心内超声和心电生理-英文课件

1、 Intracardiac Echocardiography and ElectrophysiologySteven C. Hao, MDDirector of ElectrophysiologyNorthern California Heart CareSan Francisco, CADisclosures Biosense Webster- consultant, investigator Acuson/Siemens- consultantCurrent Clinical Applications for Intracardiac Echocardiography (ICE)Elect

2、rophysiology Transseptal puncture VT ablation Aortic Cusp and RVOT Ablation LV Ablations Complex left-sided procedures Atrial flutter ablation Placement and removal of pacing leads Bi-Ventricular pacing for cardiac resynchronizationICE Imaging - Transseptal左边影象证明了房间隔穿刺后的tenting现象，请注意tenting在肺静脉平面是最大

3、的，以利于在肺静脉、肺静脉前庭以及左房后壁的控制。右图证明了正确的房间隔穿刺。Using ICE to Guide Transseptal Puncture在ICE的帮助下，可以避免不恰当的房间隔穿刺左侧影像表明穿刺针/鞘位置靠前，几乎从左房前部穿出右侧影像表明在尝试穿房间隔时穿刺针从右房穿入主动脉根部Aortic Cusp VT Ablation这些图象演示了在标测一个局部VT消融时，从动脉瓣膜看动脉根部的影像。利用多普勒影像能通过直接的可视化图形确认冠状动脉开口。这可以帮助指导在这个区域的安全的消融。LV Ablation这些图片显示的是合并巨大基底动脉瘤的左室影像。注意导管的位置在动脉瘤

4、边缘。右上图显示在射频消融因局部过热产生的微泡这个CT图演示了三个左肺静脉。ICE可以形象化的演示异常左肺静脉，减少了肺静脉消融的危险性。这是一个很罕见的左房，常见的低位开口。ICE证实后位开口（上图）及巨大的左上肺静脉（下图）。 ICE能直接的显示这类复杂解剖病例的病变部位畸形左房。左肺静脉共前庭，右上肺静脉靠前，右下肺静脉靠后，左房顶部正中有一单独肺静脉。3D CT图象扫描和ICE能对这种复杂的解剖结构的标测和消融有帮助。EsophagusInsert barium swallowICE放置右房能显示食道，通过上图能显示左右肺静脉和消融导管。Right Pulmonary Veins右侧肺

5、静脉的横切面（左图）及纵切面（右图）可通过房间隔后斜进入而显示该患者有三支右肺静脉，有一束组织从右上及右中肺静脉之间的突起处延伸至后壁直接显示肺静脉及该束组织能指导Lasso及消融导管在该部位的操作Intra-procedural early detection of complicationsACT 350s以防止在标测及消融导管上的血栓形成。低于该标准的抗凝则需要房间隔穿刺以及心内导管的操作很精确。如果血栓形成则在ICE能看见并能回缩至鞘内或者直接拉回右房Intra-procedural detection of Potential Complications 过热能导致过度的心内膜损伤（

6、左图），导致内膜下基质暴露，从而形成血栓在左房和心室消融中，过热能产生结痂形成和导致中风的潜在原因，在适当的能量和冷消融导管能防止结痂（左图显示在LASSO上和右图显示大头）% patientsUltrasound 33 ptsTemperature control482 ptsICE + Bubbles 270 ptsp = 0.029p = 0.2Embolic complications过去的一项研究表明通过ICE监测微泡的形成以防止过热能显著减少在复杂左房消融中脑卒中的风险Monitor for Pericardial EffusionCardiac Tamponade在这个图片中IC

7、E导管能早期监控和诊断心包渗出。Evaluate Pulmonary Venous FlowLeft Inferior and Superior Pulmonary Veins功能显像能证实在左房消融前后通过肺静脉血流是否正常Results - Severe PV Stenosisn=75 n=25 n=102 n=100 n=310 20.0%2.9%2.0%0%15.5%通过确认适当的肺静脉前庭损伤，而不是深部肺静脉的损伤，ICE已经被显示防止肺静脉狭窄。Visually Assists with Anatomical MapUnusual anatomical variants vert

8、ical or horizontal hearts congenital anomalies any post-operative heart Common left ostium Rapid branching of either vessel Multiple branches of right veinsCARTO and Ultrasound与精确标测系统的三维图像融合能直观地显示复杂解剖结构在CT壳下显示导管位置能准确地显示病变位置及导管稳定性，从而减少放射线暴露LUPVICE能帮助CT图象重构选择位点。Landmark Registration在复杂的左房消融时，我们通常在左房内标

9、记三点（左上肺静脉的后上，左下肺静脉后下及右上肺静脉的后上）Left Atrium and Pulmonary VeinsCARTOMERGE形象化的提供在复杂解剖结构中动态的多种工具。CARTOSOUNDOverview of the CARTOSOUND Image Integration Module and the SOUNDSTAR 3D CatheterCARTOSOUND Module FeaturesAccuracyBeam OrientationCARTOSOUND Module MapsTip to Tissue Contact VisualizationCARTOMERG

10、E Module SynergyCARTOSOUNDBeam Orientation Displaying the real-time ultrasound beam in 3D space improves ease of use and allows for easier interpretation of ICECARTOSOUNDBeam OrientationDisplaying the real-time ultrasound beam in 3D space improves ease of use and allows for easier interpretation of

11、ICECARTOSOUND CARTOSOUND Module Maps Allows for faster and more accurate maps Safely create left sided maps from the right sideCARTOSOUND Tip to Tissue Contact Improves physician confidence with real-time tip to tissue visualization在实时的ICE图象和重建的3D ICE图象能显示导管位置在上图中。CARTOSOUNDCARTOMERGE Module Synergy

12、First ICE & 3D mapping integration Enhancing safety & ease of use Two years of proven accuracy & experience Full anatomical details of pre- acquired registration综和ICE和3D系统能实时显示大头、解剖、3D重建图和三维标测系统。Conclusions ICE provides real-time 2D and functional imaging to help guide catheter manipulation in difficult anatomy, monitor lesion formation, prevent and/or monitor for complication