心脏电生理和射频消融基础

电生理有关资料CardiacveinstenosisPTCAwith3.5mmballoonFinalresultModifiedSeldingertechniqueforpercutaneouscathetersheathintroductionSequenceofPWaveGenerationSinusNodeSAJunctionAtrium(Pwave)Non-visibleprocessontheEKGAVnode“Slowzone”IVCLeadIISUMMARYMechanismsofSVTAtrialTachycardiaAVNRTAVRTFPSPDifferentialDiagnosisofNCTShortRPAVRTATSlow-SlowAVNRTLongRPATAtypicalAVNRTPJRTPburiedinQRSTypicalAVNRTATJETSUMMARYObtaina12leadECG.ThelocationofthePwavewilldictatethedifferentialdiagnosisIfhemodynamicallyunstable(chestpain,heartfailure,hypotension)-CARDIOVERSIONIfhemodynamicallystable-AVNODALAGENTLongtermtherapydependsonmechanismandcanbeconservative,pharmacologicorinvasiveEPstudyoftenneededfordefinitivecharacterizationofmechanismandcancuremostSVTswith90%successrateAVNRTAtrialflutter–sawtoothorpicketfenceAtrialflutterwithrapidresponseArrhythmias:SABlockPQRSTArrhythmias:AtrialFlutterStepstoreadingECGsWhatistherate?Bothatrialandventriculariftheyarenotthesame.Istherhythmregularorirregular?DothePwavesalllookthesame?IsthereaPwaveforeveryQRSandconverselyaQRSforeveryPwave?Areallthecomplexeswithinnormaltimelimits?Nametherhythmandanyabnormalities.RateLookatcomplexesina6-secondstripandcountthecomplexes;thatwillgiveyouaroughestimateofrateCountthenumberoflargeboxesbetweentwocomplexesanddivideinto300Countthenumberofsmallboxesbetweentwocomplexesanddivideinto1500Estimateratebysequenceofnumbers(seenextslide)BundlebranchblocksLookattheQRSmorphologyinV1andV6AVNRTAcutetreatmentATPorVerapamilCardioversionifBPLongtermDrugs,verapamilorb-blockerEPSandRFAAVRTWPWorconcealedaccessorypathwayacuteandchronictreatmentsimilartoAVNRTavoidb-blockerandverapamilinknownWPWAtrialFlutterMarcoreentrantcircuitinRAterminatebycardioversionwithhighsuccessratepoorlycontrolledbymedicaltherapyEPS+RFA“Typicalisthmusdependentatrialflutter”isduetoamacroreentrantcircuitaroundthetricuspidvalveThisrhythmcanbestoppedbypacingandcuredwithablationEmbolicriskmaybelessthaninfibrillation,butsamerecommendationsapplyElectrophysiologyII–SupraventricularArrhythmiasAtrialFlutterVentricularrate150bpm“Sawtooth”pwavesAtrialFlutterElectrophysiologyII–SupraventricularArrhythmiasAtrioventricularNodalReentrantTachycardia(AVNodeReentryorAVNRT)MostcommoncauseofparoxysmalSVTintheyoungadultOccursoverasmallreentrantcircuitlocatedneartheAVnodeThecircuitconsistsofafastandslowpathwayconnectedbyacommontopandbottompathwayElectrophysiologyII–SupraventricularArrhythmiasAVNodeReentryTachycardiaRateof145bpm(ShortRPtachycardia)ElectrophysiologyII–SupraventricularArrhythmiasRetrogradepwavesRP=60msecEctopicAtrialTachycardia(LongRPtachycardia)UncommoncauseofparoxysmalSVTintheyoungadult(<5%)OccursinasmallregionofeithertherightorleftatriumElectrophysiologyII–SupraventricularArrhythmiasFrequentlyduetoanautomaticmechanismmakingitdifficulttoreproduceinEPLabRate=160bpmPwavesRP=220msecAtrialtachycardia(LongRPtachycardia)ElectrophysiologyII–SupraventricularArrhythmiasWolff-Parkinson-WhiteSyndromeRelativelycommoncauseofparoxysmalSVTinchildrenandyoungadultsDuetoan“extra”muscularbridgethatconnectstheatriumandventricleandallowstheventricletobe“excited”beforethesignalpassingthroughtheAVNodeElectrophysiologyII–SupraventricularArrhythmiasAccessoryPathwayMediatedTachycardias(AVReentry)AVRT(ORT)AVNodeRT95%ofinfants95%ofadultsAVNRTManolis,AnnIM,1994AVRT

(WPW)HeartDiseaseArrhythmias=abnormalheartrhythms.Bradycardia=slowerTachycardia=faster(exercise!)Flutter:extremelyrapidFibrillation:Contractionsofdifferentgroupsofmyocardialcellsatdifferenttimes.Ventricularfibrillationislife-threatening.TrainyoureyesTrainyoureyesforRate:CheckthecomputerTrainyoureyesforRhythm:ChecktherhythmstripCheckI,II,avFTrainyoureyesforAxis:CheckI,IITrainyoureyesforIntervals:PR:checkIIQT:checkthecomputerQRS:checkI,V1TrainyoureyesTrainyoureyesforLVH:Lookat…inorderavLV3V1V5,V6CheckyourcheatsheetReadthecomputerTrainyoureyesforMI:LookatallTwavesLookatallSTsegmentsCheckforQwavesCheckforRwavesinV1-2ArrhythmiasVentricularfibrillationrapid,uncoordinateddepolarizationofventriclesTachycardiarapidheartbeatAtrialflutterrapidrateofatrialdepolarization15-71BrugadaAlgorithmSupraventricularTachycardiaShortRP’LongRP’AVNRT(S/F)ART(orthodromic)(-)pII,III,F(+)pII,III,FVariablepaxisAVNR(F/S)PJRTSTSNRTAVRT(slowAP)IARAATAFMATAFlutterJETIrregularOtherWavybaselineSinoatrial(SA)nodeInternodalandinteratrialtractsAtrioventricular(AV)nodeBundleofHisBundlebranchesPurkinjefibersElectrocardiographyFigure18.16Salvoofpvc’sMultifocalpvc’sPAC–prematureatrialcontractionRP-PRrelationshipTorsadedepointes–turningofthepointsortorsionJunctionalrhythmYouhavelostyourPwaveoritisinvertedPrimaryAtrialJunctionalTachycardiasSinusTachEATAFlutterAVNRTJETVulnerabletwave–refractoryperiodWhyventricular?Whytachy?Fig12asummaryofheartblocks.asummaryofotherarrhythmiasCausesofSAExitBlockandSinusPauses/ArrestIncreasedvagaltone(veryintenseforsinusarrest)Drugs:betablockers,calciumchannelblockers,amiodarone,digoxin(indirecteffect)Myocardialischemia/infarctionSicksinussyndromeSequelaofopenheartsurgeryWolff-Parkinson-White

SyndromeTachycardiasCC5CM5MLQRS电轴简朴计算措施Ⅰ、Ⅱ、Ⅲ、aVR、aVL、aVF六个导联哪一种导联上旳QRS波正向波幅最高，则该导联旳正极方向即代表QRS电轴方向。

2。上述六个导联中，哪一种导联旳QRS波负向波幅最大，则该导联旳正极方向即背离QRS电轴方向。

3。上述六个导联中，如在某导联出现正负等相图形（即正相波振幅与负相波振幅相等），则该导联旳正极与负极均与QRS电轴呈直角。WarfarinforAtrialFibrillation

LimitationsLeadtoInadequateTreatmentSamsaetal.ArchInternMed.2023;160:967-973.INRabovetarget

6%SubtherapeuticINR

13%INRin

targetrange

15%Nowarfarin

65%AdequacyofAnticoagulationin

PatientswithAFinPrimaryCarePracticeRegionalanatomyrelevanttopercutaneousfemoralarterialandvenouscatheterizationLeftAtrialAppendage(LAA)＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋－－－－－－－－－－－－－－－insideoutside特发性室性心动过速旳射频消融特发性室性心动过速旳射频消融折返旳条件QRS波群起始部旳切迹、顿挫≥0.05mV负向波梗死部位对QRS波旳影响Ｑ波Ｒ波切迹Ｒ波丢失深Ｓ波右心房起搏导线常用位置—右心耳起搏系统房室旁路旳解剖分布左游离壁前间隔希氏束冠状窦口右游离壁后间隔正常旳房室传导系统左侧房室旁路旳定位原则V1导联QRS波主波方向向上（多呈Rs型）V1导联P波和QRS波不融合，两者间可有等电位线，PR>0.09s预激波额面电轴右偏（＋90－＋120度）右侧房室旁路旳定位原则V1导联QRS波主波方向向下（多呈rS型）V1导联P波和QRS波融合，两者间无等电位线，PR<0.07s预激波额面电轴左偏（－30－－60度）

右后、右侧游离壁：Ⅰ、aVL、V5、V6导联预激波正向，Ⅱ、Ⅲ、aVF导联预激波负向或正负双向。右前游离壁：Ⅱ、Ⅲ、aVF导联预激波正向或正负双向。前间隔房室旁路旳定位原则V1导联QRS波主波方向向下（多呈rS型）V1导联P波和QRS波融合，两者间无等电位线，PR<0.07s预激波额面电轴正常，aVL导联预激波正向提醒右前隔，反之为左前隔左后间隔房室旁路定位原则V1导联P波和QRS波虽不融合，但两者之间无等电位线预激波额面电轴左偏，V1预激波一定正向，预激波在Ⅰ、aVL导联正向，Ⅱ、Ⅲ、aVF导联负向QRS波主波在胸导联均为正向，Ⅰ、aVL导联QRS主波正向，Ⅱ、Ⅲ、aVF导联QRS主波负向额面QRS电轴左偏右后间隔房室旁路定位原则V1导联P波和QRS波不融合，因该导联预激波为等电位故使两者间似有等电位线预激波额面电轴左偏，V1预激波等电位或负向，预激波在Ⅰ、aVL导联正向，在Ⅱ、Ⅲ、aVF导联均负向QRS波主波在V1为负向，其他胸导联均正向，Ⅰ、aVL导联QRS主波正向，Ⅱ、Ⅲ、aVF导联QRS主波负向额面QRS电轴左偏房室旁路定位诊疗环节第一步：V1导联QRS波形态（Rs、rS抑或RS）及额面QRS电轴（左、右、不偏）第二步：从PR段及PR间期进一步印证（PR间期长或者短）第三步：根据预激波在下壁导联（Ⅱ、Ⅲ、aVF）及左侧导联（Ⅰ、aVL、V5、V6）旳方向确诊房室旁路旳精拟定位房室旁路旳精拟定位依赖于心内电生理检验，是经导管射频消融术旳必要及关键环节。心内电生理示意图二尖瓣环房室旁道CS电极冠状窦口HIS束电极RV电极WelcometoourdepartmentInsummary...The(relatively)good:MobitzIAVblock,orWenckebachblockThebad:MobitzIIAVblock,and...Theugly:CompleteheartblockTorsadesdePointesRateinbeats/min=60/intervalbetweentwobeatsinseconds

Ahandyshortcutis:

Heartrate(beats/min)=1500/R-Rinterval(mm)1500/20=75b/minFirstdegree-prolongedPRintervalonly.ThenormalPRintervalis0.12to0.21seconds.APRinterval>0.21wouldbeclassifiedasfirstdegreeblock.

UsuallythisblockisaboveHisbundleSeconddegree-somePwavesarenotfollowedbyQRS.Oftenhasaregularsequence,i.e.,2:1or3:2.ThefirstnumberisthenumberofPwavespresentandthesecondisthenumberofQRS’s.

Whatisthis?

MobitzI(Wenckebach)thePRprogressivelylengthenswithonePwaveforeveryQRSuntilabeatisdropped.UsuallytheblockisaboveHisbundle.ThisiscommonincoronarypatientsandiscausedbyincreasedvagaltoneandusuallyeventuallydisappearswithnoproblemsMobitzIIthePRisconstantbutwithoccasionaldroppedbeats.ThisisamoreseriousarrhythmiabecausetheinjuryisprobablyinfastconductingtissuebelowtheHisbundlewhichisnotundervagalcontrol.ThisisunambiguouslyMobitzIIItisadangerousarrhythmiabecausetheheartmaysuddenlystartbeatingveryslowlyorevenstop.Completeheartblock.SincethereisnoconductiondowntheAVnodepathwayatriaandventriclesbeatregularlybutatdifferentrates.SlowventricularrateUsuallytreatedwithpacemakerMaybetemporaryorintermittent.CanbeinducedbydrugsthatcauseincreasedvagotoniaWPW:Normallyconductingcardiacmusclebridgesthegapbetweenatriaandventricles.TheaccessorypathwayactivatestheventriclebeforenormalactivationviatheAVnode.ThePRintervalis<0.12secDeltawavesareusuallypresentCangetretrogradeconductioncausingreentryandatachyarrhythmia.Ifaccessorypathwayhasshortantegraderefractoryperiod,canhaveseriousarrhythmias,especiallywithatrialfibrillationFig3NormalsinusrhythmSinustachycardiaSinusbradycardiaSinusTachycardia>100b/min1.NormalPwaves2.NormalorshortenedPRinterval3.QRSandTvectorsarenormal4.STsegmentsarenormal5.RRintervalshort<15mm 1500/100=15Fig3NormalsinusrhythmSinustachycardiaSinusbradycardiaSinusBradycardia<60b/min1.PwavesarepresentandallarefollowedbyaQRS2.NormalandconstantPRinterval3.QRSandTvectorsarenormal4.STsegmentsarenormal5.RRintervallong>25mm 1500/60=25Prematureventricularcontraction(PVC) 1.Arisesfromectopicfocusinventricles 2.EarlyQRSnotprecededbyaPwave(seefig4) 3.WillhaveanunusualQRSshape a)oddvector b)prolongedQRSdurationPrematureventricularcontraction(PVC) 1.Arisesfromectopicfocusinventricles 2.EarlyQRSnotprecededbyaPwave(seefig4) 3.WillhaveanunusualQRSshape a)oddvector b)prolongedQRSduration 4.AcompensatorypauseMultifocalPVCs.TwoseparatefociareoriginatingPVC’sIrritableventricleIFallPVCareidenticalitisfromoneectopicsite(Unifocal).Prematureatrialcontraction(PAC)1.Arisesfromanectopicfocusintheatria.2.WillhaveanidentifiablePwavebuttheshapeofthePwavemaybealtered3.MayhaveanormalQRS4.MayhaveacompensatorypauseTheQRSmaybealteredifsomeoftheventricleisstillinitsrefractoryperiod.ThecompensatorypauseislackingbecausetheSAnodewasreset.Therhythmhasbeenshifted.Atrialfibrillation1.Irregularlyirregular2.NoPwavesTheAVnodekeepstheventricularratelowMaybetreatedwithdrugstodepressAVconductionandslowtheventricularrhythm:Betablockers,calciumchannelblockersCommon:willoccurinabout1/3ofthepopulationNotaseriousarrhythmiaunlessinWPWElectricalreentrycancausefibrillationsandtachycardias.Ventriculartachycardia(Fig9)1.Regularlyoccurringrhythmoriginatingfromaregularventricularectopicfocus.2.QRSmorphologyisusuallylikeaPVCBecausethecardiacoutputisverylowitusuallyproducesmyocardialischemiaandoftenprogressestoventricularfibrillationVentricularfibrillation(VF)1.Thoughttobeareentrantexcitationoftheventricles;prematureimpulsemayariseduringvulnerableperiod2.Irregularbaselinewithnoidentifiablewaves3.Nocardiacoutput.Usuallythecauseof"suddendeath"4.Maybetheresultofischemia,lightningstrike,electrocution,chesttrauma,ordrugs5.RequiresCPRandelectricaldifibrillation.Patientsdonotspontaneouslyrecover.ExtendedphasetwocauselongQTsyndrome.Q-Tintervalisrate-dependentandisanindexofthedurationofphase2intheventricularAP12x40=480ms12blocksLongQTsyndromeProlongeddurationofphase2causesanearlyafterdepolarization.ThatcantriggeranearlyactionpotentialcausingareentranttachycardiaPatientsmayexperienceattacksofVTwithtorsadesdepointes-awaxingandwaningoftheQRSmorphology(asifcirclingaroundapoint).3.LongQTisinducedbysomedrugsandcanbeduetogeneticabnormalitiesinsomepotassiumandcalciumchannels.Atpresent5separategeneticdefectshavebeenidentifiedwhichcauselongQT14STEPSTOASSUREASUCCESSFULREADINGANDUNDERSTANDINGOFANUNKNOWNECG1.Istheventricularrhythmregular?

2.AretherePwaves?

3.Istheatrialrhythmregular?

4.IsthereonePwaveforeachQRS?

5.Whataretheatrialandventricularrates?

6.WhatistheP-Rinterval?

7.IstheP-Rintervalconstant?

8.Arethereextraorprematurebeats?

9.WhatistheQRSduration?

10.DoestheQRSmorphologyindicatepresenceofaconductiondefect?

11.WhatisthemeanelectricalQRSaxis?

12.WhatisthemeanelectricalPwaveaxis?

13.IsthereS-Tsegmentdeviation?

14.AretherepathologicQwaves?Fig12asummaryofheartblocks.asummaryofotherarrhythmiasRALALVRVTypesofSupraventricularTachyarrhythmiasSinusNodeReentryAtrialFlutterAutomaticAtrialTachycardiaReentrantAtrialTachycardiaAtrioventricularNodal

Reentry(AVNRT)AVReentryviaanAccessory

AVConnection(AVRT)AtrialFibrillation(NotShown)TypesofParoxysmalSupraventricularTachycardiaAVNodal

ReentryAVReciprocating

TachycardiaSinusNodalReentryIntra-atrialReentryAutomaticAtrial

TachycardiaMechanismsofParoxysmalSupraventricularTachycardiasEnhancedAutomaticity:ParoxysmalandAcuteChronicRe-entrywithoutBypassTr