1、CP1063458-1CP1323528-2室速消融室速消融指南建议指南建议I类适应证类适应证持续单形性室速，药物无效或不能耐受或患者不愿意长期服药，持续单形性室速，药物无效或不能耐受或患者不愿意长期服药，猝死低危患者猝死低危患者(C)束支折返室速束支折返室速(C)ICD植入后反复放电，重新程控、调整用药均无效，或不愿意接植入后反复放电，重新程控、调整用药均无效，或不愿意接受长期药物治疗的患者，导管消融作为辅助治疗受长期药物治疗的患者，导管消融作为辅助治疗(C)Circ 2006CP1206111-1“局灶局灶”“多发性多发性”流出道流出道分支分支瓣上瓣上RVLV普肯普肯野野折返折返解剖靶点解
2、剖靶点心肌病心肌病疤痕疤痕二尖瓣二尖瓣电生理策略电生理策略P.刺激刺激拖带拖带影像影像电生理电生理损伤损伤解剖解剖双电位双电位疤痕疤痕Scars0.5 mV2 mV潜在折返环潜在折返环CP1176527-5CP1233975-13横断面横断面基地部基地部心尖心尖长轴切面长轴切面间隔间隔侧壁侧壁12693前壁前壁后壁后壁CP1060083-4ABCDEV4基底部基底部心尖心尖AVRCP1060083-1AVRV4II,III,aVFCP1060083-2前壁前壁后壁后壁II,III,aVFI,aVL间隔部间隔部侧壁侧壁II,III,aVFCP1060083-3*CP1233975-13A,B,C
3、拖带，隐匿融合拖带，隐匿融合 PPI=VTCL S-QRS=EGM-QRS S-QRS VTCL S-QRS EGM-QRSF拖带，显性融合拖带，显性融合 PPI=VTCL S-QRS=EGM-QRSG拖带，显性融合拖带，显性融合 PPI VTCL S-QRS EGM-QRSABCDE*FG起搏部位起搏部位:A.缓慢传导的关键部位起搏缓慢传导的关键部位起搏B.在通道盲端起搏在通道盲端起搏C.在外环起搏在外环起搏D.环外起搏环外起搏E.无夺获无夺获ABCD哪个位置起搏与折返环有关哪个位置起搏与折返环有关?起搏部位起搏部位A.缓慢传导的关键部位起搏缓慢传导的关键部位起搏B.在通道盲端起搏在通道盲端
4、起搏C.在外环起搏在外环起搏D.环外起搏环外起搏E.无夺获无夺获*起搏部位：起搏部位：A.缓慢传导的关键部位起搏缓慢传导的关键部位起搏B.在通道盲端起搏在通道盲端起搏C.在外环起搏在外环起搏D.环外起搏环外起搏E.无夺获无夺获ABCD起搏部位起搏部位A.缓慢传导的关键部位起搏缓慢传导的关键部位起搏B.在通道盲端起搏在通道盲端起搏C.在外环起搏在外环起搏D.环外起搏环外起搏E.无夺获无夺获*起搏部位起搏部位:A.缓慢传导的关键部位起搏缓慢传导的关键部位起搏B.在通道盲端起搏在通道盲端起搏C.在外环起搏在外环起搏D.环外起搏环外起搏E.无夺获无夺获PPITCLABCDPPI=395S-QRS=26
5、5VTCL=395E-QRS=265起搏部位起搏部位:A.缓慢传导的关键部位起搏缓慢传导的关键部位起搏B.在通道盲端起搏在通道盲端起搏C.在外环起搏在外环起搏D.环外起搏环外起搏E.无夺获无夺获PPITCL*PPI=395S-QRS=265VTCL=395E-QRS=265CP1201033-1CP1270284-4VT 1VT 2VT 3VT 3CP1270284-17电压标测指导的室速消融电压标测指导的室速消融Thiele et al Circ 2001LAALACannulaEndoEpiSchweikert et al.Circulation.2003;108:1329-1335.Ed
6、uardo Sosa,JACC 2000Mitral ValveCP1063458-1Ventricular Tachycardia Ablation When and How?DISCLOSURERelevant Financial Relationship(s)NoneOff Label UsageNoneSpectrum of VT mechanismsBasic concept of reentry,entrainment,and concealed entrainment Stable,monomorphic VTUnstable VT or multiple circuitsAdv
7、anced technology and techniquesObjectivesCP1323528-2VT AblationRecommendationsClass IAblation is indicated in patients who are otherwise at low risk for SCD and have sustained predominantly monomorphic VT that is drug resistant,who are drug intolerant,or who do not wish long-term drug therapy(level
8、of evidence:C)Ablation is indicated in patients with bundle-branch reentrant VT(level of evidence:C)Ablation is indicated as adjunctive therapy in patients with an ICD who are receiving multiple shocks as a result of sustained VT that is not manageable by reprogramming or changing drug therapy or wh
9、o do not wish long-term drug therapy(level of evidence:C)Circ 2006Ventricular ArrhythmiasCP1206111-1“Focal”“Diffuse”Outflow tractFascicularSupra-valvularRVLVPurkinjeReentryAnatomic targetMyopathicScarsMitral valveEP maneuversP.StimulationEntrainmentImagingElectrophysiologyLesion creationAnatomySteps
10、 in Mapping and Ablating VT Underlying cardiac substrate,historyIschemic heart disease Idiopathic dilated cardiomyopathyOthersECG recognition of tachycardia originProgrammed stimulation,maneuversResetEntrainmentConcealed entrainmentAdvanced mappingVoltage mapping Electro-anatomical correlationImagin
11、gEpicardial approachOthersDoublepotentialsScarsScars0.5 mV2 mVPotentialcircuitsCP1176527-5CP1233975-13This VT circuit exit site is likely:A.LV/anterior/basal/lateralB.LV/posterior/apical/lateralC.LV/posterior/mid/septalD.LV/posterior/apical/septalMapping SchemeCross SectionBaseApexLongitudinal Secti
12、onSeptalLateral12693AnteriorPosteriorCP1060083-4ABCDEQRS Morphology Clues to VT Exit SiteV4BaseApexAVRCP1060083-1AVRV4II,III,aVFQRS Morphology Clues to VT Exit SiteCP1060083-2AnteriorPosteriorII,III,aVFQRS Morphology Clues to VT Exit SiteI,aVLSeptalLateralII,III,aVFCP1060083-3This VT circuit exit si
13、te is likely:A.LV/anterior/basal/lateralB.LV/posterior/apical/lateralC.LV/posterior/mid/septalD.LV/posterior/apical/septal*CP1233975-13A,B,CEntrainment with concealed fusion PPI=VTCL S-QRS=EGM-QRS S-QRS VTCL S-QRS EGM-QRSFEntrainment with manifested fusion PPI=VTCL S-QRS=EGM-QRSGEntrainment with man
14、ifested fusion PPI VTCL S-QRS EGM-QRSABCDE*FGPacing at this site is most consistent with:A.Pacing in a critical zone of slow conductionB.Pacing in a“dead end alley”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non captureABCDWhere was the pacing site in relationship to the circuit?Pacing
15、 at this site is most consistent with:A.Pacing in a critical zone of slow conductionB.Pacing in a“dead end alley”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non capture*Pacing at this site is most consistent with:A.Pacing in a critical zone of slow conductionB.Pacing in a“dead end alle
16、y”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non captureABCDPacing at this site is most consistent with:A.Pacing in a critical zone of slow conductionB.Pacing in a“dead end alley”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non capture*Pacing at this site is most consiste
17、nt with:A.Pacing in a critical zone of slow conductionB.Pacing in a“dead end alley”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non capturePPITCLABCDPPI=395S-QRS=265VTCL=395E-QRS=265Pacing at this site is most consistent with:A.Pacing in a critical zone of slow conductionB.Pacing in a“d
18、ead end alley”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non capturePPITCL*PPI=395S-QRS=265VTCL=395E-QRS=265Termination of VTCP1201033-1CP1270284-4VT 1VT 2VT 3VT 3CP1270284-17Voltage Map Guided VT Ablation55 year-old man with DCM,EF 27%Frequent ICD shocks,failed previous ablationLeft
19、Ventricular SupportThiele et al Circ 2001Induction of VT on LV SupportEndocardial and Epicardial Mapping with Left Ventricular SupportLAALACannulaEndoEpiSchweikert et al.Circulation.2003;108:1329-1335.Eduardo Sosa,JACC 2000Epicardial approach shown to be feasible for VT ablation in patients with CAD
20、.Complication seen in 4/53 patients in form of RV perforation and tamponade.Also effective for other arrhythmias(VT with&without SHD,WPW,RVOT VT,AT)especially when endocardial ablation unsuccessful.No complications reportedEndocardial and Epicardial LV AblationMitral ValveReentry mechanism is most c
21、ommonResponse to entrainment maneuvers determines the critical zone of conductionMultiple VTs and circuits are frequently presentVoltage/scar mapping is often required Epicardial approach may be required in selected patientsMost patients undergo“palliative”VT ablation for recurrent ICD shocks VT Ablation in Scar Dependent Substrate
