心脏电生理和射频消融基础课件

CardiacveinstenosisPTCAwith3.5mmballoonFinalresult7/26/20231心脏电生理和射频消融基础ModifiedSeldingertechniqueforpercutaneouscathetersheathintroduction7/26/20232心脏电生理和射频消融基础7/26/20233心脏电生理和射频消融基础SequenceofPWaveGenerationSinusNodeSAJunctionAtrium(Pwave)Non-visibleprocessontheEKG7/26/20234心脏电生理和射频消融基础AVnode“Slowzone”IVCLeadII7/26/20235心脏电生理和射频消融基础SUMMARYMechanismsofSVTAtrialTachycardiaAVNRTAVRTFPSP7/26/20236心脏电生理和射频消融基础DifferentialDiagnosisofNCTShortRPAVRTATSlow-SlowAVNRTLongRPATAtypicalAVNRTPJRTPburiedinQRSTypicalAVNRTATJET7/26/20237心脏电生理和射频消融基础SUMMARYObtaina12leadECG.ThelocationofthePwavewilldictatethedifferentialdiagnosisIfhemodynamicallyunstable(chestpain,heartfailure,hypotension)-CARDIOVERSIONIfhemodynamicallystable-AVNODALAGENTLongtermtherapydependsonmechanismandcanbeconservative,pharmacologicorinvasiveEPstudyoftenneededfordefinitivecharacterizationofmechanismandcancuremostSVTswith90%successrate7/26/20238心脏电生理和射频消融基础AVNRT7/26/20239心脏电生理和射频消融基础7/26/202310心脏电生理和射频消融基础Atrialflutter–sawtoothorpicketfence7/26/202311心脏电生理和射频消融基础Atrialflutterwithrapidresponse7/26/202312心脏电生理和射频消融基础Arrhythmias:SABlockPQRST7/26/202313心脏电生理和射频消融基础Arrhythmias:AtrialFlutter7/26/202314心脏电生理和射频消融基础StepstoreadingECGsWhatistherate?Bothatrialandventriculariftheyarenotthesame.Istherhythmregularorirregular?DothePwavesalllookthesame?IsthereaPwaveforeveryQRSandconverselyaQRSforeveryPwave?Areallthecomplexeswithinnormaltimelimits?Nametherhythmandanyabnormalities.7/26/202315心脏电生理和射频消融基础7/26/202316心脏电生理和射频消融基础7/26/202317心脏电生理和射频消融基础RateLookatcomplexesina6-secondstripandcountthecomplexes;thatwillgiveyouaroughestimateofrateCountthenumberoflargeboxesbetweentwocomplexesanddivideinto300Countthenumberofsmallboxesbetweentwocomplexesanddivideinto1500Estimateratebysequenceofnumbers(seenextslide)7/26/202318心脏电生理和射频消融基础BundlebranchblocksLookattheQRSmorphologyinV1andV67/26/202319心脏电生理和射频消融基础AVNRTAcutetreatmentATPorVerapamilCardioversionifBPLongtermDrugs,verapamilorb-blockerEPSandRFA7/26/202320心脏电生理和射频消融基础AVRTWPWorconcealedaccessorypathwayacuteandchronictreatmentsimilartoAVNRTavoidb-blockerandverapamilinknownWPW7/26/202321心脏电生理和射频消融基础AtrialFlutterMarcoreentrantcircuitinRAterminatebycardioversionwithhighsuccessratepoorlycontrolledbymedicaltherapyEPS+RFA7/26/202322心脏电生理和射频消融基础“Typicalisthmusdependentatrialflutter”isduetoamacroreentrantcircuitaroundthetricuspidvalveThisrhythmcanbestoppedbypacingandcuredwithablationEmbolicriskmaybelessthaninfibrillation,butsamerecommendationsapplyElectrophysiologyII–SupraventricularArrhythmiasAtrialFlutter7/26/202323心脏电生理和射频消融基础Ventricularrate150bpm“Sawtooth”pwavesAtrialFlutterElectrophysiologyII–SupraventricularArrhythmias7/26/202324心脏电生理和射频消融基础AtrioventricularNodalReentrantTachycardia(AVNodeReentryorAVNRT)MostcommoncauseofparoxysmalSVTintheyoungadultOccursoverasmallreentrantcircuitlocatedneartheAVnodeThecircuitconsistsofafastandslowpathwayconnectedbyacommontopandbottompathwayElectrophysiologyII–SupraventricularArrhythmias7/26/202325心脏电生理和射频消融基础AVNodeReentryTachycardiaRateof145bpm(ShortRPtachycardia)ElectrophysiologyII–SupraventricularArrhythmiasRetrogradepwavesRP=60msec7/26/202326心脏电生理和射频消融基础EctopicAtrialTachycardia(LongRPtachycardia)UncommoncauseofparoxysmalSVTintheyoungadult(<5%)OccursinasmallregionofeithertherightorleftatriumElectrophysiologyII–SupraventricularArrhythmiasFrequentlyduetoanautomaticmechanismmakingitdifficulttoreproduceinEPLab7/26/202327心脏电生理和射频消融基础Rate=160bpmPwavesRP=220msecAtrialtachycardia(LongRPtachycardia)ElectrophysiologyII–SupraventricularArrhythmias7/26/202328心脏电生理和射频消融基础Wolff-Parkinson-WhiteSyndromeRelativelycommoncauseofparoxysmalSVTinchildrenandyoungadultsDuetoan“extra”muscularbridgethatconnectstheatriumandventricleandallowstheventricletobe“excited”beforethesignalpassingthroughtheAVNodeElectrophysiologyII–SupraventricularArrhythmias7/26/202329心脏电生理和射频消融基础AccessoryPathwayMediatedTachycardias(AVReentry)7/26/202330心脏电生理和射频消融基础AVRT(ORT)AVNodeRT95%ofinfants95%ofadults7/26/202331心脏电生理和射频消融基础AVNRTManolis,AnnIM,1994AVRT

(WPW)7/26/202332心脏电生理和射频消融基础HeartDiseaseArrhythmias=abnormalheartrhythms.Bradycardia=slowerTachycardia=faster(exercise!)Flutter:extremelyrapidFibrillation:Contractionsofdifferentgroupsofmyocardialcellsatdifferenttimes.Ventricularfibrillationislife-threatening.7/26/202333心脏电生理和射频消融基础7/26/202334心脏电生理和射频消融基础TrainyoureyesTrainyoureyesforRate:CheckthecomputerTrainyoureyesforRhythm:ChecktherhythmstripCheckI,II,avFTrainyoureyesforAxis:CheckI,IITrainyoureyesforIntervals:PR:checkIIQT:checkthecomputerQRS:checkI,V17/26/202335心脏电生理和射频消融基础TrainyoureyesTrainyoureyesforLVH:Lookat…inorderavLV3V1V5,V6CheckyourcheatsheetReadthecomputerTrainyoureyesforMI:LookatallTwavesLookatallSTsegmentsCheckforQwavesCheckforRwavesinV1-27/26/202336心脏电生理和射频消融基础ArrhythmiasVentricularfibrillationrapid,uncoordinateddepolarizationofventriclesTachycardiarapidheartbeatAtrialflutterrapidrateofatrialdepolarization15-717/26/202337心脏电生理和射频消融基础BrugadaAlgorithm7/26/202338心脏电生理和射频消融基础SupraventricularTachycardiaShortRP’LongRP’AVNRT(S/F)ART(orthodromic)(-)pII,III,F(+)pII,III,FVariablepaxisAVNR(F/S)PJRTSTSNRTAVRT(slowAP)IARAATAFMATAFlutterJETIrregularOther7/26/202339心脏电生理和射频消融基础7/26/202340心脏电生理和射频消融基础Wavybaseline7/26/202341心脏电生理和射频消融基础7/26/202342心脏电生理和射频消融基础7/26/202343心脏电生理和射频消融基础Sinoatrial(SA)node7/26/202344心脏电生理和射频消融基础Internodalandinteratrialtracts7/26/202345心脏电生理和射频消融基础Atrioventricular(AV)node7/26/202346心脏电生理和射频消融基础BundleofHis7/26/202347心脏电生理和射频消融基础Bundlebranches7/26/202348心脏电生理和射频消融基础Purkinjefibers7/26/202349心脏电生理和射频消融基础ElectrocardiographyFigure18.167/26/202350心脏电生理和射频消融基础Salvoofpvc’s7/26/202351心脏电生理和射频消融基础Multifocalpvc’s7/26/202352心脏电生理和射频消融基础PAC–prematureatrialcontraction7/26/202353心脏电生理和射频消融基础RP-PRrelationship7/26/202354心脏电生理和射频消融基础Torsadedepointes–turningofthepointsortorsion7/26/202355心脏电生理和射频消融基础JunctionalrhythmYouhavelostyourPwaveoritisinverted7/26/202356心脏电生理和射频消融基础PrimaryAtrialJunctionalTachycardiasSinusTachEATAFlutterAVNRTJET7/26/202357心脏电生理和射频消融基础7/26/202358心脏电生理和射频消融基础7/26/202359心脏电生理和射频消融基础7/26/202360心脏电生理和射频消融基础Vulnerabletwave–refractoryperiodWhyventricular?Whytachy?7/26/202361心脏电生理和射频消融基础7/26/202362心脏电生理和射频消融基础Fig12asummaryofheartblocks.7/26/202363心脏电生理和射频消融基础asummaryofotherarrhythmias7/26/202364心脏电生理和射频消融基础7/26/202365心脏电生理和射频消融基础7/26/202366心脏电生理和射频消融基础CausesofSAExitBlockandSinusPauses/ArrestIncreasedvagaltone(veryintenseforsinusarrest)Drugs:betablockers,calciumchannelblockers,amiodarone,digoxin(indirecteffect)Myocardialischemia/infarctionSicksinussyndromeSequelaofopenheartsurgery7/26/202367心脏电生理和射频消融基础7/26/202368心脏电生理和射频消融基础Wolff-Parkinson-White

SyndromeTachycardias7/26/202369心脏电生理和射频消融基础7/26/202370心脏电生理和射频消融基础7/26/202371心脏电生理和射频消融基础CC5CM5ML7/26/202372心脏电生理和射频消融基础QRS电轴简单计算方法Ⅰ、Ⅱ、Ⅲ、aVR、aVL、aVF六个导联哪一个导联上的QRS波正向波幅最高，则该导联的正极方向即代表QRS电轴方向。

2。上述六个导联中，哪一个导联的QRS波负向波幅最大，则该导联的正极方向即背离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），则该导联的正极与负极均与QRS电轴呈直角。7/26/202373心脏电生理和射频消融基础WarfarinforAtrialFibrillation

LimitationsLeadtoInadequateTreatmentSamsaetal.ArchInternMed.2000;160:967-973.INRabovetarget

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PatientswithAFinPrimaryCarePractice7/26/202374心脏电生理和射频消融基础7/26/202375心脏电生理和射频消融基础Regionalanatomyrelevanttopercutaneousfemoralarterialandvenouscatheterization7/26/202376心脏电生理和射频消融基础LeftAtrialAppendage(LAA)7/26/202377心脏电生理和射频消融基础＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋－－－－－－－－－－－－－－－insideoutside7/26/202378心脏电生理和射频消融基础7/26/202379心脏电生理和射频消融基础特发性室性心动过速的射频消融7/26/202380心脏电生理和射频消融基础特发性室性心动过速的射频消融7/26/202381心脏电生理和射频消融基础7/26/202382心脏电生理和射频消融基础折返的条件7/26/202383心脏电生理和射频消融基础7/26/202384心脏电生理和射频消融基础7/26/202385心脏电生理和射频消融基础QRS波群起始部的切迹、顿挫≥0.05mV负向波7/26/202386心脏电生理和射频消融基础梗死部位对QRS波的影响Ｑ波Ｒ波切迹Ｒ波丢失深Ｓ波7/26/202387心脏电生理和射频消融基础右心房起搏导线常用位置—右心耳7/26/202388心脏电生理和射频消融基础起搏系统7/26/202389心脏电生理和射频消融基础7/26/202390心脏电生理和射频消融基础房室旁路的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7/26/202391心脏电生理和射频消融基础正常的房室传导系统7/26/202392心脏电生理和射频消融基础左侧房室旁路的定位标准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）7/26/202393心脏电生理和射频消融基础右侧房室旁路的定位标准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，二者间无等电位线，PR<0.07s预激波额面电轴左偏（－30－－60度）7/26/202394心脏电生理和射频消融基础

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。7/26/202395心脏电生理和射频消融基础前间隔房室旁路的定位标准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，二者间无等电位线，PR<0.07s预激波额面电轴正常，aVL导联预激波正向提示右前隔，反之为左前隔7/26/202396心脏电生理和射频消融基础左后间隔房室旁路定位标准V1导联P波和QRS波虽不融合，但二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7/26/202397心脏电生理和射频消融基础右后间隔房室旁路定位标准V1导联P波和QRS波不融合，因该导联预激波为等电位故使二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，其余胸导联均正向，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7/26/202398心脏电生理和射频消融基础房室旁路定位诊断步骤第一步：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）的方向确诊7/26/202399心脏电生理和射频消融基础房室旁路的精确定位房室旁路的精确定位依赖于心内电生理检查，是经导管射频消融术的必要及关键步骤。7/26/2023100心脏电生理和射频消融基础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7/26/2023101心脏电生理和射频消融基础7/26/2023102心脏电生理和射频消融基础7/26/2023103心脏电生理和射频消融基础Welcometoourdepartment7/26/2023104心脏电生理和射频消融基础7/26/2023105心脏电生理和射频消融基础7/26/2023106心脏电生理和射频消融基础7/26/2023107心脏电生理和射频消融基础Insummary...The(relatively)good:MobitzIAVblock,orWenckebachblockThebad:MobitzIIAVblock,and...Theugly:Completeheartblock7/26/2023108心脏电生理和射频消融基础TorsadesdePointes7/26/2023109心脏电生理和射频消融基础Rateinbeats/min=60/intervalbetweentwobeatsinseconds

Ahandyshortcutis:

Heartrate(beats/min)=1500/R-Rinterval(mm)1500/20=75b/min7/26/2023110心脏电生理和射频消融基础Firstdegree-prolongedPRintervalonly.ThenormalPRintervalis0.12to0.21seconds.APRinterval>0.21wouldbeclassifiedasfirstdegreeblock.

UsuallythisblockisaboveHisbundle7/26/2023111心脏电生理和射频消融基础Seconddegree-somePwavesarenotfollowedbyQRS.Oftenhasaregularsequence,i.e.,2:1or3:2.ThefirstnumberisthenumberofPwavespresentandthesecondisthenumberofQRS’s.

Whatisthis?7/26/2023112心脏电生理和射频消融基础

MobitzI(Wenckebach)thePRprogressivelylengthenswithonePwaveforeveryQRSuntilabeatisdropped.UsuallytheblockisaboveHisbundle.Thisiscommonincoronarypatientsandiscausedbyincreasedvagaltoneandusuallyeventuallydisappearswithnoproblems7/26/2023113心脏电生理和射频消融基础7/26/2023114心脏电生理和射频消融基础MobitzIIthePRisconstantbutwithoccasionaldroppedbeats.ThisisamoreseriousarrhythmiabecausetheinjuryisprobablyinfastconductingtissuebelowtheHisbundlewhichisnotundervagalcontrol.7/26/2023115心脏电生理和射频消融基础ThisisunambiguouslyMobitzIIItisadangerousarrhythmiabecausetheheartmaysuddenlystartbeatingveryslowlyorevenstop.7/26/2023116心脏电生理和射频消融基础Completeheartblock.SincethereisnoconductiondowntheAVnodepathwayatriaandventriclesbeatregularlybutatdifferentrates.7/26/2023117心脏电生理和射频消融基础SlowventricularrateUsuallytreatedwithpacemakerMaybetemporaryorintermittent.Canbeinducedbydrugsthatcauseincreasedvagotonia7/26/2023118心脏电生理和射频消融基础WPW:Normallyconductingcardiacmusclebridgesthegapbetweenatriaandventricles.TheaccessorypathwayactivatestheventriclebeforenormalactivationviatheAVnode.7/26/2023119心脏电生理和射频消融基础ThePRintervalis<0.12secDeltawavesareusuallypresent7/26/2023120心脏电生理和射频消融基础Cangetretrogradeconductioncausingreentryandatachyarrhythmia.Ifaccessorypathwayhasshortantegraderefractoryperiod,canhaveseriousarrhythmias,especiallywithatrialfibrillation7/26/2023121心脏电生理和射频消融基础7/26/2023122心脏电生理和射频消融基础Fig3NormalsinusrhythmSinustachycardiaSinusbradycardiaSinusTachycardia>100b/min1.NormalPwaves2.NormalorshortenedPRinterval3.QRSandTvectorsarenormal4.STsegmentsarenormal5.RRintervalshort<15mm 1500/100=157/26/2023123心脏电生理和射频消融基础Fig3NormalsinusrhythmSinustachycardiaSinusbradycardiaSinusBradycardia<60b/min1.PwavesarepresentandallarefollowedbyaQRS2.NormalandconstantPRinterval3.QRSandTvectorsarenormal4.STsegmentsarenormal5.RRintervallong>25mm 1500/60=257/26/2023124心脏电生理和射频消融基础Prematureventricularcontraction(PVC) 1.Arisesfromectopicfocusinventricles 2.EarlyQRSnotprecededbyaPwave(seefig4) 3.WillhaveanunusualQRSshape a)oddvector b)prolongedQRSduration7/26/2023125心脏电生理和射频消融基础Prematureventricularcontraction(PVC) 1.Arisesfromectopicfocusinventricles 2.EarlyQRSnotprecededbyaPwave(seefig4) 3.WillhaveanunusualQRSshape a)oddvector b)prolongedQRSduration 4.Acompensatorypause7/26/2023126心脏电生理和射频消融基础MultifocalPVCs.TwoseparatefociareoriginatingPVC’sIrritableventricleIFallPVCareidenticalitisfromoneectopicsite(Unifocal).7/26/2023127心脏电生理和射频消融基础Prematureatrialcontraction(PAC)1.Arisesfromanectopicfocusintheatria.2.WillhaveanidentifiablePwavebuttheshapeofthePwavemaybealtered3.MayhaveanormalQRS4.Mayhaveacompensatorypause7/26/2023128心脏电生理和射频消融基础TheQRSmaybealteredifsomeoftheventricleisstillinitsrefractoryperiod.ThecompensatorypauseislackingbecausetheSAnodewasreset.Therhythmhasbeenshifted.7/26/2023129心脏电生理和射频消融基础Atrialfibrillation1.Irregularlyirregular2.NoPwaves7/26/2023130心脏电生理和射频消融基础TheAVnodekeepstheventricularratelowMaybetreatedwithdrugstodepressAVconductionandslowtheventricularrhythm:Betablockers,calciumchannelblockers7/26/2023131心脏电生理和射频消融基础Common:willoccurinabout1/3ofthepopulationNotaseriousarrhythmiaunlessinWPW7/26/2023132心脏电生理和射频消融基础Electricalreentrycancausefibrillationsandtachycardias.7/26/2023133心脏电生理和射频消融基础Ventriculartachycardia(Fig9)1.Regularlyoccurringrhythmoriginatingfromaregularventricularectopicfocus.2.QRSmorphologyisusuallylikeaPVC7/26/2023134心脏电生理和射频消融基础Becausethecardiacoutputisverylowitusuallyproducesmyocardialischemiaandoftenprogressestoventricularfibrillation7/26/2023135心脏电生理和射频消融基础Ventricularfibrillation(VF)1.Thoughttobeareentrantexcitationoftheventricles;prematureimpulsemayariseduringvulnerableperiod2.Irregularbaselinewithnoidentifiablewaves7/26/2023136心脏电生理和射频消融基础3.Nocardiacoutput.Usuallythecauseof"suddendeath"4.Maybetheresultofischemia,lightningstrike,electrocution,chesttrauma,ordrugs5.RequiresCPRandelectricaldifibrillation.Patientsdonotspontaneouslyrecover.7/26/2023137心脏电生理和射频消融基础ExtendedphasetwocauselongQTsyndrome.7/26/2023138心脏电生理和射频消融基础Q-Tintervalisrate-dependentandisanindexofthedurationofphase2intheventricularAP12x40=480ms12blocks7/26/2023139心脏电生理和射频消融基础LongQTsyndromeProlongeddurationofphase2causesanearlyafterdepolarization.ThatcantriggeranearlyactionpotentialcausingareentranttachycardiaPatientsmayexperienceattacksofVTwithtorsadesdepointes-awaxingandwaningoftheQRSmorphology(asifcirclingaroundapoint).7/26/2023140心脏电生理和射频消融基础3.LongQTisinducedbysomedrugsandcanbeduetogeneticabnormalitiesinsomepotassiumandcalciumchannels.Atpresent5separategeneticdefectshavebeenidentifiedwhichcauselongQT7/26/2023141心脏电生理和射频消融基础14STEPSTOASSUREASUCCESSFULREADINGANDUNDERSTANDINGOFANUNKNOWNECG1.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?7/26/2023142心脏电生理和射频消融基础Fig12asummaryofheartblocks.7/26/2023143心脏电生理和射频消融基础asummaryofotherarrhythmias7/26/2023144心脏电生理和射频消融基础7/26/2023145心脏电生理和射频消融基础RALALVRVTypesofSupraventricularTachyarrhythmiasSinusNodeReentryAtrialFlutterAutomaticAtrialTachycardiaReentrantAtrialTachycardiaAtrioventricularNodal

Reentry(AVNRT)AVReentryviaanAccessory

AVConnection(AVRT)AtrialFibrillation(NotShown)7/26/2023146心脏电生理和射频消融基础TypesofParoxysmalSupraventricularTachycardiaAVNodal

ReentryAVReciprocating

TachycardiaSinusNodalReentryIntra-atrialReentry