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1、心室颤动和多形性室速 -消融触发灶广东省心血管病研究所 广 东 省 人 民 医 院 吴书林吴书林1 1自旋波2 2室颤的分类Wu et al. Circulation 2002;100:1859-1866快速,电恢复曲线 1(APD/DI)快速,电恢复曲线3d 细胞连接失偶联，心肌拉伸 纤维化 导致Reentry1212折返机制1313Purkinje fiber在室颤的触发和维持中作用Tabereax PB,et al:Circulation.2007;116:1113-1119PFV1414151516161717Percentage of wave-front activation pa
2、tterns at different VF durations18181919Copyright 2003 American Heart AssociationHaissaguerre, M. et al. Circulation 2003;108:925-9281.Purkinje-triggered VFA, Twelve-lead ECG showing LQTS (7th QRST complex) and polymorphic ventricular tachycardia demonstrated to be of Purkinje origin, as shown in th
3、e right panel (arrows). B, Endocardial mapping in LQTS demonstrating Purkinje triggers of multiple morphology. Each QRS complex is morphologically different but preceded by a Purkinje potential (arrow) with a varying conduction time. The same activity is also present during sinus rhythm with a short
4、 conduction time.20202121Haissaguerre, M. et al. Circulation 2003;108:925-9282.RVOT-triggered VFA, Holter demonstrates LQTS and polymorphic ventricular tachycardia, minutes later followed by VF requiring resuscitation (not shown because of tracing artifact). B, Defibrillator interrogation demonstrat
5、es isolated monomorphic premature beats that subsequently initiate VF in Brugada syndrome. C, Twelve-lead ECG demonstrating features of Brugada syndrome and characteristic RVOT premature beat, subsequently inducing an arrhythmic storm requiring 11 shocks. 22222323其他：低血钾所致VF242454岁女性,腹泻 3天,晕厥1次 25252
6、626室颤颤触发发灶消融2727 消融触发VF的PVC27例 随访2428个月，24例（89% ）无VF 常见触发灶 85% Purkinje fiber 15% RVOTHaissaguerre Circulation,2002 28282929Trigger的局部电图特点3030P电位消失伴局部室波轻度延迟3131Trigger的局部电图特点（LV）3232Trigger的局部电图特点3333短阵加速节律 Trigger消失郭成军（中华心律失常学杂志，2002）.4例特发VF， 消融触发VF的PVC,随访11个月3年无晕厥发作3434长QT的PVC353529例缺血性心肌病并VF（ICD植
7、入且有记录结果），21例经AAD和抗心衰治疗控制VF风暴。8例行Carfo标测和RFCA5例频发PVCs诱发VF，标测到激动部位位于心梗疤痕区，PVCs前有浦氏电位（PLP）。另3例偶发室早，未标测到PLP，沿疤痕区消融。8例即时成功随访106个月，1例单次VF发作，另1例出现持续单形性VT。无VF风暴出现Marrouche NF,et al. JACC.2004;43:1715-20Mode of initiation and ablation of ventricular fibrillation Mode of initiation and ablation of ventricular
8、 fibrillation storms in patients with ischemic cardiomyopathystorms in patients with ischemic cardiomyopathy3636ECG记录Carto Mapping and RFCA373738383939VF4040VE1 Target4141多形性室速 -消融触发灶4242Monomorphic VT,Pleomorphic VT and Polymorphic VT4343Mapping and Ablation of Polymorphic Ventricular Tachycardia A
9、fter Myocardial InfarctionSzumowski L,.Haissagurre M.JACC2004;44:1700-65例MI后PVT行RFCA,PVCs时，PLP提前于QRS波20- 160ms.RFCA全部成功4444Carto Mapping and RFCA靶点4545PFs电位(PLP)领先于V波(SR or VT)4646 21岁女性 心悸10余年, 反复晕厥，近 一年半每2-3月晕厥1次 Holter ： 27176 VE, 207 nonsustained VT, 425 run, 1597 bigeminy Echo： LVED 55 LVES 37L
10、VEF 57%Lian yulu2007-6-11 4747484849495050 一月后复查 症状消失 室早 0/24小时5151 6.6. Ablation Recommendations Class IIb 1. 对于由相同室性早搏触发的室性心律失常 风暴的病人，可考虑行浦氏纤维电位消融。 (LoE: C) 2. 对无症状的室性早搏，如室性早搏非常频 繁，为避免或治疗心动过速介导的心肌病， 可考虑行消融治疗。 (LoE: C)2006年AHA/ACC/HRS 室性心律失常 处理指南5252小 结1.室颤发生机制复杂 2.Purkinje 纤维和RVOT心肌在室颤触发 和维持中作用 3.消融触发灶是治疗VF和PVT的有效方法 4.ICD仍是VF治疗的有效方法 5.与结构性心脏病或心电异常相关的VF消除Trigger有效性？5353谢谢！5454
