房室旁路的射频消融

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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AccessoryAVPathwaysSymptoms:Rangefromasymptomatictosuddencardiacdeath症状:无症状到猝死SVTmaybefrequentorrecurrentSVT频繁发作,表现为心慌、胸闷。Upto40%ofpatientsremainasymptomatic40%无症状Orthodromicreciprocatingtachycardia顺向型(30%ofPSVTs)clinicalprese

2、ntation:AntegradeconductionoverAVnode房室结前传Retrogradeconductionoveraccessorypathway旁路逆传KayGN.AmJMed.1996;100:344-345.Wolff-Parkinson-WhiteSyndrome心电图表现Theelectrocardiogrammayshowpre-excitation(deltawave)心电图QRS起始部粗钝形成预激波Ifaccessorypathwaynotcapableofanterogradeconduction,theECGmaynotshowpre-excitat

3、ion(concealedpathway)ECG无预激(隐匿性旁路)IfaccessorypathwaycapableofrapidantegradeconductionIncreasedrisktodevelopVFfromrapidconductionofAF房扑发展为室颤Pre-excitation预激体表心电图KayNG.AmJofMed.1996;10:344-356.WPW:CaseStudy病例18yearoldmalebasketballplayer篮球运动员PresentedtoERwith:症状Multipleepisodesofnear-syncope先兆晕厥Ade

4、nosine12mgacceleratedtheheartrate12mg腺苷心室率加快Emergencycardioversionperformed紧急电复律WPW:CaseStudyECG旁路前传CourtesyofDr.BrianOlshansky.WPW:CaseStudyStudiedintheelectrophysiologylaboratory电生理检查InducedAF®VF诱发房扑演化为室扑Mapping:twopathways双旁路Posteriorseptal后间隔Leftlateralaccessorypathway游离壁Ablationofbothpathways

5、消融2条旁路Noadditionaltherapyneeded无需药物治疗AFwithMultipleAccessoryPathways房扑CourtesyofDr.BrianOlshansky.AFwithMultipleAccessoryPathways房扑CourtesyofDr.BrianOlshansky.AF®VF房扑转为室扑CourtesyofDr.BrianOlshansky.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

6、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。PosteriorBasalView–LeftAtrium左心房后面观R.superiorpulmonaryveinR.inferiorpulmonaryveinCoronarysinusL.inferiorpulmonaryveinL.atriumL.superiorpulmonaryveinL.auricleL.pulmonaryarteryR.pulmonaryarteryNetterF.AtlasofHum

7、anAnatomy.1989;Plate202.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性心律靶点图B型预激心动过速时心内图B型预激OrthodromicReciprocatingTachycardia顺向型KayNG.AmJofMed.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