1、起源于心外膜心律失常起源于心外膜心律失常的识别与消融的识别与消融中国医科大学盛京医院孙英贤起源于起源于心外膜心外膜心律失心律失常包括常包括哪些？哪些？心外膜旁路心外膜旁路起源于心外膜的室速起源于心外膜的室速Tricuspid Annulus LAO Projection Mitral AnnulusLA Connections RA ConnectionsLV ConnectionLV ConnectionIdeal Ablation SiteEpicardial Posteroseptal and Left Posterior Accessory Pathways:Connections B
2、etween the CS Myocardial Coat and the Atria and Left VentriclePosteriorCoronary Vein Middle Cardiac Vein Ideal Ablation siteMCVVentricularConnection Mitral Annulus Tricuspid AnnulusCS Myocardial CoatEpicardial Posteroseptal and Left Posterior Accessory PathwaysLAORAORAACSMCVPVLVMapHBABHBLVMapCSRAAMC
3、V1.2cmPVCCSRAAHBMCVRVABRAAHBMCVRV2.0cmLAORAOCSCEpicardial Accessory Pathways171 Patients99911115(9%)318120(70%)36(21%)327DiverticulaNarrow NeckWide NeckSeptal to MCV(5/27)Lateral to MCV(22/27)CSCSCSCSMCVDDDDMCVCSMCVSCV Enlargement of SCV,MCV and CS15/171(9%)Pts Bulbous Enlargement of MCV or CS(3 Pat
4、ients)Fosiform Enlargement of SCV or MCV(12 pts)LAOAtrial Diastole Atrial systoleCSMCVPV PosteriorDescending Coronary Artery Right Coronary ArteryFig 2Tricuspid Annulus Mitral AnnulusLA Connection RA Connection Ideal Ablation site Middle Cardiac VeinLocation of the Distal Right Coronary Artery Relat
5、ive to Ideal Ablation SitePosteriorCoronary Vein Ideal Ablation siteCS Angiography (LAO)RCA Angiography (LAO)LCA Angiography (RAO)CSDAblationAblationA.Before AblationB.After Ablation 左前斜位行选择性冠状动脉造影，该处未见相邻冠状动脉，心外膜旁路心外膜旁路起源于心外膜的室速起源于心外膜的室速心外膜室速的心电图特征 Pseudo delta wave34ms Intrinsicoid deflection time8
6、5ms RS complex duration121msec QRS198msCirculation 109:1842-1847,2004.心外膜室速与基础心脏病 特发性室性心动过速 伴缺血性心脏病 伴扩张性心肌病心外膜室速的心内电图特征 心内膜标测不到最早激动 心内膜的最早激动分布范围较广 心内膜起搏标测不理想 心内膜处消融不成功心外膜消融心外膜消融 冠状窦冠状窦 心外膜心外膜 其他其他(主动脉主动脉,心内膜等心内膜等)心外膜室速的消融方法后室间静脉内标测电极心内膜消融电极心外膜标测电极处隐匿拖带 经冠状静脉系统标测指导心内膜消融Heart 79:59-63,1998心外膜消融的激动标测JI
7、CE 2004,10:281-288心外膜室速的拖带标测PACE 1999.22:128-130心外膜消融心外膜消融 冠状窦冠状窦 心外膜心外膜 其他其他(主动脉主动脉,心内膜等心内膜等)心外膜室速的消融方法 经剑下穿刺心包内标测消融 心外膜拖带标测JCE 16:449-452,2005经剑下心外穿刺消融的注意事项 避免冠状动脉操作:常规行冠脉造影 心外膜脂肪垫影响消融效果:应用灌注消融 术后合并心包炎:对症抗炎镇痛 合并膈神经损伤:消融前高能量起搏心外膜消融心外膜消融 冠状窦冠状窦 心外膜心外膜 其他其他(主动脉主动脉,心内膜等心内膜等)小结 心外膜室速多伴有冠脉病变或扩张性心肌病 体表心电图及心内电图的一些特征可以提示存在心外膜室速 经心包途径是消融心外膜室速的最佳方法 心外膜消融前应常规行冠状动脉造影 必要时可行盐水灌注消融
