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1、血液动力学学习目的:心脏基础解剖学熟悉基本的血液动力学术语理解常见的心脏血动手术流程 心脏解剖为什么要进行血液动力学监测？在导管手术中提供实时而精确的压力和ECG监测及记录结合影像资料可进一步确诊心血管疾病导管手术中需监测哪些指标？不同心脏腔室及血管压力的监测瓣膜两侧的压力/压力 差值测量（压力梯度）心排量 (用于心功能评价)正常压力值RV25/0/4RA6/5/3LA10/12/8PA(肺动脉)25/9/15LV左室120/5/10AO(主动脉）120/80/95PCW肺毛压11/12/9左心导管并冠脉检查基线测量选择性冠脉造影用猪尾导管进行LV左室基本功能测量LV造影LV导管回撤压测量（连
2、续测压）心电及左心系统压力波形P-波波 - 心房收缩心房收缩(除极除极) * A-wave of LA QRS 心室收缩心室收缩(心脏收缩心脏收缩) *AO 舒张舒张, LV EDP(舒末压舒末压)ST 段段 压低压低 (缺血缺血) 抬高抬高 (损伤损伤)T-波波 复极复极 或心肌舒张或心肌舒张 (舒张舒张) * V-wave of LA, AO/LV 收缩收缩左、右心导管并冠脉检查通常使用两根导管猪尾导管冠脉Swan-ganz漂浮导管右心系统压力Fick法COTDCO（热稀释法心排量）CommonMeasurementsobtained左心导管,猪尾导管同步实时压力测量LV/PCWLV/AO
3、冠脉注射心电及右心系统压力波形P-wave - Contraction(depolarization) of the atria *A-wave of PCW and RAQRS Ventricular contraction (systole) *PA diastole, RV EDPST segment Depression (ischemia) Elevation (injury)T-wave Repolarization or Myocardial relaxation (diastole) * V-wave of PCW and RA PA systole, RV systole正常
4、 O2 饱和度 (+/- 5%)RV75%RA75%LA95%PA75%LV95%AO95%PCW97%SVC70%IVC75%LV 至 AO Pullback连续测压电生理基础学习目的:熟悉基本的电生理术语理解基本EP 手术流程 理解导管手术中在CardioLab和 Mac-Lab记录的信息Reasons for an EP Study心律失常的评估心脏电生理传导系统异常的诊断起博器,ICD的评估心脏传导系统SA Node 窦房结AV Node 房室结HIS Bundle 希氏束Bundle Branches 束枝Purkingee fibers 普肯野氏纤维心脏传导窦房结窦房结窦房结窦房结
5、心房传导心房传导心房传导心房传导 房室结房室结房室结房室结 希氏束希氏束希氏束希氏束左左左左, ,右束枝右束枝右束枝右束枝蒲肯野氏纤维蒲肯野氏纤维蒲肯野氏纤维蒲肯野氏纤维蒲肯野氏纤维蒲肯野氏纤维蒲肯野氏纤维蒲肯野氏纤维窦房结激动心率的起始自主性70Beats/minuteP波开始心房激动右房RightAtrium房间隔InteratrialSeptum左房LeftAtriumP波持续房室结AV Node调节器Regulator自主节律50bpm延迟100msA-H间隔40-140 msHISECGA H快速传导路径HISBundleBranchesPurkinjeFibersH-VInterv
6、al心室激动室间隔右，左室游离壁房室间沟A-VGrooveQRS持续期复极Repolarization不应期RefractoryPeriod休眠期RestPhase无激动性Non-excitabilityQT持续期心内电信号Intra-Cardiac SignalsThe EP LabComponentsHardware可移动操作台ComputerAmplifier&StimulatorDisplayPrinterKeyboardandmouseRFablationdeviceIsolated power supply Hardware (cont.)英特尔至强处理器E3-1225v24GB(
7、2x2GB)DDR3UDIMM内存,1600MHz500GB7200RPM3.5SATA3硬盘x21GBNVIDIAQuadro600(1个DP与1个DVI-I)16X最大可变速DVD-ROM刻录光驱Video1forreal-timeVideo2fornon-real-time(optional)ComputerHardware (cont.)TOOP-2001 Amplifier What is 16/32/64/96 channels?PowerTOOP-2001: External Power controls 220 vLine Frequency (Notch filters)TO
8、OP-2001: Manufacture builds unique amp to specificationCLab II Plus: Auto recognition of 50 Hz or 60 HzTOOP-2001B(16导)TOOP-2001C(32导)TOOP-2001D(64导)TOOP-2001E(96导)CatheterInputs16326496IntracardiacChannels0164864ECG12121212Inv.Pressure4444Hardware (cont.)Amplifer HardwareECGIECG1/2/3BP1/2MAP50Hzbutt
9、onResetbuttonPowerbuttonHardware (cont.)Amplifier POWERGNDUSB portNetwork portStim Control COM心脏电生理检查及射频消融手术常用仪器射频消融手术实况图Basic EP Study患者准备PatientPrepped插入导管CatheterInsertions基线测量BaselineMeasurements起博/刺激Pacing/Stimulator(Bloom)诊断Evaluationofinformation治疗/消融治疗Intervention/AblationGenerator心脏传导的解剖Rig
10、ht VentricleRight AtriumLeft AtriumLeft VentricleSA NodeAV NodePurkinjeFibersBundle ofHisPulmonary Vein电传导Electric Propagation70Beats/MinuteA-V顺序激动SequentialActivationRV/LV同步激动不应期RefractoryRestPeriod电机械耦合Electro-MechanicalCoupling有效的心输出量EfficientCardiacOutput电机械耦合心室同步收缩心肌收缩，相当于不应期250-450 msArterial
11、PressureTechniques for Recording12 导ECG双极腔内心电Bipolar Catheter ElectrogramsHRAHISRVCSMapping动脉压Arterial Pressure12 导ECG4 个肢6 个胸导联作为电活动的无创参考Non-Invasive Reference of Electrical Activity定位心律失常的来源Locate the source of arrhythmias室速Ventricular Tachycardia旁道Pathways12 导 ECG体表记录RecordedfromBodySurface无创Non-
12、InvasiveECG电极Electrodes总体观察心电活动ElectricalOverviewEP Catheters双极心电Bipolar Electrogram记录波形传导RecordsPropagatingWaves电极距离较近CloselySpacedElectrodes检测局部激动DetectsLocalActivation双相波单极心电Unipolar Electrogram用于研究目的ResearchApplication细胞表面记录Extra-cellularRecording较远的参考电极RemoteReference双向波术前检查Pre-Procedure Testin
13、gWBC白细胞评估有无感染Risk of Sepsis if ElevatedPlatelet Count血小板计数评估有无出血趋向Risk of Bleeding if LowHemoglobin & Hematocrit血红蛋白及红血球Possible alternate cause of SyncopeSodium and Potassium Levels电解质Na+ &K+Common cause of DysrhythmiaAnti-Arrhythmic Medications Stopped or Levels Drawn停用抗心律失常药物12 Lead ECGSome home
14、meds may alter the ECG手术部位Procedure SitesVT Studies室速Groin or Arm ApproachSVT Studies室上速Groin Approach股动，静脉插管Possible Arm Approach肘动，静脉插管Possible Subclavian or Internal Jugular锁骨下静脉插管ICD Follow ups are usually non-invasive ICD随访通常用无创方法插管Catheter Insertion局麻LocalanesthesiaSeldingertechnique通常采用静脉插管Ge
15、nerallyvenoussideonly左锁骨下静脉插管常用于插入冠状静脉窦导管HRA 导管起博Pace:远端Distal1,2前传测试AntegradeConductionTesting记录Record:近短Proximal3,4HIS 导管记录Record:近端Prox3,4中端Mid2,3远端Dist1,2RVA导管起博Pace:远端Distal1,2逆传测试RetrogradeConductionTesting记录Record:近端Prox3,4心室激动VentricularActivationCS 导管记录Record:CS7,8CS5,6起博Pace:标测左侧旁路Mappingo
16、fLeftSidePathways激动顺序Sequence of ActivationEP Protocol方案基线传导记录Baseline Conduction Recordings12 LeadHRA, HIS, RV起博HRA (前传Antegrade Conduction)窦房结恢复Sinus Node Recovery递增心房刺激Incremental Atrial Pacing (Wenkebach)房性期前刺激Atrial Extra-Stimulus起博RVA (逆传Retrograde Conduction)递增心室刺激Incremental Ventricular Pacing室性期前刺激Ventricular Extra-Stimulus术中Procedure在记录基线测量后，采用在8个刺激后增加房性早搏或室性早搏的方法检测心律失常的性质及部位After Baseline Measurements are taken and recorded, Pacing is Done for 8 beats, then PVCs or PACs are added.房性早搏
