起源于心外膜心律失常的识别与消融

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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TricuspidAnnulusLAOProjectionMitralAnnulusLAConnectionsRAConnectionsLVConnectionLVConnectionIdealAblationSiteEpicardialPosteroseptalandLeftPosteriorAccessoryPathways:ConnectionsBetweentheCSMyocardialCoatandtheAtriaandLeftVentriclePos

2、teriorCoronaryVeinMiddleCardiacVeinIdealAblationsiteMCVVentricularConnectionMitralAnnulusTricuspidAnnulusCSMyocardialCoatEpicardialPosteroseptalandLeftPosteriorAccessoryPathwaysLAORAORAACSMCVPVLVMapHBABHBLVMapCSRAAMCV1.2cmPVCCSRAAHBMCVRVABRAAHBMCVRV2.0cmLAORAOCSCEpicardialAccessoryPathways17

3、1Patients99911115(9%)318120(70%)36(21%)327DiverticulaNarrowNeckWideNeckSeptaltoMCV(5/27)LateraltoMCV(22/27)CSCSCSCSMCVDDDDMCVCSMCVSCVEnlargementofSCV,MCVandCS15/171(9%)PtsBulbousEnlargementofMCVorCS(3Patients)FosiformEnlargementofSCVorMCV(12pts)LAOAtrialDiastoleAtrialsystoleCSMCVPVPosteriorD

4、escendingCoronaryArteryRightCoronaryArteryFig2TricuspidAnnulusMitralAnnulusLAConnectionRAConnectionIdealAblationsiteMiddleCardiacVeinLocationoftheDistalRightCoronaryArteryRelativetoIdealAblationSitePosteriorCoronaryVeinIdealAblationsiteCSAngiography(LAO)RCAAngiography(LAO)LCAAngiography(RAO)

5、CSDAblationAblationA.BeforeAblationB.AfterAblation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膜的室速心外膜室速的心电图特征Pseudodeltawave>34msIntrinsicoiddeflectiontime>85msRScomplexduration>121msecQRS>198msCirculation109:1842-1847,2004.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

6、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测电极处隐匿拖带经冠状静脉系统标测指导心内膜消融Heart79:59-63,1998心外膜消融的激动标测JICE2004,10:281-288心外膜室速的拖带标测PACE1999.22:128-130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JCE16:449-452,2005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

7、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