心脏起搏器培训资料：HF 重塑和静脉造影的重要性

1、1 2021-5-9 HF 重塑和静脉造影的重要性重塑和静脉造影的重要性 2 24-Oct- 04 Large K9 Heart (approximately the size of normal human heart) Heart from MIRACLE study patient Autopsied Hearts 3 24-Oct- 04 Right Atrial Anatomical Features 4Tricuspid annulus三尖瓣环 4Fossa ovalis卵圆窝 4Eustachian ridge欧氏脊 4Coronary sinus冠状窦 4Thebesian v

2、alve冠状窦瓣 4Eustachian fossa欧氏窝 4Inferior vena cava下腔静脉 4 24-Oct- 04 心衰导致解剖变化的心衰导致解剖变化的X线影像线影像Fluoroscopic Views of Anatomical Changes Due to Congestive Heart Failure Click to Play Movie 5 24-Oct- 04 CRT手术中普遍遇到的苦难手术中普遍遇到的苦难 nCS开口位置较高 ostium located higher on atrial wall due to lower floor in RA nCS 成角

3、锐利steeply angulated in HF pts n瓣膜阻挡鞘管或电极导线推送Valves obstructing catheter or lead advancement 1. Niazi NASPE 2002 presentation 6 24-Oct- 04 CS解剖解剖 高度上的变异高度上的变异Variations in Height over the RA Floor 1. Niazi NASPE 2002 presentation HF pts.较非心衰患较非心衰患 者者CS起源更高起源更高 tended to have higher CS origin than non

4、-HF pts. (p0.001) CS 起源的高度在心起源的高度在心 衰患者中变异稍大衰患者中变异稍大 origin slightly more variable in HF pts. 7 24-Oct- 04 Anatomy of The CS 垂直成角垂直成角Variations in Vertical Angulation 1. Niazi NASPE 2002 presentation CS 成角程度在心衰中成角程度在心衰中 更陡更陡angulation was more steep in HF pts (p=0.001) 起始部位的成角会影响起始部位的成角会影响 鞘管进入冠状窦及推

5、送鞘管进入冠状窦及推送 Initial angulation impacts ability to cannulate CS and advance catheter 8 24-Oct- 04 瓣膜结构瓣膜结构Valve Structures nThebesian瓣 膜性瓣，覆盖在CS开口的后下部位 membranous valve covering postero-inferior aspect of CS ostium In 10-20% 的病例中，会影响冠状窦插管of cases, can impede CS cannulation nVieussens瓣 通常冠状窦的远端接近第一个大分

6、支 usually in distal portion of CS near the first large transference branch n在侧支中有静脉瓣Venous valves in side branches 1. Niazi NASPE 2002 presentation 9 24-Oct- 04 人类人类CS开口的影像开口的影像 v Thebesian Valve O CS Ostium 10 24-Oct- 04 由于心衰导致解剖结构的改变由于心衰导致解剖结构的改变Anatomical Changes due to Congestive Heart Failure C

7、lick to Play Movie 11 2021-5-9 静脉造影静脉造影Venograms 12 24-Oct- 04 学习目标学习目标Learning Objective: 在在X线影像下辨线影像下辨 认静脉解剖并描认静脉解剖并描 述其与电极导线述其与电极导线 放置的相关性放置的相关性 Identify venous anatomy in flouro images, and describe its relevance to lead placement 13 24-Oct- 04 什么是静脉造影什么是静脉造影What is a Venogram? n两维X线静脉解剖影像，通常在不同

8、角度观测 2-dimentional x-ray image of venous anatomy often viewed at various angles n动态电影影像: 实时图像记录real time image recording 14 24-Oct- 04 提供心脏静脉解剖的影像资料Provide a Visualization of Cardiac Venous Anatomy 增加电极导线植入的成功率 Increase Chance of Successful Lead Placement 提供游离壁途径Access to lateral free wall 提供静脉粗细和扭曲

9、程度信息Insight into size and tortuosity of veins 提供后备方案Provides a Back-Up Plan 提供理想左室电极位置的路线图Provides a roadmap to the optimal LV Lead position! 为什么要进行静脉造影为什么要进行静脉造影Why perform a venogram? 15 24-Oct- 04 静脉解剖静脉解剖Venous Anatomy 16 24-Oct- 04 * Click on object to run clip 静脉解剖的静脉解剖的3维图像维图像3-D Perspective

10、of Venous Anatomy 底部底部Base 中部中部Mid 心尖部心尖部Apex 17 24-Oct- 04 减少血管重叠问题Reduce Vessel Overlap Issues 提供整体血管图像信息Provide Visualization of Entire Vessel 增进对解剖的理解Increased understanding of anatomy 确定后外侧位置Ensure posterior lateral position 在两个或多个切面上的静脉造影图像在两个或多个切面上的静脉造影图像 Venograms in TWO or more Views 18 24-

11、Oct- 04 多个切面的重要性多个切面的重要性Importance of Multiple Views 注意侧支靶血管的起源Notice the origin of the lateral target vessel LAO View RAO View Images compliments of Dr. Seth Worley 目标侧支目标侧支Target Lateral Branch 目标侧支目标侧支 Target Lateral Branch 19 24-Oct- 04 静脉造影静脉造影Venograms A 3-维图像维图像Dimensional Perspective Click o

12、n image to Play Movie 20 24-Oct- 04 Question: LV电极放置何处电极放置何处Where would you place the LV lead? LAO View Images compliments of Dr. Seth Worley D C E B A 21 24-Oct- 04 不同的切面提供不同的信息不同的切面提供不同的信息 nAP 最简单的观测切面Easiest perspective to see 从前部到后部Shows front to back nRAO 可显示冠状窦的静脉分叉点Isolates vessels point of b

13、ifurcation from coronary sinus 可显示心尖部到心底部的分离程度Reveals apical to basal lead separation(RV Lead) nLAO 可发现哪些静脉位于左室壁Isolates which veins are on left ventricular wall 揭晓室间隔与外侧电极导线的分离程度Reveals septal to lateral lead separation LV 电极导线的松弛性Lead slack 22 24-Oct- 04 AP View (Ribs) nFrom the AP view, ribs curv

14、e away from the spine with the same angulation on both sides * Click on object to run clip 23 24-Oct- 04 RAO RAO: 观测观测 脊柱在左侧 Spine on left 开胸手术后胸骨缝线在右侧 Staples on right 脊突在左侧Spinal processes on left CS 在脊突右侧on right of spine 心影拉长Elongated heart shadow 电极导线位于脊柱右侧Leads to right of spine 24 24-Oct- 04

15、RAO View (Ribs) nFrom the RAO view, ribs can be seen sloping downward as shown by the arrow (negative slope) 25 24-Oct- 04 Lateral RAO Venogram 26 24-Oct- 04 LAO 脊柱在右侧Spine on right 胸骨缝线在左侧Staples on left 脊突在右侧Spinal processes on right CS 横跨脊柱crosses spine 电极在脊柱左侧Leads left of spine LAO: 观测观测What to

16、 look for 27 24-Oct- 04 LAO View (Ribs) nFrom the LAO view, ribs can be seen sloping upward as shown by the arrow (positive slope) * Click on object to run clip 28 24-Oct- 04 LAO Venogram 29 24-Oct- 04 通过画图使之更易于理解通过画图使之更易于理解 30 24-Oct- 04 LAO Os MCV Post Post Lat Ant Ant Lat Lateral 31 24-Oct- 04 RA

17、O Os Ant Ant Lat Post Lat Post MCV Lat 32 24-Oct- 04 AP RA RV MCV Post Post Lat Ant Lat Os Ant Lat 33 24-Oct- 04 侧后静脉侧后静脉 侧静脉侧静脉 心前静脉心前静脉 心中静脉心中静脉 心大静脉心大静脉 CS OS 34 24-Oct- 04 投影投影Projection? RAO view Shallow LAO view LV 电极导线在两个切面上都在电极导线在两个切面上都在2:00-5:00 位置上？位置上？ 35 24-Oct- 04 投影投影Projection? RAO Vi

18、ew 36 24-Oct- 04 投影投影Projection? LAO View 37 24-Oct- 04 投影举例投影举例Projection Example: AP View 38 24-Oct- 04 静脉造影解释静脉造影解释 Guide Catheter CS 开口 39 24-Oct- 04 40 24-Oct- 04 41 24-Oct- 04 42 24-Oct- 04 模型与影像的对应模型与影像的对应 43 24-Oct- 04 Balloon Balloon Catheter Ostium Guide Catheter B A C D Middle Cardiac Pos

19、tero- Lateral AIV 你可以标记吗你可以标记吗? LAO View 44 24-Oct- 04 B A C D CS Lateral Great Cardiac AIV Venogram LAO View 45 24-Oct- 04 B A D C E A=后静脉后静脉 Venogram F B=CS C=心前静脉心前静脉 D=侧静脉侧静脉 E=心中静脉心中静脉 F=CS 开口开口 AP View 46 24-Oct- 04 B A D C E F AP Venogram A= CS B= 后静脉后静脉 C = 心前静脉？心前静脉？ D = 侧静脉？侧静脉？ E=心中静脉心中静脉

20、 F=心大静脉心大静脉 47 24-Oct- 04 心脏静脉的侧支交通支充盈心脏静脉的侧支交通支充盈 Collateral filling of cardiac veins 48 24-Oct- 04 CRT电极导线植入选择静脉电极导线植入选择静脉Selecting Vein for CRT Lead Placement A. 心脏侧静脉 (marginal) cardiac vein B. 后外侧静脉Postero-lateral cardiac vein C. 后静脉Posterior cardiac vein D. 心中静脉Middle cardiac vein E. 心大静脉Great

21、 cardiac vein A B C D E 目标: 左室游离壁 (侧，后外侧，前外侧) 1,2,3 1. Ansalone et al. JACC. 2002;39:489-499 2. Butter et al. CIRCULATION. 2001;104:3026-3029 3. Auricchio et al. AJC. 1999;83:136D-142D A B C D E LAO View 49 24-Oct- 04 在左室后外侧游离壁对数个靶静脉进行选择排序在左室后外侧游离壁对数个靶静脉进行选择排序 Prioritize Several Target Veins on the Left Postero-Lateral Free Wall 选择血管Select vessels that: n左右室电极导线分离最大Maximize separation between RV and LV leads n避免膈神经刺激和梗死心肌Avoid infarcted myocardium and phrenic nerve stimulation n血管细小以