CARTO临床应用培训课件.ppt

1、CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLYCARTOCARTO临临床应用床应用CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY Carto 3平台可用于各类心律失常的标测 1.AVNRT 2.AVRT 3.房扑 4.房速 5.房颤 6.VTCARTO 3 临床应用 CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY CARTO在旁道中的应用CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONL

2、Y右侧疑难旁道 右侧旁路的心房的插入点可能远离三尖瓣环。使用CARTO系统可以准确地找到和消融这些不常见旁路Courtesy of Anzhen HospitalCARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY标测房室交界/瓣环区域标出旁道位置记忆功能：当消融过程中导管移位或消融后旁道恢复，可轻松回到旁道部位优势：较少爆光（儿童），减少消融次数右侧常见旁道Courtesy of Runrun Shao HospitalCARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY 左侧旁道（逆行途径）Co

3、urtesy of Ningbo First Hospital导管精确显示，直指靶点体位互补，减少手术时间较少爆光（儿童，孕妇），减少消融次数AVCARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY 将逆传A波最早的CS电极高亮,显示靶点 穿间隔，导管操作更方便，减少手术时间左侧旁道（穿房间隔）Courtesy of Dr.Cal at Casilino Hospital,Rome.CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY旁道（心室起搏下标测）-参数设置机制:大折返（但当作局灶标测）关键

4、部位:二尖瓣环，三尖瓣环标测方式:心室起搏时，稳定模式下逐点激动标测或FAM+激动标测逆传A波参考通道:体表QRS波或起搏钉标测通道：标注逆传A波 MAP1-2电位的起始,同时利用单极M1来验证兴趣窗:从起搏钉后10ms至QRS波后方（需包含所有逆传A波）Point Viewer窗口的排列:体表导联，多个CS通道，MAP 1-2,MAP 3-4和M1通道CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY旁道（心室起搏下标测）-手术流程穿刺股静脉和锁骨下静脉，分别放置右心室电极、高右房电极、6极His束导管和冠状窦电极。常规电生理检查，诱发心动过

5、速，鉴别诊断明确为AVRT。心室起搏时，利用NaviStar 4mm导管（右侧旁路）或Thermocool导管（左侧旁路）沿三尖瓣或二尖瓣环逐点激动标测或FAM同时激动标测逆传A波。标测方法类似于局灶性房速，沿瓣环“热点追踪”最早逆传A波。在最早逆传A波处，结合单极电位，放电消融，及时标记消融点。消融后，心室起搏下，室房分离或室房沿房室结逆传，则手术成功。CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY显性旁道（心房起搏下标测）-参数设置机制:大折返（但当作局灶标测）关键部位:二尖瓣环，三尖瓣环标测方式:心房起搏时，稳定模式下逐点激动标测或F

6、AM+逐点激动标测最早V波参考通道:体表QRS波或起搏钉标测通道：标注前传V波 MAP1-2电位的起始,同时利用单极M1来验证兴趣窗:从起搏钉后10ms至QRS波结束。Point Viewer窗口的排列:体表导联，多个CS通道，MAP 1-2,MAP 3-4和M1通道CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY显性旁道（心房起搏下标测）-手术流程穿刺股静脉和锁骨下静脉，分别放置右心室电极、高右房电极、6极His束导管和冠状窦电极。通过心电图初步定位旁道位置。常规电生理检查，诱发心动过速，鉴别诊断明确为AVRT。高右房起搏下，利用NaviS

7、tar 4mm导管（右侧旁路）或Thermocool导管（左侧旁路）沿三尖瓣或二尖瓣环逐点激动标测或FAM同时激动标测前传V波。标测方法类似于局灶性室速，沿瓣环“热点追踪”最早前传V波。在最早前传V波处，结合单极电位，放电消融，及时标记消融点。消融后，体表心电图预激波消失，心室起搏下，室房分离或室房沿房室结逆传，则手术成功。CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLYCARTO在旁道中的应用优势 激动标测准确-帮助标测旁道走向，提高成功率 导管精确可视 -缩短手术时间、减少X线曝光量 标记损伤靶点 -容易机械阻断的旁道，提高成功率CART

8、O 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY CARTO在AVNRT中的应用CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY复杂AVNRTKoch三角解剖结构变异CARTO帮你精确的标测出HIS更好的消融靶点，提高手术成功率Courtesy of Huashan HospitalCARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY冠状窦造影CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY常见 AV

9、NRT 推荐方法：电生理检查+选择FAM快速建模Courtesy of Ningbo First HospitalCARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY常见 AVNRT熟练术者：电生理检查+直接标记HIS束区域CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLYAVNRT解剖消融-参数设置机制:折返性关键部位:慢径标测方式:窦律时，稳定模式下逐点标测或FAM重建解剖模型参考通道:CS A波或体表QRS波的最高点或最低点 标测通道：MAP1-2电位的最高点兴趣窗:I.CS A波为参考，从

10、P波起始前80ms至QRS波前；II.QRS波为参考，从-240至-40ms。Point Viewer窗口的排列:体表导联，参考通道，MAP 1-2,MAP 3-4和M1通道CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLYAVNRT解剖消融-手术流程穿刺股静脉和锁骨下静脉，分别放置右心室电极，高右房电极、6极His导管和冠状窦电极。常规电生理检查，诱发心动过速，鉴别诊断明确为AVNRT。利用NaviStar 4mm导管标记冠状窦口和His位置（不建模）。标记His位置时应记录多个His位点（称为His束云），特别是最下方的His位点。结合解剖

11、位置和大头上电位，放电行慢径改良，放电时注意大头的位置和腔内电图变化，防止并发症。放电消融后，重复电生理检查，若心动过速不能诱发，手术成功。CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLYCARTO在AVNRT中的应用优势 标记希氏束 -避免损伤，减少并发症 导管精确显示-指导解剖位置和靶点 提示解剖变异-提高手术成功率CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY CARTO在房扑中的应用CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY

12、典型房扑-参数设置机制:大折返关键部位:三尖瓣峡部（CTI）标测方式:心动过速时，稳定模式下逐点激动标测或FAM+逐点激动标测参考通道:CS 9-10或CS 7-8 A波的最高点或最低点 标测通道：标注MAP1-2电位的起始兴趣窗:采用Dr.De Ponti的方法，兴趣窗占TCL的95-100%，P波在兴趣窗的中间Point Viewer窗口的排列:体表导联，参考通道，MAP 1-2,MAP 3-4和M1通道CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY典型房扑-手术流程穿刺股静脉和锁骨下静脉，分别放置右心室电极和冠状窦电极。自发或诱发心动

13、过速后，右房多点拖带证实为典型房扑。心动过速下，NaviStar Thermocool导管逐点激动标测或FAM同时逐点激动标测。重点标记出三尖瓣环，下腔静脉，冠状窦口，His束等解剖位置。右房标测完成后，打开“early meet late”功能，观察激动传导顺序。从三尖瓣环6点开始放电消融，线性消融至下腔静脉。（消融时，主图足位，辅图RAO45+透明化）消融过程中房扑终止，继续放电完成消融线。起搏验证三尖瓣峡部双向阻滞（见下文）。重复心房刺激，若不能诱发，手术成功。CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY 典型房扑-6点法消融穿刺股

14、静脉和锁骨下静脉，分别放置右心室电极和冠状窦电极。自发或诱发心动过速后，右房多点拖带证实为典型房扑。足位下，NaviStar Thermocool导管在三尖瓣侧取3个点（右图绿点），下腔静脉侧取3个点（右图粉色点）。从三尖瓣环6点开始放电消融，线性消融至下腔静脉。（消融时，主图足位，辅图RAO45 ）消融过程中房扑终止，继续放电完成消融线。起搏验证三尖瓣峡部双向阻滞（见下文）。重复心房刺激，若不能诱发，手术成功。CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY典型房扑-峡部阻滞验证（a)起搏CS 9-10，沿三尖瓣环，Remap右房激动顺序。

15、参考零点设为起搏钉；兴趣窗从起搏钉后10ms至200ms。若激动顺序为绕三尖瓣环逆时针传导，且最晚激动在消融线的游离壁侧，证明三尖瓣峡部顺钟向阻滞。(b)消融导管放置在低位右房（消融线的游离壁侧），起搏M1-2，测量起搏信号至CS9-10 A波距离；然后起搏M3-4，测量起搏信号至CS9-10 A波。若前者大于后者，证明三尖瓣峡部逆钟向阻滞。CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY疤痕性房扑-参数设置机制:折返性关键部位:先前的消融部位、先前的手术疤痕、房间隔补片等疤痕之间的缓慢传导标测方式:心动过速时，稳定模式下，逐点激动标测或FA

16、M+逐点激动标测参考通道:CS A波的最高点或最低点 标测通道：标注MAP1-2电位的起始,同时利用单极M1来验证兴趣窗:采用Dr.De Ponti的方法，兴趣窗占TCL的95-100%，P波在兴趣窗的中间Point Viewer窗口的排列:体表导联，参考通道，MAP 1-2,MAP 3-4和M1通道CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY疤痕性房扑-手术流程术前回顾患者既往病史，外科手术史和消融史，分析体表心电图。穿刺股静脉和锁骨下静脉，分别放置右心室电极，高右房电极和冠状窦电极。自发或诱发心动过速后，右房多部位及冠状窦近、远端拖带

17、初步判断房扑位置。心动过速下，NaviStar Thermocool导管逐点激动标测或FAM重建同时逐点激动标测。标记双电位、碎裂电位、疤痕等特殊电位。右/左房标测完成后，打开“early meet late”功能，查看是否出现红接紫。切换到激动传导图，观察激动传导顺序。在房扑关键峡部拖带验证，结合疤痕和解剖结构，设计消融线。放电消融，消融过程中房扑终止，继续放电完成消融线。验证消融线阻滞，重复心房刺激，若不能诱发，手术成功。CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLYCARTO在房扑中的应用优势 明确折返机制 -缩短标测时间，减少无效放

18、电 指导线性消融 -保证消融线连续性，发现漏点 有效验证阻滞 -验证双向阻滞，提高成功率CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY左房房速CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY RA是旁观者 最早点位于LIPV附近左房房速Courtesy of Dr.Dr Cal at Casilino Hospital,Rome.CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY左房局灶性房速Courtesy of Dr.Cal at Ca

19、silino Hospital,Rome.无需高密度标测热点追踪寻找最早激动点CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY不典型房扑CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY 使用FAM可获得CT般的解剖影像 使用FAM可大大缩短房颤学习曲线 清晰的Lasso导管显示可减少X线房颤Courtesy of Dr.Liu Xu at Shanghai Chest HospitalCARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY房颤Co

20、urtesy of Dr.Li Yigang at Shanghai Xinhua HospitalCARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY指导肺静脉隔离CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLYRVOT VTCourtesy of Dr.Chu Huimin at Ningbo First HospitalCARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLYCourtesy of Dr.Cal at Casilino Hospi

21、tal,Rome.LVOT VTCARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY左室乳头肌室早LAORAOCARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY左右分支形室速CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY左室乳头肌室早CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY左室乳头肌室早CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY

22、基质改良消融晚电位消融碎裂电位消融孤立电位消融疤痕间的残存心肌设计消融线CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLYLightNormalDenseCARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY疤痕相关室速疤痕相关室速-心内膜基质标测心内膜基质标测后前位后前位左侧位左侧位CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY心内膜碎裂电位心内膜碎裂电位CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY心内膜消融室速仍频繁发作心内膜消融室速仍频繁发作后前位后前位左侧位左侧位CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY心动过速时心外膜舒张期电位心动过速时心外膜舒张期电位CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY心内膜和心外膜标测心内膜和心外膜标测CARTO 3 TRAINING COURSEFOR PHYSICIAN TRAINING ONLY