心脏电生理及射频消融基础

电生理相关资料CardiacveinstenosisPTCAwith3.5mmballoonFinalresultModifiedSeldingertechniqueforpercutaneouscathetersheathintroductionSequenceofPWaveGenerationSinusNodeSAJunctionAtrium(Pwave)Non-visibleprocessontheEKGAVnode“Slowzone”IVCLeadIISUMMARYMechanismsofSVTAtrialTachycardiaAVNRTAVRTFPSPDifferentialDiagnosisofNCTShortRPAVRTATSlow-SlowAVNRTLongRPATAtypicalAVNRTPJRTPburiedinQRSTypicalAVNRTATJETSUMMARYObtaina12leadECG.ThelocationofthePwavewilldictatethedifferentialdiagnosisIfhemodynamicallyunstable(chestpain,heartfailure,hypotension)-CARDIOVERSIONIfhemodynamicallystable-AVNODALAGENTLongtermtherapydependsonmechanismandcanbeconservative,pharmacologicorinvasiveEPstudyoftenneededfordefinitivecharacterizationofmechanismandcancuremostSVTswith90%successrateAVNRTAtrialflutter–sawtoothorpicketfenceAtrialflutterwithrapidresponseArrhythmias:SABlockPQRSTArrhythmias:AtrialFlutterStepstoreadingECGsWhatistherate?Bothatrialandventriculariftheyarenotthesame.Istherhythmregularorirregular?DothePwavesalllookthesame?IsthereaPwaveforeveryQRSandconverselyaQRSforeveryPwave?Areallthecomplexeswithinnormaltimelimits?Nametherhythmandanyabnormalities.RateLookatcomplexesina6-secondstripandcountthecomplexes;thatwillgiveyouaroughestimateofrateCountthenumberoflargeboxesbetweentwocomplexesanddivideinto300Countthenumberofsmallboxesbetweentwocomplexesanddivideinto1500Estimateratebysequenceofnumbers(seenextslide)BundlebranchblocksLookattheQRSmorphologyinV1andV6AVNRTAcutetreatmentATPorVerapamilCardioversionifBPLongtermDrugs,verapamilorb-blockerEPSandRFAAVRTWPWorconcealedaccessorypathwayacuteandchronictreatmentsimilartoAVNRTavoidb-blockerandverapamilinknownWPWAtrialFlutterMarcoreentrantcircuitinRAterminatebycardioversionwithhighsuccessratepoorlycontrolledbymedicaltherapyEPS+RFA“Typicalisthmusdependentatrialflutter”isduetoamacroreentrantcircuitaroundthetricuspidvalve•Thisrhythmcanbestoppedbypacingandcuredwithablation•Embolicriskmaybelessthaninfibrillation,butsamerecommendationsapplyElectrophysiologyII–SupraventricularArrhythmiasAtrialFlutterVentricularrate150bpm“Sawtooth”pwavesAtrialFlutterElectrophysiologyII–SupraventricularArrhythmiasAtrioventricularNodalReentrantTachycardia(AVNodeReentryorAVNRT)•MostcommoncauseofparoxysmalSVTintheyoungadult•OccursoverasmallreentrantcircuitlocatedneartheAVnode•ThecircuitconsistsofafastandslowpathwayconnectedbyacommontopandbottompathwayElectrophysiologyII–SupraventricularArrhythmiasAVNodeReentryTachycardiaRateof145bpm(ShortRPtachycardia)ElectrophysiologyII–SupraventricularArrhythmiasRetrogradepwavesRP=60msecEctopicAtrialTachycardia(LongRPtachycardia)•UncommoncauseofparoxysmalSVTintheyoungadult(5%)•OccursinasmallregionofeithertherightorleftatriumElectrophysiologyII–SupraventricularArrhythmias•FrequentlyduetoanautomaticmechanismmakingitdifficulttoreproduceinEPLabRate=160bpmPwavesRP=220msecAtrialtachycardia(LongRPtachycardia)ElectrophysiologyII–SupraventricularArrhythmiasWolff-Parkinson-WhiteSyndrome•RelativelycommoncauseofparoxysmalSVTinchildrenandyoungadults•Duetoan“extra”muscularbridgethatconnectstheatriumandventricleandallowstheventricletobe“excited”beforethesignalpassingthroughtheAVNodeElectrophysiologyII–SupraventricularArrhythmiasAccessoryPathwayMediatedTachycardias(AVReentry)AVRT(ORT)AVNodeRT95%ofinfants95%ofadultsAVNRTManolis,AnnIM,1994AVRT(WPW)HeartDiseaseArrhythmias=abnormalheartrhythms.Bradycardia=slowerTachycardia=faster(exercise!)Flutter:extremelyrapidFibrillation:Contractionsofdifferentgroupsofmyocardialcellsatdifferenttimes.Ventricularfibrillationislife-threatening.TrainyoureyesTrainyoureyesforRate:CheckthecomputerTrainyoureyesforRhythm:ChecktherhythmstripCheckI,II,avFTrainyoureyesforAxis:CheckI,IITrainyoureyesforIntervals:PR:checkIIQT:checkthecomputerQRS:checkI,V1TrainyoureyesTrainyoureyesforLVH:Lookat…inorderavLV3V1V5,V6CheckyourcheatsheetReadthecomputerTrainyoureyesforMI:LookatallTwavesLookatallSTsegmentsCheckforQwavesCheckforRwavesinV1-2ArrhythmiasVentricularfibrillation•rapid,uncoordinateddepolarizationofventriclesTachycardia•rapidheartbeatAtrialflutter•rapidrateofatrialdepolarization15-71BrugadaAlgorithmSupraventricularTachycardiaShortRP’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–turningofthepointsortorsionJunctionalrhythmYouhavelostyourPwaveoritisinvertedPrimaryAtrialJunctionalTachycardiasSinusTachEATAFlutterAVNRTJETVulnerabletwave–refractoryperiodWhyventricular?Whytachy?Fig12asummaryofheartblocks.asummaryofotherarrhythmiasCausesofSAExitBlockandSinusPauses/ArrestIncreasedvagaltone(veryintenseforsinusarrest)Drugs:betablockers,calciumchannelblockers,amiodarone,digoxin(indirecteffect)Myocardialische