心肌梗死患者抢救消融电风暴-英文课件.ppt

RescueAblationofElectricalStormsinaPatientwith

RemoteMyocardialInfarctionKatherineFanGranthamHospitalHongKongSAR

PatientMr.LM/64HistoryofinferiorMI1989-MVRforpapillarymuscleruptureandsevereMRIschemiccardiomyopathy(EF30%)VT1997-ICDimplanted/generatorchange2002Chronicsmoker/COPD

VentricularArrhythmiasICD(single-chamber)1997Amiodaroneaddedin2001forPAF/NSVTRecurrentVTepisodesin3/2005withincreaseddosageofamiodaroneDevelopedSOB-diagnosedamiodaroneinducedpulmonaryfibrosis:Amiodaronestopped/Highdosesteroidsrequired?-blockers/sotalol-nottolerated–exacerbationofCOPDRecurrentVTepisodes-mexiletinestartedbutcomplicatedbyneurologicalsigns(limbtremorandgaitinstability)

ElecticalStormsNov2005-admittedafterrecurrentICDshocksInterrogations:58episodesofVTdetectedMostterminatedwithATPSomeaccerleratedtofastVTwhichwasthentermiantedwithcardioversionshocksEarlyre-initiationofVT

VTMorphologiesLBBB/LeftsuperioraxisQRSRBBB/RightsuperioraxisQRS

ATPRBBB/RsupLBBB/LsupRBBB/Rsup

MitralvalveprothesisRAOINF

SinusRhythm

VT1

VT2

LesionsCreated

TerminationofVT(RF#38!)onRF

CatheterAblationoftheMitralIsthmusforVTassociatedwithInferiorInfarction

Wilberetal.Circulation1995;92:3481-3489Byvirtueofitsnarrowdimension,theisthmusbecamethevulnerablepointtointerruptthiscircumferentialactivationRBBB/RightsuperioraxisLBBB/Leftsuperioraxis

MitralIsthmusVentricularTachycaridaCriticalzoneofslowconductionactivatedparalleltomitralisthmusineitherdirectionresultingin2distinctbutcharacteristicQRSconfigurationsLBBBwithleftsuperioraxis-rSinV1andaVR/RinV6,I,aVLRBBBwithrightsuperioraxis-RinV1andaVR/QSinV6,I,aVLLBBB/LADRBBB/RADWilberetal.Circulation1995

DynamicSubstrateMap

SinusRhythmLowVoltageZoneRAOviewInferiorview

DynamicSubstrateMap

VentricularTachycardiaRAOviewInferiorviewLowV