电生理及血液动力学简介完整版

InvasiveCardiology电生理及血液动力学简介GEMS－ITPrucka应用培训教程血液动力学学习目的:心脏基础解剖学熟悉基本的血液动力学术语理解常见的心脏血动手术流程心脏解剖

为什么要进行血液动力学监测？在导管手术中提供实时而精确的压力和ECG监测及记录结合影像资料可进一步确诊心血管疾病导管手术中需监测哪些指标？不同心脏腔室及血管压力的监测瓣膜两侧的压力/压力差值测量（压力梯度）心排量(用于心功能评价)正常压力值RV25/0/4RA6/5/3LA10/12/8PA(肺动脉)25/9/15LV左室120/5/10

AO(主动脉）120/80/95PCW肺毛压11/12/9左心导管并冠脉检查基线测量选择性冠脉造影用猪尾导管进行LV左室基本功能测量LV造影LV导管回撤压测量（连续测压）心电及左心系统压力波形P-波-心房收缩(除极)***A-waveofLAQRS–心室收缩(心脏收缩)***AO舒张,LVEDP(舒末压)ST段–压低(缺血)抬高(损伤)T-波–复极或心肌舒张(舒张)***V-waveofLA,AO/LV

收缩左、右心导管并冠脉检查通常使用两根导管

猪尾导管–冠脉

Swan-ganz漂浮导管右心系统压力Fick法CO–TDCO（热稀释法心排量）CommonMeasurementsobtained左心导管,猪尾导管同步实时压力测量LV/PCWLV/AO冠脉注射心电及右心系统压力波形P-wave-Contraction(depolarization)oftheatria***A-waveofPCWandRAQRS–Ventricularcontraction(systole)***PAdiastole,RVEDPSTsegment–Depression(ischemia)Elevation(injury)T-wave–RepolarizationorMyocardialrelaxation(diastole)***V-waveofPCWandRAPAsystole,RVsystole正常O2饱和度(+/-5%)RV75%RA75%LA95%PA75%LV95%

AO95%PCW97%SVC70%IVC75%LV至AOPullback连续测压电生理基础学习目的:熟悉基本的电生理术语理解基本EP手术流程理解导管手术中在CardioLab和Mac-Lab记录的信息ReasonsforanEPStudy心律失常的评估心脏电生理传导系统异常的诊断起博器,ICD的评估心脏传导系统SANode窦房结AVNode房室结HISBundle希氏束BundleBranches束枝Purkingeefibers普肯野氏纤维心脏传导窦房结心房传导

房室结

希氏束左,右束枝蒲肯野氏纤维蒲肯野氏纤维窦房结激动心率的起始自主性70Beats/minuteP波开始心房激动右房RightAtrium房间隔InteratrialSeptum左房LeftAtriumP波持续房室结AVNode调节器Regulator自主节律50bpm延迟100msA-H间隔40-140msHISECGAH快速传导路径HISBundleBranchesPurkinjeFibersH-VInterval心室激动室间隔右，左室游离壁房室间沟A-VGrooveQRS持续期复极Repolarization不应期RefractoryPeriod休眠期RestPhase无激动性Non-excitabilityQT持续期心内电信号Intra-CardiacSignals

TheEPLabComponentsHardware可移动操作台ComputerAmplifier&StimulatorDisplayPrinterKeyboardandmouseRFablationdeviceIsolatedpowersupplyHardware(cont.)英特尔®至强®处理器E3-1225v2

4GB(2x2GB)DDR3UDIMM内存,1600MHz500GB7200RPM3.5‘’SATA3硬盘x2

1GBNVIDIAQuadro600(1个DP与1个DVI-I)16X最大可变速DVD-ROM刻录光驱

Video1forreal-timeVideo2fornon-real-time(optional)ComputerHardware(cont.)TOOP-2001AmplifierWhatis16/32/64/96channels?

PowerTOOP-2001:ExternalPowercontrols220vLineFrequency(Notchfilters)TOOP-2001:ManufacturebuildsuniqueamptospecificationCLabIIPlus:Autorecognitionof50Hzor60HzTOOP-2001B(16导)TOOP-2001C(32导)TOOP-2001D(64导)TOOP-2001E(96导)CatheterInputs16326496IntracardiacChannels0164864ECG12121212Inv.Pressure4444Hardware(cont.)AmpliferHardwareECGIECG1/2/3BP1/2MAP50HzbuttonResetbuttonPowerbuttonHardware(cont.)AmplifierPOWERGNDUSBportNetworkportStimControlCOM心脏电生理检查及射频消融手术常用仪器射频消融手术实况图BasicEPStudy患者准备PatientPrepped插入导管CatheterInsertions基线测量BaselineMeasurements起博/刺激Pacing/Stimulator(Bloom)诊断Evaluationofinformation治疗/消融治疗Intervention/AblationGenerator心脏传导的解剖RightVentricleRightAtriumLeftAtriumLeftVentricleSANodeAVNodePurkinjeFibersBundleofHisPulmonaryVein电传导ElectricPropagation70Beats/MinuteA-V顺序激动SequentialActivationRV/LV同步激动不应期RefractoryRestPeriod电－机械耦合Electro-MechanicalCoupling有效的心输出量EfficientCardiacOutput电－机械耦合心室同步收缩心肌收缩，相当于不应期250-450msArterialPressureTechniquesforRecording12导ECG双极腔内心电BipolarCatheterElectrogramsHRAHISRVCSMapping动脉压ArterialPressure12导ECG4个肢6个胸导联作为电活动的无创参考Non-InvasiveReferenceofElectricalActivity定位心律失常的来源Locatethesourceofarrhythmias室速VentricularTachycardia旁道Pathways12导ECG体表记录RecordedfromBodySurface无创Non-InvasiveECG电极Electrodes总体观察心电活动ElectricalOverviewEPCatheters双极心电BipolarElectrogram记录波形传导RecordsPropagatingWaves电极距离较近CloselySpacedElectrodes检测局部激动DetectsLocalActivation双相波单极心电UnipolarElectrogram用于研究目的ResearchApplication细胞表面记录Extra-cellularRecording较远的参考电极RemoteReference双向波术前检查Pre-ProcedureTestingWBC白细胞评估有无感染RiskofSepsisifElevatedPlateletCount血小板计数评估有无出血趋向RiskofBleedingifLowHemoglobin&Hematocrit血红蛋白及红血球PossiblealternatecauseofSyncopeSodiumandPotassiumLevels电解质Na+&K+CommoncauseofDysrhythmiaAnti-ArrhythmicMedicationsStoppedorLevelsDrawn停用抗心律失常药物12LeadECGSomehomemedsmayaltertheECG手术部位ProcedureSitesVTStudies室速GroinorArmApproachSVTStudies室上速GroinApproach股动，静脉插管PossibleArmApproach肘动，静脉插管PossibleSubclavianorInternalJugular锁骨下静脉插管ICDFollowupsareusuallynon-invasiveICD随访通常用无创方法插管CatheterInsertion局麻LocalanesthesiaSeldingertechnique通常采用静脉插管Generallyvenoussideonly左锁骨下静脉插管常用于插入冠状静脉窦导管HRA导管起博Pace:远端Distal1,2前传测试AntegradeConductionTesting记录Record:近短Proximal3,4HIS导管记录Record:近端Prox3,4中端Mid2,3远端Dist1,2RVA导管起博Pace:远端Distal1,2逆传测试RetrogradeConductionTesting记录Record:近端Prox3,4心室激动VentricularActivationCS导管记录Record:CS7,8CS5,6起博Pace:标测左侧旁路MappingofLeftSidePathways激动顺序SequenceofActivationEPProtocol方案基线传导记录BaselineConductionRecordings12LeadHRA,HIS,RV起博HRA(前传AntegradeConduction)窦房结恢复SinusNodeRecovery递增心房刺激IncrementalAtrialPacing(Wenkebach)房性期前刺激AtrialExtra-Stimulus起博RVA(逆传RetrogradeConduction)递增心室刺激IncrementalVentricularPacing室性期前刺激VentricularExtra-Stimulus术中Procedure在记录基线测量后，采用在8个刺激后增加房性早搏或室性早搏的方法检测心律失常的性质及部位AfterBaselineMeasurementsaretakenandrecorded,PacingisDonefor8beats,thenPVC’sorPAC’sareadded.房性早搏通常用于研究源于心房的心律失常PAC’sareusedforstudyofArrhythmiasoriginatingfromtheAtria室性早搏通常用于研究源于心室的心律失常PVC’sareusedforstudyofArrhythmiasoriginatingfromtheVentricles术中Procedure通过各种刺激方案可确定心律失常的类型及部位AvarietyofpacingprotocolswillrevealthearrhythmiatypeanditsbasiclocationInducingthearrhythmiathroughpacingwillhelptopinpointthearrhythmiaCathetermappingintheareaofarrhythmiainductionwillindicatethebestpositionforRadiofrequency(RF)catheterablation窦房结恢复时间SinusNodeRecoveryTime:SNRT基于超速抑制BasedonOverdriveSuppression30秒起博30secondspacingSNRT=IntervalbetweenpacingandrecoverybysinuscSNRT=SNRTminusintrinsicheartrate房性早搏AtrialExtra-Stimulus典型的Typical:8个刺激(S1ms)1个早搏(decreasingS2ms)AH传导间隔延长，最终阻滞脱落intervalextension,andeventualblock(depicted)寻找慢径Seekingslowpathway心律失常Arrhythmias室上速SupraventricularTachycardia(SVT)AVNodalReentryAVReentryWolff-Parkinson-WhiteAtrialTachycardiaAtrialFlutterAtrialFibrillation室速VentricularTachycardia(VT)房室结折返性心动过速AVNodalReentry(AVNRT)Causes:CongenitalAging–SVTCharacteristics:ReentrantActivationAroundAVNodeAtrial/VentricularActivationFastPathway(longrefractoryperiod)SlowPathway(shortrefractoryperiod)LongerP-RintervalatonsetV-AactivationonECG房室折返性AVReentry(AVRT)Causes:CongenitalCharacteristics:AccessoryPathwayatA-VGrooveRight,Left,Posterior,orSeptalAccessoryPathwayWPW综合症SyndromeCauses:CongenitalCharacteristics:AtrialArrhythmiaandAntegrade-ConductingAccessoryPathwayAccessoryPathwayatA-VGrooveRight,Left,Posterior,orSeptalShortP-Rinterval(<0.12sec)ProlongedQRSinterval(>0.1sec)SlurringoftheupstrokebyadeltawaveAccessoryPathway房扑AtrialFlutterTheFlutteringAtriaproduceasawtooth-typecharacterfortheAtrialWaveformTheAratehasa4:1ratiototheVrateTheAVNodepreventsalloftheAtrialbeatsfromreachingtheVentricles房颤AtrialFibrillationTherearenoidentifiableP-waveformsTheVentricularresponseisirregularMostoftheAtrialimpulsesareblockedbytheAVnodeAtrialrateof350-600BPMAtriumbeatsirregularlylikeJello!

室速VentricularTachycardiaCauses:MyocardialInfarctionCongenitalCardiomyopathyCharacteristics:OnlyinVentricleUni-orMultifocalSustainedorIntermittentAverageHRof150–250BPMLifeThreatening治疗Treatments/Therapies药物Anti-ArrhythmicDrugs起博器/除颤起博Pacemaker/ICDImplant射频RFAblation标测Mapping找出心律失常部位的方法Requiresameansoflocatingthesourceofthearrhythmia:用一根导管环绕心脏Moveasinglecatheteraroundtheheart使用高密度电极Useacatheterwithahighdensityofelectrodes其他Othertechnologies标测电极导管MappingCatheterRecordPaceAblateHalo电极导管BasketCatheter篮状电极导管SteerableAblationCatheter

大头电极导管消融Ablation通过发放射频能量进行消融AblationsareusuallyperformedbydeliveringRFenergy.射频产生的高温可破坏局部组织Thehightemperaturecreatedbytheenergykillsthelocaltissue.射频通过类似普通标测电极导管的大头电极进行消融RFenergyisdeliveredbyaspecialcatheterthatissimilartoanormalEPcatheter.也可用超声，微波，激光及低温的方法进行消融Alternativeformsofablationsarebeingconsidered:ultrasound,microwave,laser,andcryogenic.