心肌梗死患者抢救消融电风暴-英文课件.ppt

Rescue Ablation of Electrical Storms in a Patient with Remote Myocardial Infarction Katherine Fan Grantham Hospital Hong Kong SAR Patient Mr. L M/64 History of inferior MI 1989- MVR for papillary muscle rupture and severe MR Ischemic cardiomyopathy (EF 30%) VT 1997- ICD implanted / generator change 2002 Chronic smoker/ COPD Ventricular Arrhythmias ICD (single-chamber) 1997 Amiodarone added in 2001 for PAF/ NSVT Recurrent VT episodes in 3/2005 with increased dosage of amiodarone Developed SOB- diagnosed amiodarone induced pulmonary fibrosis: Amiodarone stopped/ High dose steroids required ?-blockers / sotalol- not tolerated – exacerbation of COPD Recurrent VT episodes- mexiletine started but complicated by neurological signs (limb tremor and gait instability) Electical Storms Nov 2005- admitted after recurrent ICD shocks Interrogations: 58 episodes of VT detected Most terminated with ATP Some accerlerated to fast VT which was then termianted with cardioversion shocks Early re-initiation of VT VT Morphologies Sinus Rhythm VT 1 VT 2 Lesions Created Termination of VT (RF #38!) Catheter Ablation of the Mitral Isthmus for VT associated with Inferior InfarctionWilber et al. Circulation 1995;92:3481-3489 Mitral Isthmus Ventricular Tachycarida Critical zone of slow conduction activated parallel to mitral isthmus in either direction resulting in 2 distinct but characteristic QRS configurations LBBB with left superior axis- rS in V1 and aVR/ R in V6, I, aVL RBBB with right superior axis- R in V1 and aVR/ QS in V6, I, aVL Dynamic Substrate MapSinus Rhythm Composite Substrate Profile Marked Lesions Another Marked Lesions Substrate-Orientated VT Ablation A definite trigger or delineated scar has been characterized as a requirement for substrate orientated ablation of intractable unmappable VT Targets Critical isthmus Areas of slow conduction Exit sites- often located at the border of the scarred myocardium Scar Border Zone Substrate VT originated from area of diseased tissu