源于RVOT起搏标测和激动标测靶点良好放电后室早形态发生改变－PVC2起搏标测和激动标测最佳靶点位于肺动脉靶点窦律下高频电位VPB时高频电位领先放电消融后室早消失第一次放电RVOT间隔-32ms第二次放电RVOT-18ms第三次放电PA-47ms室早形态发生多次改变室早形态改变可能的机制18msLAORAO第一次放电放电前放电后15ms第二种VPB第二种VPB第二次放电第一次放电第二种VPB放电过程中第三种VPB第三种VPB第三种VPB第三种VPB25ms第三种VPB主动脉根部起源VPB的特点QRS较宽下壁导联直立胸导联移行于V2或V2-V3V1导联多呈rS形二尖瓣环起源的PVCIIIIIIavRavLavFV1V2V3V4V5V6起源部位？V1呈rS形但胸导联移行于V3-V4RAOLAO鉴别方法之一：CS电极深插或微电极心电图特征——Chunetal.Herz2007;32:226–232主动脉根部起源的VT 起源部位右冠窦左冠窦无冠窦被心肌和少量纤维组织包绕大量脂肪组织和纤维组织临床意义：左冠窦和右冠窦起源的VPB多见，而无冠窦起源的VPB少见左右冠窦连接部位（L-RCC)起源的VPB符合瓦氏窦起源的VPB的特点，V1－V3至少一个导联呈qrS型从L-RCC起搏qrSinV1-V3Figure7.Successfulablationsiteoftheprematureventricularcontractions(PVCs)originatingfromtheL-RCC.ThefirstbeatisasinusbeatandthesecondoneisaPVC.Atthesuccessfulablationsite,2ventricularactivationcomponentsandnoatrialactivationswererecordedduringsinusrhythm(leftpanel).Thesequenceofthe2componentswasreversedduringthePVCs.TheaortagramshowedthattheablationcatheterwaslocatedintheL-RCC(midpanels).NotethatthetipoftheablationcatheterwaspositionedattheL-RCCbydeflectingtheloopoftheablationcatheterintheLVcavity.TheactivationmapduringthePVCsrevealedtheearliestactivationwasattheL-RCC(rightpanel).ABLd(p)indicatesthedistal(proximal)electrodepairsoftheablationcatheter;ABLuni,thedistalunipolarelectrodeoftheablationcatheter;AP,antero-posterior;LL,leftlateral;LVOT,leftventricularoutflowtract;RAO,therightanteriorobliqueview.Theotherabbreviationsareasinpreviousfigures.ReproducedwithpermissionfromJAmCollCardiol.2008;52:139–147.瓦氏窦起源的VPB消融时避免损伤冠脉需要冠脉造影确认IIIIIIAVRAVLAVFV1V2V3V4V5V6左冠窦起源的VPBIIIIIIAVRAVLAVFV1V2V3V4V5V6RFA左冠窦内消融-40ms左冠窦起搏时VT形态与自发VT一致左冠窦起搏VT自发VTKanagaratnametal.JACC2001;37:1408–14VPB患者左冠窦记录到的最早激动SinusbeatVPB右冠窦起搏时PVC形态与自发PVC一致Storeyetal.JCE2002;13:1050-1053  主动脉窦消融优先选择冷冻消融法d’Avilaetal.JICE2006;16:31–38StandardRFLesionCryoablationLesionLesiondepthShortaxisLongaxis消融导管位于无冠窦IIIIIIavRavLavFV1V2V3V4V5V6放电时出现III度AVBIII度伴交界性心律HR55bpm36秒III度伴交界性心律HR55bpmLVOT起源的VPB主动脉瓣下心电图与瓦氏窦起源VPB相似缺乏特异性的鉴别点LVOT(瓣下)起源部位？心外膜VPB、VT的心电图特点心外膜室速体表标准12导联EKG特点假Δ波（PseudodeltaWave）≥34msR波峰值时限增宽（IntrinsicoidDeflectionTime,ID）≥85ms胸前导联R波起点到QRS波最低点时限增宽（RS）≥121ms研究通过对9例病人分别经心外膜及心内膜起搏，记录分析12导体表ECG证实了心外膜起源的室性激动的QRS初始部分较宽的设想。据此，对14例经心内膜消融失败后进行非外科的经胸心外膜消融的RBBB型VTs病例（A组）和27例经心内膜消融成功的RBBB型VTs（B组），以及28例无法经心内膜消融的RBBB型VTs（C组）进行分析比较发现，心室激动间期有四种不同特征：（1）假Δ波，（2）V2偏移时间（ID），（3）RS波，（4）QRS波。A组和C组有明显的假Δ波，ID、RS和QRS间期均延长（分别比较B组，p值均<0.05）。A组和C组各项之间对比无显著差异。心外膜起源VTs：假Δ波间期≥34ms时敏感性达83%，特异性为95%；R波峰值时限增宽（ID）≥85ms时敏感性87%，特异性90%；RS间期≥121ms时敏感性76%，特异性85%。相关概念：假Δ波（pseudodeltawave）：从最早心室激动点（对于起搏心电图从起搏信号开始）到最早的快速转折点的时间（任一胸前导联）。在起搏器植入后的患者中，还测量跨壁激动时间，即从心外膜起搏信号开始到远端心内膜双极导管电极记录到最大快速转折时的间隔时间（图3）。R波峰值时限增宽（IntrinsicoidDeflectionTime）：指从最早心室激动点（对于起搏心电图从起搏信号开始）到V2导联R波波峰的时间。RS间期（shortestRScomplex）：指从最早心室激动点（对于起搏心电图从起搏信号开始）到任一胸前导联S波最低点的时间。QRS波持续时间：指从最早心室激动点（对于起搏心电图从起搏信号开始）到QRS波转折点的时间。Thepseudodeltawavewasmeasuredfromtheearliestventricularactivation(fromthestimulationartifactinpacedpatients)totheearliestfastdeflectioninanyprecordiallead.Inpacedpatients,wemeasuredalsothetransmuralactivationtime,fromthestimulationartifactintheepicardiumtothelargestrapiddeflectionrecordedfromthedistalbipolarelectrogramoftheendocardialsurfacecatheter5(Figure3).Theintrinsicoiddeflectiontimewasdefinedastheintervalmeasuredfromtheearliestventricularactivation(fromthestimulationartifactinpacedpatients)tothepeakoftheRwaveinV2.ShortestRSComplexTheshortestRScomplexwasdefinedastheintervalmeasuredfromtheearliestventricularactivation(fromthestimulationartifactinpacedpatients)tothenadirofthefirstSwaveinanyprecordiallead.QRSComplexDurationTheQRScomplexdurationwasdefinedastheintervalmeasuredfromtheearliestventricularactivation(fromthestimulationartifactinpacedpatients)totheoffsetofQRSintheprecordialleads*心外膜室速体表标准12导联EKG特点最大偏转指数（maximumdeflectionindex）≥0.55心外膜起源室速无特异的心电图表现。但胸前导联QRS起始的延迟，即最大偏转指数对其有很高的诊断价值。与所有其他起源的心外膜源性室速相比（包括主要起源于主动脉根部近端、左前降支以及后左室间隔的心外膜原发性室速），最大偏转指数≥0.55诊断主动脉窦远端的心外膜源性室速时，敏感性达100%，特异性达98.7%。NoECGpatternwasspecificforepicardialVT.However,slowedinitialprecordialQRSactivation,asquantifiedbyanovelmetric,themaximumdeflectionindex,wasmoreuseful.Adelayedprecordialmaximumdeflectionindex>=0.55identifiedepicardialVTremotefromtheASOVwithasensitivityof100%andaspecificityof98.7%relativetoallothersitesoforigin,identifiedanepicardialidiopathicLV-VToriginprimarilylocatedinproximitytotheaorticrootandleftanteriordescendingcoronaryartery,andtotheposteriorLVseptum*Pseudo-deltawaveMDI：maximumdeflectionindex>=0.55MDI=TMD/QRSdTMD:theearliesttimetomaximaldeflectionQRSd:thetotaldurationofQRScomplex起源于主动脉窦远端的心外膜源性的特发性左室室速（ILVT）是一种儿茶酚胺增强、腺苷敏感的心动过速，在大多数病例中与cAMP介导的触发活性一致。这些心动过速起源于心外膜冠状血管附近。尽管技术上比较复杂，但仍能通过经静脉或经皮心包穿刺导管消融治疗。从VT发作时12导联心电图上测量的最大偏转指数（MDI），可作为起源于主动脉窦远端的心外膜源性室速的诊断标准。延长的MDI（0.55）诊断此种起源室速具有极高的敏感性和特异性。这些心动过速可能解释经心内膜或主动脉窦消融失败的情况，另外在评价上述室速时应早期考虑行心外膜标测。EpicardialILVTarisingremotefromtheASOVappearstobeacatecholamine-enhanced,adenosine-sensitivetachycardiaconsistentwithcAMP-mediatedtriggeredactivityinmostcases.Thesetachycardiasariseadjacenttoepicardialcoronaryvasculature.Despitetechnicalchallenges,theyareamenabletoeithertransvenousorpercutaneoustranspericardialcatheterablation.TheMDI,derivedfroma12-leadECGduringVT,isanovelmetricforidentifyinganepicardialoriginofVTremotefromtheASOV;aprolongedMDI(0.55)suggestssuchanoriginwithhighsensitivityandspecificity.ThesetachycardiasmaybeacommoncauseoffailedablationfromtheendocardiumorASOV,andepicardialmappingshouldbeconsideredearlyinthecourseoftheirevaluation.*GuidewireCSneedlecontrastGuidewireLAOLAOSlidekindlyprovidedby:ESosa,MScanavacca,Ad’Avila,UniversityofSãoPaulo.*WefollowedtheneedleinsertionthroughthefluoroscopyimageinLAO.Theneedletippositionwasconfirmedbyinfusingsomesmallamountofcontrast.Weweresuretheneedlehadreachedthepericardialspacewhentheinfusedcontrastspreadaroundthecardiacsilhouette.Then,weinsertedaguidewireinthepericardialspace,whichwasfollowedbyacatheterintroducer,andfinallythecatheter[Sosa,Scanavacca,d’Avila].EpicardialcatheterEpicardialcatheterCSCSRVRVLAOLAOSlidekindlyprovidedby:ESosa,MScanavacca,Ad’Avila,UniversityofSãoPaulo.*themappingcatheter,thatwecouldeasilymovearoundthesurfaceoftheheart.[Sosa,Scanavacca,d’Avila]2.5F的导管在心中静脉，注意该导管的远端已经放置在心中静脉的分支*上图为左侧心大静脉造影。心大静脉从近端分支，远端呈节段型。导管位于近段的终末（星号）。在远端，心大静脉从房室交界区转向前沿左前降支走行。在右侧可见消融导管位于室性异位激动的早期激动点。冠脉造影提示它接近左前降支和左旋支。Left,Venogramofthegreatcardiacvein(GCV).Thegreatcardiacveinisdividedinaproximal(prox.)anddistalsegment.Thecatheterislocatedattheendoftheproximalsegment(asterisk).Inthedistalsegment,thegreatcardiacveinchangesitscircularcoursearoundtheatrioventricularjunctiontoananteriorcoursefollowingtheleftanteriordescendingartery.Right,Theablationcatheterislocatedatthesiteoftheearliestactivationduringventricularectopy.Acoronaryangiogramillustratestheproximitytobothleftanteriordescendingcoronaryarteryandleftcircumflexcoronaryartery.*心外膜VPB、VT的分布特发性VT前室间静脉心中静脉心大静脉RCCLAORAO25s起搏标测无法夺获12s 优势传导现象Yamadaetal.JACC2007;50:884–91ThankYou!Figure7.Successfulablationsiteoftheprematureventricularcontractions(PVCs)originatingfromtheL-RCC.ThefirstbeatisasinusbeatandthesecondoneisaPVC.Atthesuccessfulablationsite,2ventricularactivationcomponentsandnoatrialactivationswererecordedduringsinusrhythm(leftpanel).Thesequenceofthe2componentswasreversedduringthePVCs.TheaortagramshowedthattheablationcatheterwaslocatedintheL-RCC(midpanels).NotethatthetipoftheablationcatheterwaspositionedattheL-RCCbydeflectingtheloopoftheablationcatheterintheLVcavity.TheactivationmapduringthePVCsrevealedtheearliestactivationwasattheL-RCC(rightpanel).ABLd(p)indicatesthedistal(proximal)electrodepairsoftheablationcatheter;ABLuni,thedistalunipolarelectrodeoftheablationcatheter;AP,antero-posterior;LL,leftlateral;LVOT,leftventricularoutflowtract;RAO,therightanteriorobliqueview.Theotherabbreviationsareasinpreviousfigures.ReproducedwithpermissionfromJAmCollCardiol.2008;52:139–147.研究通过对9例病人分别经心外膜及心内膜起搏，记录分析12导体表ECG证实了心外膜起源的室性激动的QRS初始部分较宽的设想。据此，对14例经心内膜消融失败后进行非外科的经胸心外膜消融的RBBB型VTs病例（A组）和27例经心内膜消融成功的RBBB型VTs（B组），以及28例无法经心内膜消融的RBBB型VTs（C组）进行分析比较发现，心室激动间期有四种不同特征：（1）假Δ波，（2）V2偏移时间（ID），（3）RS波，（4）QRS波。A组和C组有明显的假Δ波，ID、RS和QRS间期均延长（分别比较B组，p值均<0.05）。A组和C组各项之间对比无显著差异。心外膜起源VTs：假Δ波间期≥34ms时敏感性达83%，特异性为95%；R波峰值时限增宽（ID）≥85ms时敏感性87%，特异性90%；RS间期≥121ms时敏感性76%，特异性85%。相关概念：假Δ波（pseudodeltawave）：从最早心室激动点（对于起搏心电图从起搏信号开始）到最早的快速转折点的时间（任一胸前导联）。在起搏器植入后的患者中，还测量跨壁激动时间，即从心外膜起搏信号开始到远端心内膜双极导管电极记录到最大快速转折时的间隔时间（图3）。R波峰值时限增宽（IntrinsicoidDeflectionTime）：指从最早心室激动点（对于起搏心电图从起搏信号开始）到V2导联R波波峰的时间。RS间期（shortestRScomplex）：指从最早心室激动点（对于起搏心电图从起搏信号开始）到任一胸前导联S波最低点的时间。QRS波持续时间：指从最早心室激动点（对于起搏心电图从起搏信号开始）到QRS波转折点的时间。Thepseudodeltawavewasmeasuredfromtheearliestventricularactivation(fromthestimulationartifactinpacedpatients)totheearliestfastdeflectioninanyprecordiallead.Inpacedpatients,wemeasuredalsothetransmuralactivationtime,fromthestimulationartifactintheepicardiumtothelargestrapiddeflectionrecordedfromthedistalbipolarelectrogramoftheendocardialsurfacecatheter5(Figure3).Theintrinsicoiddeflectiontimewasdefinedastheintervalmeasuredfromtheearliestventricularactivation(fromthestimulationartifactinpacedpatients)tothepeakoftheRwaveinV2.ShortestRSComplexTheshortestRScomplexwasdefinedastheintervalmeasuredfromtheearliestventricularactivation(fromthestimulationartifactinpacedpatients)tothenadirofthefirstSwaveinanyprecordiallead.QRSComplexDurationTheQRScomplexdurationwasdefinedastheintervalmeasuredfromtheearliestventricularactivation(fromthestimulationartifactinpacedpatients)totheoffsetofQRSintheprecordialleads*心外膜起源室速无特异的心电图表现。但胸前导联QRS起始的延迟，即最大偏转指数对其有很高的诊断价值。与所有其他起源的心外膜源性室速相比（包括主要起源于主动脉根部近端、左前降支以及后左室间隔的心外膜原发性室速），最大偏转指数≥0.55诊断主动脉窦远端的心外膜源性室速时，敏感性达100%，特异性达98.7%。NoECGpatternwasspecificforepicardialVT.However,slowedinitialprecordialQRSactivation,asquantifiedbyanovelmetric,themaximumdeflectionindex,wasmoreuseful.Adelayedprecordialmaximumdeflectionindex>=0.55identifiedepicardialVTremotefromtheASOVwithasensitivityof100%andaspecificityof98.7%relativetoallothersitesoforigin,identifiedanepicardialidiopathicLV-VToriginprimarilylocatedinproximitytotheaorticrootandleftanteriordescendingcoronaryartery,andtotheposteriorLVseptum*起源于主动脉窦远端的心外膜源性的特发性左室室速（ILVT）是一种儿茶酚胺增强、腺苷敏感的心动过速，在大多数病例中与cAMP介导的触发活性一致。这些心动过速起源于心外膜冠状血管附近。尽管技术上比较复杂，但仍能通过经静脉或经皮心包穿刺导管消融治疗。从VT发作时12导联心电图上测量的最大偏转指数（MDI），可作为起源于主动脉窦远端的心外膜源性室速的诊断标准。延长的MDI（0.55）诊断此种起源室速具有极高的敏感性和特异性。这些心动过速可能解释经心内膜或主动脉窦消融失败的情况，另外在评价上述室速时应早期考虑行心外膜标测。EpicardialILVTarisingremotefromtheASOVappearstobeacatecholamine-enhanced,adenosine-sensitivetachycardiaconsistentwithcAMP-mediatedtriggeredactivityinmostcases.Thesetachycardiasariseadjacenttoepicardialcoronaryvasculature.Despitetechnicalchallenges,theyareamenabletoeithertransvenousorpercutaneoustranspericardialcatheterablation.TheMDI,derivedfroma12-leadECGduringVT,isanovelmetricforidentifyinganepicardialoriginofVTremotefromtheASOV;aprolongedMDI(0.55)suggestssuchanoriginwithhighsensitivityandspecificity.ThesetachycardiasmaybeacommoncauseoffailedablationfromtheendocardiumorASOV,andepicardialmappingshouldbeconsideredearlyinthecourseoftheirevaluation.**WefollowedtheneedleinsertionthroughthefluoroscopyimageinLAO.Theneedletippositionwasconfirmedbyinfusingsomesmallamountofcontrast.Weweresuretheneedlehadreachedthepericardialspacewhentheinfusedcontrastspreadaroundthecardiacsilhouette.Then,weinsertedaguidewireinthepericardialspace,whichwasfollowedbyacatheterintroducer,andfinallythecatheter[Sosa,Scanavacca,d’Avila].*themappingcatheter,thatwecouldeasilymovearoundthesurfaceoftheheart.[Sosa,Scanavacca,d’Avila]2.5F的导管在心中静脉，注意该导管的远端已经放置在心中静脉的分支*上图为左侧心大静脉造影。心大静脉从近端分支，远端呈节段型。导管位于近段的终末（星号）。在远端，心大静脉从房室交界区转向前沿左前降支走行。在右侧可见消融导管位于室性异位激动的早期激动点。冠脉造影提示它接近左前降支和左旋支。Left,Venogramofthegreatcardiacvein(GCV).Thegreatcardiacveinisdividedinaproximal(prox.)anddistalsegment.Thecatheterislocatedattheendoftheproximalsegment(asterisk).Inthedistalsegment,thegreatcardiacveinchangesitscircularcoursearoundtheatrioventricularjunctiontoananteriorcoursefollowingtheleftanteriordescendingartery.Right,Theablationcatheterislocatedatthesiteoftheearliestactivationduringventricularectopy.Acoronaryangiogramillustratestheproximitytobothleftanteriordescendingcoronaryarteryandleftcircumflexcoronaryartery.*