房室旁路的射频消融

房室旁路的射频消融临床电生理研究室楚建民2021/5/91如何判定左右侧旁路心律失常的形成机制旁路的解剖基础旁路的标测和消融技术2021/5/92AccessoryAVPathwaysSymptoms:Rangefromasymptomaticto

suddencardiacdeath症状:无症状到猝死SVTmaybefrequentorrecurrentSVT频繁发作,表现为心慌、胸闷。Upto40%ofpatientsremainasymptomatic40%无症状Orthodromicreciprocatingtachycardia顺向型(30%ofPSVTs)clinicalpresentation:AntegradeconductionoverAVnode房室结前传Retrogradeconductionoveraccessorypathway旁路逆传KayGN.AmJMed.1996;100:344-345.2021/5/93Wolff-Parkinson-WhiteSyndrome

心电图表现Theelectrocardiogrammayshow

pre-excitation(deltawave)心电图QRS起始部粗钝形成预激波Ifaccessorypathwaynotcapableofanterogradeconduction,theECGmaynotshowpre-excitation(concealedpathway)ECG无预激(隐匿性旁路)IfaccessorypathwaycapableofrapidantegradeconductionIncreasedrisktodevelopVFfromrapid

conductionofAF房扑发展为室颤2021/5/94Pre-excitation预激体表心电图KayNG.AmJofMed.1996;10:344-356.2021/5/95WPW:CaseStudy病例18yearoldmalebasketballplayer

篮球运动员PresentedtoERwith:症状Multipleepisodesofnear-syncope先兆晕厥Adenosine12mgacceleratedtheheartrate12mg腺苷心室率加快Emergencycardioversionperformed紧急电复律2021/5/96WPW:CaseStudyECG旁路前传CourtesyofDr.BrianOlshansky.2021/5/97WPW:CaseStudyStudiedintheelectrophysiologylaboratory电生理检查InducedAF®VF诱发房扑演化为室扑Mapping:twopathways双旁路Posteriorseptal后间隔Leftlateralaccessorypathway游离壁Ablationofbothpathways消融2条旁路Noadditionaltherapyneeded无需药物治疗2021/5/98AFwithMultiple

AccessoryPathways房扑CourtesyofDr.BrianOlshansky.2021/5/99AFwithMultiple

AccessoryPathways房扑CourtesyofDr.BrianOlshansky.2021/5/910AF®VF房扑转为室扑CourtesyofDr.BrianOlshansky.2021/5/911心动过速时的心电图表现顺向型心动过速心电图特点：QRS后可见P波，RP<PR,RP>70ms。P波与T波融合，导致T波僵硬、畸形。逆向型心动过速心电图：宽大QRS心动过速，形态与窦性心律时一致。2021/5/912左右侧旁路的判定A型预激：V1预激波和QRS主波向上，旁路位于左心房和左心室之间，即二尖瓣环上。B型预激：V1预激波和QRS主波向下，旁路位于右心房和右心室之间，即三尖瓣环上。2021/5/913PosteriorBasalView–

LeftAtrium左心房后面观R.superiorpulmonaryveinR.inferior

pulmonaryveinCoronarysinusL.inferiorpulmonaryveinL.atriumL.superiorpulmonaryveinL.auricleL.pulmonaryarteryR.pulmonaryarteryNetterF.AtlasofHumanAnatomy.1989;Plate202.2021/5/914A型预激心电图2021/5/915A型预激窦性心律时心内图2021/5/916A型预激心动过速时心电图2021/5/917心内图2021/5/918左侧旁路靶点图2021/5/919成功后靶点图2021/5/9202021/5/921A型预激2021/5/9222021/5/923心室起搏诱发心动过速2021/5/924窦性心律靶点图2021/5/925B型预激2021/5/926心动过速时心内图2021/5/927B型预激2021/5/928OrthodromicReciprocatingTachycardia顺向型KayNG.AmJofMed.1996;10:344-356.2021/5/929旁路形成的心律失常旁路逆传，房室结前传:顺向型心动过速旁路前传:房扑房颤时旁路前传导致：室速/室颤；阵发性心动过速时旁路前传：逆向型心动过速2021/5/930顺向型AVRT形成机制2021/5/931逆向型房室折返性心动过速

形成机制2021/5/932B型预激心内图2021/5/933心动过速2021/5/934另一种形态心动过速2021/5/935左侧旁路参与2021/5/936第3种形态2021/5/9372021/5/938所有旁路消融后心电图2021/5/939旁路的性质Kent束：全和无普通旁路、慢旁路

ATP无影响Mahim纤维：无逆传只有前向递减性传导2021/5/940房室旁路解剖示意图2021/5/941CatheterPlacementforAblationof

LeftFree-WallAccessoryPathway左侧旁路导管放置MoradyF.NEnglJofMed.1999;340:534-544.2021/5/942AccessoryAVPathwaysLocation: Rightfree-wall右游离壁部位 Septalaccessorypathways间隔部

Leftfree-wall左游离壁Approach: Venous,transseptalorretrogradeaortic途径静脉,穿间隔,主动脉逆行Efficacy 89-99%

疗效 Highestleft-sidedpathways

左侧旁路高

Lowerseptalandright-sidedpathways

右侧旁路低Recurrence 3-9%复发率MoradyF.NEnglJofMed.1999;340:534-544.2021/5/943旁路的标测旁路前传时:V波最早旁路逆传时:A波最早2021/5/944房室旁路的射频消融(右侧)2021/5/945左侧旁路的旁路电位2021/5/946隐匿性旁路的旁路电位2021/5/947不同部位旁路的特点左前旁路