房室旁路的射频消融 案例.ppt

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 Accessory AV Pathways Symptoms: Range from asymptomatic to sudden cardiac death 症状:无症状到猝死 SVT may be frequent or recurrent SVT频繁发作,表现为心慌、胸闷。 Up to 40% of patients remain asymptomatic 40%无症状 Orthodromic reciprocating tachycardia顺向型 (30% of PSVTs) clinical presentation: Antegrade conduction over AV node房室结前传 Retrograde conduction over accessory pathway旁路逆传 Wolff-Parkinson-White Syndrome心电图表现 The electrocardiogram may show pre-excitation (delta wave)心电图QRS起始部粗钝形成预激波 If accessory pathway not capable of anterograde conduction, the ECG may not show pre-excitation (concealed pathway) ECG无预激(隐匿性旁路) If accessory pathway capable of rapid antegrade conduction Increased risk to develop VF from rapid conduction of AF房扑发展为室颤 Pre-excitation预激体表心电图 WPW: Case Study 病例 18 year old male basketball player 篮球运动员 Presented to ER with: 症状 Multiple episodes of near-syncope 先兆晕厥 Adenosine 12 mg accelerated the heart rate 12mg腺苷心室率加快 Emergency cardioversion performed 紧急电复律 WPW: Case Study ECG旁路前传 WPW: Case Study Studied in the electrophysiology laboratory 电生理检查 Induced AF ? VF 诱发房扑演化为室扑 Mapping: two pathways双旁路 Posterior septal后间隔 Left lateral accessory pathway游离壁 Ablation of both pathways 消融2条旁路 No additional therapy needed无需药物治疗 AF with Multiple Accessory Pathways房扑 AF with Multiple Accessory Pathways房扑 AF ? VF 房扑转为室扑 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，RPPR,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。 左右侧旁路的判定 Posterior Basal View – Left Atrium左心房后面观 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 Orthodromic Reciprocating Tachycardia 顺向型 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:房扑房颤时旁路前传导致：室速/室颤；阵发性心动过速时旁路前传：逆向型心动过速 顺向型AVRT形成机制 逆向型房室折返性心动过速形成机制 B型预激心内图 心动过速 另一种形态心动过速 左侧旁路参与 第3种形态 所有旁路消融后心电图 旁路的性质 Kent束：全和无