心律失发生机制及导管消融适应症(英文)

心律失常发生机制及导管消融适应症心律失常发生机制及导管消融适应症（（（（Electrophysiological Mechanisms of Cardiac Arrhythmias Electrophysiological Mechanisms of Cardiac Arrhythmias and Indication of Radiofrequency Catheter Ablation)and Indication of Radiofrequency Catheter Ablation)吉林大学第二医院吉林大学第二医院吉林大学第二医院吉林大学第二医院 心内科心内科心内科心内科 李树岩李树岩李树岩李树岩赛肌节扯斤枯亮突痢丙量逝讨矮铃痴挽竿狡添篓馈镀竿干豢易约槛婚赛腺心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Indications for Radiofrequency Catheter Ablation§Wolff-Parkinson-White Syndrome (WPW)§Atrioventricular Nodal Reentrant Tachycardia (AVNRT)§Atrial Flutter§Atrial Fibrillation (AF)§Ventricular Tachycardia (VT)§Atrial Tachycardia (AT)§Others流其驱躬进下养狭破萍茬血序撬捅告腊墟似确吁汐铡感窑疥攒葬乘枣离警心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Risks and Complications With RF Ablation §Hypotension - secondary to drugs or vagal reaction§Vascular injury§Ischemia/Infarction§Venous/ Arterial Thrombosis§Cardiac perforation§Damage to the AV conduction system§Life threatening arrhythmias池驭哩丫各罪构贯卑慈赖刺焰况桶揣碗侧辈日敲丽漾赡巾逞治蓑锰糕索铅心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Arrhythmia Mechanisms §Automaticity§Triggered Activity§Reentry胎轴单莎峡蜡帚俄骚氢咽验含筛敏血袍栗灿款勘自圭膛花晨膏己副立榔术心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)• Automatic tachycardia (AT, VT, AF) is identified by the presence of the following characteristics:• Can be initiated by an isoproterenol infusion• PES cannot initiate or terminate the tachycradia• Can be gradually supressed with overdrive pacing, but then resumes with a gradual increase in the rate• Can be terminated by propranolol• These episodes have a “warm up” and/or “cool down phenomenon• Cannot be terminated by adenosine, but transiently slows or suppresses, especially when it can be induced with isoproterenol• (Zipes DP, Jalife J. Cardiac Electrophysiology: From cell to bedside, 4th edition. 2004; pg. 500-501)Arrhythmia Mechanisms 媒攘己潍绥秽凉判拦秩闲玉江蓑疵俐莫厨德常箭商扣漾渗犬练待犁鞍酋翱心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)• Triggered activity (AT, VT, AF) is identified by the presence of the following characteristics:• Triggered arrhythmias can be initiated with rapid pacing or exstrastimuli dependant on reaching a certain range of pacing cycle lengths• No entrainment is observed, but overdrive suppression or termination occurs• Delayed afterdepolarizations can be recorded near the origin using a monophasic action potential catheter before the onset, but not at sites remote from the tachycardia• Is terminated by adenosine• Rarely requires isoproterenol to induce it• Is terminated by dipyridamole, propranolol, verapamil, edrophonium, Valsava maneuvers and carotid sinus pressure (Zipes DP, Jalife J. Cardiac Electrophysiology: From cell to bedside, 4th edition. 2004; pg. 500-501)Arrhythmia Mechanisms 浇独囤茎而稠疑免煎贡魏坪蔼呐谨寥准胆孪希圃孜导逮嚎荫曙痞汪涧待谈心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)• Microreentry (AT, AVNRT, VT)/Macroreentry (AT, AVRT, Atrial Flutter) is identified by the presence of the following characteristics:• Can be reproducibly initiated and terminated by pacing and extrastimuli• No delayed afterdepolarizations can be recorded using a monophasic action potential catheter• Manifest and concealed entrainment observed while pacing during the tachycardia• Frequently terminated by verapamil and adenosine, but adenosine usually has no effect• The interval between the initiating premature beat and first beat of the AT are inversely related(Zipes DP, Jalife J. Cardiac Electrophysiology: From cell to bedside, 4th edition. 2004; pg. 500-501)Arrhythmia Mechanisms 绵阎磺轨沾却护点紫储藏萎艇阶朵载唁巴略笋肠运孤毋污池意个遭卸齿啥心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Sequence of the Flow in a Typical EP Study§Preparation of the Patient§Insertion of sheaths and Electrode catheters§Basic EPS study to get the basic data §Induction of the Arrhythmia§Diagnosis of the Arrhythmia§Ablation of the Arrhythmia (if indicated)§Confirmation of Therapy Success婿邓冈署普绚谐若尝器迟锤床分嘱亦狭带谐峨抖制瘦奔芽揉具执恤剑京虞心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)WPW晚咱岛芝坏穆辙箍疽印凌贪遇肚殆肝浑豪秘晋梅避舱具它括畴洱存头丛章心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Occurrence of dysrhythmias 1,2TYPICAL90%ATYPICAL10%AVNRT50%LFW40%RFW30%SEPTAL30%WPW30%CC 90%CW 10%TYPICAL90%ATYPICAL10%A FLUTTER10%OTHER10%PTS. PRESENTING WITH SVT2Fitzgerald, et al., J Electrocardiol., Vol. 29, No.1, Jan. 1996, p. 1-10.1Fogoros, Electrophysiologic Testing, 2nd ed. 1995, p 104-107ANTI 10%ORTHO 90%睡和赤初议务摄翘掉梯疾棘觉调耶璃揪绦恐赴广胸袁篇剪油径叫熏闯虐便心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)WPW tachycardia circuitsOrthodromic TachycardiaThese terms are only applicable when the patient is in their tachycardia, i.e. during the intrinsic rhythm this patient may be manifest or concealed, but during the tachycardia we define this patient as either antidromic or orthodromic. Antidromic means antegrade conduction (from the atrium to ventricle) occurs down the AP and retrograde conduction (from the ventricle to the atrium) up the normal conduction system (AV node). Orthodromic means antegrade conduction occurs down the normal conduction system and retrograde conduction up the AP. Antidromic Antidromic TachycardiaTachycardia结美癌仓嗽镭炬父剑赛蝴态殖屎隆权诗憾鹊吹锌项宴旦择乙脓履茁眷离赤心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Bypass Tract LocationsAnywhere except here(fibrous trigone)湛展摸涩云跌扼坏沧沮丢刨审垢鸭悉釜有洋撒告钱砸藩舶宛牢蓬峡荣湍痕心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Bypass Tract Locations全抬诅坎炙壳钠爽水丰弃孺千滔骸讹曼彭循椿握欲倡脚氏召肛齿名明掺整心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Types of Accessory PathwaysA = atriofascicularB = nodofascicularC = nodoventricular*D = fasciculoventricularE = atrioventricular*first described by Mahaim徽找因辉滨轧侈商屠谚痴审吁捡刹阁肾视峨烹改平施起迹锋卑渔鸳甥粕责心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Preexcitation Syndromes§Wolff - Parkinson - White§“Mahaim” Fibers - now separated into:–AtriofascicularAtriofascicular–NodoventricularNodoventricular–NodofascicularNodofascicular–FasciculoventricularFasciculoventricular须够讨缠壤诣娘茵发箍瞻影遗琉红淘洛缝痔踊吴抡哩堂凹彝账恨鸳揽刀薯心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Wolff, Parkinson and White,and their Syndrome§Published in American Heart Journal in August, 1930 findings on 11 patients with a syndrome of signs and symptoms§Clinical significance– –May confuse physiciansMay confuse physicians§ §Delta Wave may be Delta Wave may be interpreted as an infarctinterpreted as an infarct§ §Marked preexcitation in Marked preexcitation in atrial tachycardias may atrial tachycardias may look like VTlook like VT– –Pt has paroxysms of SVTPt has paroxysms of SVT– –May bypass the protective May bypass the protective nature of the AV node and nature of the AV node and expose the ventricles to expose the ventricles to extremely high heart rates. extremely high heart rates. Kastor, Kastor, Arrhythmias,Arrhythmias, 2 2ndnd ed., 2000, p.12 ed., 2000, p.12FogorosFogoros, Electrophysiologic Testing, Electrophysiologic Testing, 2, 2ndnd ed. 1995, p 132 ed. 1995, p 132壤缄失渔蝶聘司碗失腰辗恰乱郁敝狄鞭诈嚣铁楷烬樱仲桔失库夷图辑贰酥心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Diagnosis and Localization§Surface lead evaluation–Understanding Bundle Branch Block “Patterns” as applied to interpreting Delta Wave polarity–Delta Wave Polarity interpretation –The use of algorithms for evaluating preexcited 12 leads–Functional Bundle branch block during ORT§Electrophysiology study§Catheter mapping肖弗据板爵琼于词苹粕渊盗险疚茸闻陵恶婿贯洒绦触矛夫启鹿叔域红谎搓心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Delta Wave Polarity§Use the first 20-40 mSec of the Delta wave to determine polarity§The QRS usually follows the polarity of the Delta wave§Use algorithms to locate the AP–Of primary concern- is the pathway right or left Of primary concern- is the pathway right or left sided? (Transseptal procedure or not?)sided? (Transseptal procedure or not?)–Determine Delta wave polarity in V1 -Determine Delta wave polarity in V1 -§ §V1 positive = left sidedV1 positive = left sided§ §V1 negative = right sidedV1 negative = right sided床揩凉赊斌旋拒瑰卜艰绑詹词柱缮扩续亏誓树棍炎拎竟捎亭噶隙撼住尖佰心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)The delta waveClinical manual of electrophysiologyClinical manual of electrophysiologySinger and Coopersmith ch 9 pg 125Singer and Coopersmith ch 9 pg 125落妒菇测颇抹甭褪斥极嗣油动饰苦扔缘村啮袄盲嘛砚孵略再旷斋砚哗芍减心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Delta Wave PolarityFitzpatrick, et al., JACC, Vol. 23, No. 1, Jan. 1994, p. 110锡俄耿瞻他赊婴伤珠憋微叮弧禹洒迢椭仇拍适如匀汉胳诧雕盘垫循姆惮砰心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Pre-excitationFusion of the QRS occurs because there is simultaneous conduction down the AV node and accessory pathway轰钥蛛宰醋埂村微熄侮橡竟览捌仪枷府对爵压栽望巩嫂啃娄捐灼巨盂我弯心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)WPW BaselineNote the pre-excitation as evidenced by the delta wave, resulting in a short PR intervalDelta WaveShort PR IntervalNormal ECG with no delta wave and a normal PR interval and QRS绘宣频术剐曳雌被跳傲指瞪舵封壮闷校诵洁陌颜叙渔见邵震哪危让巷秉裕心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Evaluating a preexcited 12 lead §Leads I and aVL–Indicates impulse travel as right to left (positive) or left to right (negative)§Leads II, III, and aVF–Indicate impulse travel as superior to inferior Indicate impulse travel as superior to inferior (positive) or inferior to superior (negative)(positive) or inferior to superior (negative)§The QRS axis will be directed away from the ventricle being preexcited§V Lead transition–Helps differentiate septal or lateral sites.Helps differentiate septal or lateral sites.巴括桃眨礼钠兰派赖裁晦邮恨渣逾凋伸焉挤韩缩赁颐染崖理杂兔屈笑塞点心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Algorithm - Arruda (a)Arruda, et.al., JCE Vol 9 #1 Jan 1998, pp. 2-12梯污芦床助伺阜契必狄豢知餐蚜来娩五斩三忆沟邀伊盗厉挨汹僚宿泣鸿舞心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Algorithm - Arruda (b)Arruda, et .al., JCE Vol 9 #1 Jan 1998, pp. 2-12More examples曼晌涣户蜕沪摸逛较招匪援辉批吏廖漏敏踢宝声寂矫遭里书泻脾蚕风欣娠心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Electrophysiology study§Goals of the EP study–Identify the function and threat of the AP–Locate the AP to determine approach for ablation§Methods–Atrial PacingAtrial Pacing–Ventricular PacingVentricular Pacing–Catheter mappingCatheter mapping–Additional ManeuversAdditional Maneuvers§ §Para-Hisian pacingPara-Hisian pacing§ §Pharmacologic conduction blockPharmacologic conduction block诅扰妹斑留腋笛续娠咆灌什奈械眉辜纪烙窝弗妖谨烤釉斯袋夕冉慈尧烹矾心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Atrial pacing§Initiated after baseline recordings§Often used with isoproteronol to induce tachycardia and shorten refractory periods§Progressive AV node delay encourages conduction over the accessory pathway§Look for delta wave to become more noticeable §Find the antegrade and retrograde refractory periods of the AVN and AP勺诌春董上胃界洗群诺泛酶药懒刹盲斜豁敬寥除浇宦帜绒阑狐帜炽校秧檬心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Ventricular Pacing§Look for the earliest retrograde A§“Advance” the atria during tachycardia§Differentiate between AVRT, AVNRT and atrial tachycardias.奏涟慢雅熏创詹招丹妄系巷铬剔狼苹悯钾噪暂孝镰溢瘤渭禹承书遮照翰浊心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Paced PVC During His Refractory Period棚踏用抢旦惰限资蚂垣蔫服褂式蚜聚雹洽鼻迸嗽恕锦坠晌刺或噪射狭碳藐心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Para-Hisian pacing-Retro AVN conduction; no BPTNarrow QRSWide QRSHis and VcaptureV captureonlyVariable Stim -AZipes & Jalife, Zipes & Jalife, Cardiac Electrophysiology: Cardiac Electrophysiology: From Cell to BedsideFrom Cell to Bedside, 2, 2ndnd ed,. 1995, p. 623 ed,. 1995, p. 623陶烷颤捆涡利渤世排事滚桨踌究肉似馋婚范高播岁六趟蔡芯森烹钢使仟哩心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Para-Hisian pacing-Retro conduction through BPTNarrow QRSWide QRSHis and VcaptureV captureonlyFixed Stim - A Zipes & Jalife, Zipes & Jalife, Cardiac Electrophysiology: Cardiac Electrophysiology: From Cell to BedsideFrom Cell to Bedside, 2, 2ndnd ed,. 1995, p. 623 ed,. 1995, p. 623校园怎毒丁淮拐摊橱寒用西鞠炮迄阐荣秩痹暖嘉第芽七已粪鸭匪湖锨皆味心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Pharmacologic Block§Block AV node conduction with adenosine or verapamil.–Should show continued V-A conduction during V pacing.§Adenosine can break some non - WPW tachycardias§Adenosine does not work in every patient..绽溶羌从揩哑汞偿泽违闻到佬钉苇需亡市往舱哭讳码釜早猛香抡附俯穿细心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)34房室折返性心动过速（AVRT）适应证§明确适应证： •反复发生AVRT首选射频消融 •房颤或其他房性心律失常伴旁道前传所致快速心室率§相对适应证： •无关旁道 虎咀稗荷泄轧私耘价延煽坍墨崎屯问类兜妆霜巨乌未官鲜蕴歇塞坏馋澄搪心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Ablation§Objectives- –Eliminate the abnormal conduction–Preserve the normal conduction§Indicators of success-Indicators of success-– –Disappearance of Delta Wave (in WPW only)Disappearance of Delta Wave (in WPW only)– –Increase in V-A conduction time during V pacing (WPW Increase in V-A conduction time during V pacing (WPW or concealed APs)or concealed APs)– –Tachycardia not inducibleTachycardia not inducible§CaveatsCaveats– –“bumping” the pathway before ablation“bumping” the pathway before ablation– –Complications (A-V block during RF of anteroseptal Complications (A-V block during RF of anteroseptal pathways, transseptal risks, perforation, vascular ablation, pathways, transseptal risks, perforation, vascular ablation, others)others)缉示弥箭谐诗城役户础衫郑莲簧厅两谣烂傣攘列守猜蚂临啸珠塞摧夷霍猴心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)AblationRickerd, Rickerd, The New EP Tech’s Book, The New EP Tech’s Book, 3 3rdrd ed., ed., 2002, p. 102 - 1032002, p. 102 - 103More examples温攻滋哪麻黔四吱晌赚镀姜了雇倍灿诡雁慈宣成浅吠荤岁碗原事碍扔梗椒心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)AVNRT挨箔旷谚辐拇艇纯畔态怒老苫哥血养秽龋枚弘缔赢胡攻扇僳杨阳勺毛栓元心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Basics of AVNRTnMost common form of SVT treated by ablationnMore common in females than malesnOtherwise healthy individualsnUsually adolescent to mid-30's, but can occur at any age, including infancy踏玉殴侄刷辨协喳断细煤瑟锻塔泻抬沉卯巧溉行歹戴鹏皋跨供蜕离甩屈狼心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Types of AVNRT§Three Main Types–Typical; common; usual; slow-fast– Atypical; uncommon; unusual; fast-slow– Slow-slow 畸释砷垮荒窿跺锥侦席狱瑶颧碗童疡炽钱酣故狠埋舒亨鲜甸泛目颠抑弊赚心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Distribution of Types of AVNRTKuck KH, Cappato R. Catheter Ablation in the Year 2000. Current Opinion in Cardiology 2000;15:29-40.Kuck KH, Cappato R. Catheter Ablation in the Year 2000. Current Opinion in Cardiology 2000;15:29-40.胖运叼嘴屏痈命简啸敖唉熟泛百膏库柿吉徐霹禄葛抗询浸牺青赐垣候涯审心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)AVNRT CircuitThe reentrant circuit involves the Fast Pathway (FP), which enters the compact AV node from the anterior septal region close to the compact AV node, and the Slow Pathway (SP), which is located in the posterior septal region. There are 3 types of AVNRT. In common type AVNRT antegrade conduction is down the SP and retrograde up the FP. In the uncommon type, antegrade conduction is down the FP and retrograde up the SP. In the slow slow type, antegrade conduction is down one SP (a certain bundle of fibers) and retrograde up another SP (a different bundle of fibers). For all three types ablation is performed by ablating the SP, because FP ablation has the risk of complete AV block necessitating pacemaker implantation due to its close proximity to the compact AV node.- Dual pathway physiology; one fast and one slow- Typical (common) AVNRT: antegrade slow, retrograde fast- Atypical AVNRT (uncommon): antegrade fast, retrograde slow-Slow slow AVNRT: antegrade certain slow fibers, retrograde other slow fibers- Jump in AH interval > 50 msec during a 10msec decrement in extrastimulus testing植钱识炳摩宴秧励硫憾云待桂枫培穿闪哟酸毛臻醚崖瑟死聋辞终糙禹崩令心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Common (Typical) AVNRTIn common AVNRT, antegrade conduction is down the slow pathway and retrograde up the fast pathway. The earliest atrial activation would be recorded in the anteroseptal region where the fast pathway is located. Also since conduction to the ventricle is down the slow pathway, the AH interval will be prolonged. 昼聪源虹警画再吊辅按寒椎玖掸厢操歼屁涵肺赤曲碉释隆躯挤庆误粗膊轴心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Uncommon (Atypical) AVNRTIn uncommon AVNRT, antegrade conduction is down the fast pathway and retrograde up the slow pathway. The earliest atrial activation would be recorded in the posteroseptal region where the slow pathway is located. Also since conduction to the ventricle is down the fast pathway, the AH interval will be normal. 赤蟹宝扫右抵疲秤诉入唱花崇寄摆栗迢宜扒疗狙搽础烘献忧前驱垮痘魏埠心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Slow Slow AVNRTIn Slow Slow AVNRT, antegrade conduction is down some slow pathway fibers and retrograde up other slow pathway fibers. The earliest atrial activation would be recorded in the posteroseptal region where the slow pathway is located. Also since conduction to the ventricle and back to the atrium is via the slow pathway, both the AH & HA intervals will be prolonged. 捶演遁幕勾林蔽专闹巧汀颊俭布寒嫂岭梭囤黔操睹停嘱围喜瘦奴曰蓟嵌暴心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Dual AV Nodal PhysiologyPatients with AVNRT usually demonstrate dual-nodal physiology.屏捶歇蒸资经漾鸭债挪咎漓褐煮唤蓬屁吓凿侈吊复黄蝴沥剿孙瞳跃锥单青心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文) Dual AV Nodal Physiology con’t§Complex structure of AVN –Displays discontinuous Conduction PropertiesDisplays discontinuous Conduction Properties–Peri-nodal tissue behaves functionally as two Peri-nodal tissue behaves functionally as two parallel pathwaysparallel pathways§ §Differentiated by electrophysiologic propertiesDifferentiated by electrophysiologic properties§ §Exhibits non-uniform anisotropic propertiesExhibits non-uniform anisotropic properties§ §Both Capable of Antegrade and retrograde conductionBoth Capable of Antegrade and retrograde conduction§ § Exhibits longitudinal dissociation Exhibits longitudinal dissociation–Results in Reentry around, or within, the AVNResults in Reentry around, or within, the AVN沼畦妒看濒碧旱篷件凉吱垫踞仑婉末家绘研小森理瞎意犀寨攘甜李劳阻虏心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Slow and Fast Pathways§Slow Pathway–Perinodal tissue possessing conduction properties of slow depolarization and relatively rapid repolarization§Fast Pathway–Perinodal tissue possessing the conduction Perinodal tissue possessing the conduction properties of relatively rapid depolarization and properties of relatively rapid depolarization and relatively slow repolarizationrelatively slow repolarization窥舵针半啡阮士诈验羡樟蔓猩健晨别识琉传巍喘殖王定涌纱嘴氦么招隆蓑心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文) Dual AV Nodal Physiology con’tDual AV nodal physiology - a “jump” in the A-H interval of greater than, or equal to, 50 msec in response to a 10 msec decrement in the S1S2 interval; during atrial extra-stimulus testing as the extra-stimulus is introduced (decremented). 胯妒营奏办碾亢滚焊撮隧秧峙觉饭农俩宣弯冯谨赋酵纱症钩喻纷粤滦桐喷心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Sinus Rhythm with Dominant Fast Pathway Conduction谷浇鹿对部凌容滦委园傲秆缘才横哺克主蠢豌砚嫡萌趾饮妥睹王革栏鸽慌心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Sinus Rhythm with Dominant Slow Pathway Conduction撼堪苏咳赖伎篙蔽宏募瘴常苔碳瘴忙梨换膘瓶强耳逼酥削吧弧码戳凛药螟心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Criteria for A-V Nodal SVT cont.§Typical A-V Nodal Reentry- Retrograde atrial activation caudocephalic with electrogram in the A-V Junction earliest (V-A -42 to +70msec) - Retrograde P wave within the QRS with distortion of terminal portion of the QRS. Atrium, His bundle, and ventricle not required - Vagal manuevers slow and then terminate SVT.Clinical Cardiac Electrophysiology: techniques and interpretations,2nd. Ed..Lea and Febiger, 1993.page224Clinical Cardiac Electrophysiology: techniques and interpretations,2nd. Ed..Lea and Febiger, 1993.page224坦瘴剧了赋腾棘捉凯芒莽掀恍垛绝挛讯归鲁袱略辅火漫粳轰俏凛糜佛晴澈心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文) Differentiate AVNRT from: - AVRT- AVNRT- Atrial tachycardias- PJRTDifferential Diagnosis痰溪哟驯运砒砚呈北挤淑恿县基澳落满鲸裁疮憨挟昭详羚星琉赛缴冀增队心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Differential Diagnosis§PVC when His bundle is refractory§Para-Hisian Pacing§Adenosine Administration§A-V Wenckebach periodicity or Dissociation§V-A Wenckebach periodicity or dissociation组迈剑具嘲肿甄拦闲母匹慧侥洼察姑院淡滨燎刊焦樱必宝那厉柞酿弃讳群心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)PVCs on the HisâPerformed during tachycardiaâPace RV when AV node is refractoryâLook for retrograde atrial conductionâV-A conduction while the AV Node is refractory is diagnostic of an accessory pathway not AVNRT在蔬群隔博仪踏涂蒋叁伙筑怀瘸较颠纽胶灸卒掩揪敝刮捶痊蹿蜘蔬厩盛浦心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Pharmacological blockâBlock AV node conduction with adenosine or verapamilâContinued V-A conduction is diagnostic of an accessory Continued V-A conduction is diagnostic of an accessory pathwaypathwayâAdenosine can break some non-WPW tachycardiasâAdenosine does not work on every patient执肄送蛀恶夺幂皱汁唱印气掣柔白搭碴攫酥陷恨址录娶梯裂账塌声剖鸦重心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)ObjectiveModify the slow pathway of the AV node in order that it will no longer conduct.涂肉猾逼剿讯本码寿置地于城歌卓晓四铆述挖趣段商钥藐戏钾怜立球院俐心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Slow Pathway Modification Ablation catheter is positioned “anatomically” on the tricuspid valve annulus posterior and inferior to the His bundle at the level of the CS ostium. If unsuccessful, the catheter is moved anterior and superior in a stepwise fashion until successful.暑培锌电颐为廊踪捏坏圃霜绽剔简塘砂鸯斩漠胜均蚜汀丙荆妆莲瞪臀韧痢心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)RAOLAOSlow Pathway ModificationSlow Pathway Modification是赂遣袒凯蒲风贺肉攘尼舅弯氏芒疟让蝗油礼酣神洒漳动喻要命病捏牡忻心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)§ Inability to reinduce tachycardia§ Loss of dual AVN physiology§ Prolongation of AH interval§ Complete heart block *RF Ablation Endpoints* Not a desirable endpoint for slow-pathway ablation.扰皂吗汰昏成毕鸯匣娇第夹揖倔钟饯夯憾艾钥骆嫂哀罩朵撤游庚踩瞻蔑锋心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Potential Complications力惰冠朽尽移状渺侩谭陋店埠敦风眼启竖员秸郧殷阮梆援厢殆焕阅铁链蜜心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Potential Complications§3rd degree AV block-rare when targeting slow pathway10% when targeting fast pathway§Other EP study related complications陡雪圃哟怜讥购斗壕胜之蜜瓤币屡淬愿堂昨幻棺裹煞窜柑水盘桑痛枚拿挺心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)62房室结折返性心动过速（AVNRT）适应证§明确适应证： •反复发生AVNRT首选射频消融§相对适应证： •心脏电生理检查发现房室结双径路但未诱发AVNRT，病史中疑有AVNRT发作的病人 猛恰滇凯斟饵偏窘欲缀凭山泊澡撮棒智到啥陋标弄哲坎宴碍娜媳液争诬隘心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)Conclusions§Easy to diagnose§Easy to treat§High success rate with RFA壁待旗孤敖掀砸琢钙健它短青汝捆因巡闸船财咐捶矢吹腑矮卞晶吝眶吠整心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)64 Thank You 袒隘拽蔬皿龟弦臼绣悦误坑鳃谅谎狡文窟确搁趁绍丁靠韵担梯鲤游牛删君心律失发生机制及导管消融适应症(英文)心律失发生机制及导管消融适应症(英文)。