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1、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
2、李树岩Indications for Radiofrequency Catheter AblationWolff-Parkinson-White Syndrome (WPW)Atrioventricular Nodal Reentrant Tachycardia (AVNRT)Atrial FlutterAtrial Fibrillation (AF)Ventricular Tachycardia (VT)Atrial Tachycardia (AT)OthersRisks and Complications With RF Ablation Hypotension - secondary t
3、o drugs or vagal reactionVascular injuryIschemia/InfarctionVenous/ Arterial ThrombosisCardiac perforationDamage to the AV conduction systemLife threatening arrhythmiasArrhythmia Mechanisms AutomaticityTriggered ActivityReentry Automatic tachycardia (AT, VT, AF) is identified by the presence of the f
4、ollowing 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 “coo
5、l 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 Triggered activity (AT, VT, AF) is
6、 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 afterdepolarizatio
7、ns 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 a
8、nd carotid sinus pressure (Zipes DP, Jalife J. Cardiac Electrophysiology: From cell to bedside, 4th edition. 2004; pg. 500-501)Arrhythmia Mechanisms Microreentry (AT, AVNRT, VT)/Macroreentry (AT, AVRT, Atrial Flutter) is identified by the presence of the following characteristics: Can be reproducibl
9、y 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 h
10、as 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 Sequence of the Flow in a Typical EP StudyPreparation of the Patien
11、tInsertion of sheaths and Electrode cathetersBasic EPS study to get the basic data Induction of the ArrhythmiaDiagnosis of the ArrhythmiaAblation of the Arrhythmia (if indicated)Confirmation of Therapy SuccessWPWOccurrence of dysrhythmias 1,2TYPICAL90%ATYPICAL10%AVNRT50%LFW40%RFW30%SEPTAL30%WPW30%CC
12、 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%WPW tachycardia circuitsOrthodromic TachycardiaThese terms are only appli
13、cable 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 a
14、nd 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. AntidromicAntidromic TachycardiaTachycardiaBypass Tract LocationsAnywhere except
15、 here(fibrous trigone)Bypass Tract LocationsTypes of Accessory PathwaysA = atriofascicularB = nodofascicularC = nodoventricular*D = fasciculoventricularE = atrioventricular*first described by MahaimPreexcitation SyndromesWolff - Parkinson - White“Mahaim” Fibers - now separated into:AtriofascicularAt
16、riofascicularNodoventricularNodoventricularNodofascicularNodofascicularFasciculoventricularFasciculoventricularWolff, Parkinson and White,and their Syndrome Published in American Heart Published in American Heart Journal in August, 1930 findings Journal in August, 1930 findings on 11 patients with a
17、 syndrome of on 11 patients with a syndrome of signs and symptomssigns and symptoms Clinical significanceClinical 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 preexcitat
18、ion 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 hear
19、t 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 132Diagnosis and LocalizationSurface lead evaluationUnderstanding Bundle B
20、ranch Block “Patterns” Understanding Bundle Branch Block “Patterns” as applied to interpreting Delta Wave polarityas applied to interpreting Delta Wave polarityDelta Wave Polarity interpretation Delta Wave Polarity interpretation The use of algorithms for evaluating preexcited The use of algorithms
21、for evaluating preexcited 12 leads12 leadsFunctional Bundle branch block during ORTFunctional Bundle branch block during ORTElectrophysiology studyCatheter mappingDelta Wave PolarityUse the first 20-40 mSec of the Delta wave to determine polarityThe QRS usually follows the polarity of the Delta wave
22、Use algorithms to locate the APOf 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 s
23、idedV1 positive = left sided V1 negative = right sidedV1 negative = right sidedThe delta waveClinical manual of electrophysiologyClinical manual of electrophysiologySinger and Singer and CoopersmithCoopersmith chch 9 pg 125 9 pg 125Delta Wave PolarityFitzpatrick, et al., JACC, Vol. 23, No. 1, Jan. 1
24、994, p. 110Pre-excitationFusion of the QRS occurs because there is simultaneous conduction down the AV node and accessory pathwayWPW 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 P
25、R interval and QRSEvaluating a preexcited 12 lead Leads I and aVLIndicates impulse travel as right to left (positive) Indicates impulse travel as right to left (positive) or left to right (negative)or left to right (negative)Leads II, III, and aVFIndicate impulse travel as superior to inferior Indic
26、ate 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 preexcitedV Lead transitionHelps differentiate septal or lateral sites.Helps differentiate septal or latera
27、l sites.Algorithm - Arruda (a)Arruda, et.al., JCE Vol 9 #1 Jan 1998, pp. 2-12Algorithm - Arruda (b)Arruda, et .al., JCE Vol 9 #1 Jan 1998, pp. 2-12More examplesElectrophysiology studyGoals of the EP studyIdentify the function and threat of the APIdentify the function and threat of the APLocate the A
28、P to determine approach for ablationLocate the AP to determine approach for ablationMethodsAtrial PacingAtrial PacingVentricular PacingVentricular PacingCatheter mappingCatheter mappingAdditional ManeuversAdditional Maneuvers Para-Para-HisianHisian pacing pacing Pharmacologic conduction blockPharmac
29、ologic conduction blockAtrial pacingInitiated after baseline recordingsOften used with isoproteronol to induce tachycardia and shorten refractory periodsProgressive AV node delay encourages conduction over the accessory pathwayLook for delta wave to become more noticeable Find the antegrade and retr
30、ograde refractory periods of the AVN and APVentricular PacingLook for the earliest retrograde A“Advance” the atria during tachycardiaDifferentiate between AVRT, AVNRT and atrial tachycardias.Paced PVC During His Refractory PeriodPara-Hisian pacing-Retro AVN conduction; no BPTNarrow QRSWide QRSHis an
31、d 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. 623Para-Hisian pacing-Retro conduction through BPTNarrow QRSWide QRSHis and VcaptureV captur
32、eonlyFixed 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. 623Pharmacologic BlockBlock AV node conduction with adenosine or verapamil.Should show continued V-A conduction
33、 during V Should show continued V-A conduction during V pacing.pacing.Adenosine can break some non - WPW tachycardiasAdenosine does not work in every patient.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 AblationObjectives- Objectives- Eliminate the abnormal conduction
34、Eliminate the abnormal conduction Preserve the normal conductionPreserve the normal conductionIndicators 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 conductio
35、n time during V pacing (WPW or concealed APs)or concealed APs) Tachycardia not inducibleTachycardia not inducibleCaveatsCaveats “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 anterose
36、ptal pathways, transseptal risks, perforation, vascular ablation, pathways, transseptal risks, perforation, vascular ablation, others)others)AblationRickerd, Rickerd, The New EP Techs Book, The New EP Techs Book, 3 3rdrd ed., ed., 2002, p. 102 - 1032002, p. 102 - 103More examplesAVNRTBasics of AVNRT
37、nMost common form of SVT treated by ablationnMore common in females than malesnOtherwise healthy individualsnUsually adolescent to mid-30s, but can occur at any age, including infancyTypes of AVNRTThree Main TypesTypical; common; usual; slow-fast Atypical; uncommon; unusual; fast-slow Slow-slow Dist
38、ribution of Types of AVNRTKuck KH, Kuck KH, CappatoCappato R. Catheter Ablation in the Year 2000. Current Opinion in Cardiology 2000;15:29-40. R. Catheter Ablation in the Year 2000. Current Opinion in Cardiology 2000;15:29-40.AVNRT CircuitThe reentrant circuit involves the Fast Pathway (FP), which e
39、nters 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, ant
40、egrade 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 ri
41、sk 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: antegr
42、ade certain slow fibers, retrograde other slow fibers- Jump in AH interval 50 msec during a 10msec decrement in extrastimulus testingCommon (Typical) AVNRTIn common AVNRT, antegrade conduction is down the slow pathway and retrograde up the fast pathway. The earliest atrial activation would be record
43、ed 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. Uncommon (Atypical) AVNRTIn uncommon AVNRT, antegrade conduction is down the fast pathway and retrograde up the slow pathway. The earli
44、est 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. Slow Slow AVNRTIn Slow Slow AVNRT, antegrade conduction is down some slow pathway fibers and retrogr
45、ade 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. Dual AV Nodal Physiol
46、ogyPatients with AVNRT usually demonstrate dual-nodal physiology. Dual AV Nodal Physiology contcontComplex structure of AVN Displays discontinuous Conduction PropertiesDisplays discontinuous Conduction PropertiesPeri-nodal tissue behaves functionally as two Peri-nodal tissue behaves functionally as
47、two parallel pathwaysparallel pathways Differentiated by electrophysiologic propertiesDifferentiated by electrophysiologic properties Exhibits non-uniform anisotropic propertiesExhibits non-uniform anisotropic properties Both Capable of Both Capable of AntegradeAntegrade and retrograde conduction an
48、d retrograde conduction Exhibits longitudinal dissociation Exhibits longitudinal dissociationResults in Reentry around, or within, the AVNResults in Reentry around, or within, the AVNSlow and Fast PathwaysSlow PathwayPerinodalPerinodal tissue possessing conduction properties tissue possessing conduc
49、tion properties of slow depolarization and relatively rapid of slow depolarization and relatively rapid repolarizationrepolarizationFast PathwayPerinodalPerinodal tissue possessing the conduction tissue possessing the conduction properties of relatively rapid depolarization and properties of relativ
50、ely rapid depolarization and relatively slow relatively slow repolarizationrepolarization Dual AV Nodal Physiology contDual 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 t
51、esting as the extra-stimulus is introduced (decremented). Sinus Rhythm with Dominant Fast Pathway ConductionSinus Rhythm with Dominant Slow Pathway ConductionSinus Rhythm with Dominant Slow Pathway ConductionCriteria for A-V Nodal SVT cont.cont.Typical A-V Nodal Reentry- Retrograde atrial activation
52、 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: techni
53、ques and interpretations,2nd. Ed.Lea and Clinical Cardiac Electrophysiology: techniques and interpretations,2nd. Ed.Lea and FebigerFebiger, 1993.page224, 1993.page224 Differentiate AVNRT from: - AVRT- AVNRT- Atrial tachycardias- PJRTDifferential DiagnosisDifferential DiagnosisPVC when His bundle is
54、refractoryPara-Hisian PacingAdenosine AdministrationA-V Wenckebach periodicity or DissociationV-A Wenckebach periodicity or dissociationPVCs on the HisPerformed during tachycardiaPace RV when AV node is refractoryLook for retrograde atrial conductionV-A conduction while the AV Node is refractory is
55、diagnostic of an accessory pathway not AVNRTPharmacological blockBlock AV node conduction with adenosine or verapamilContinued V-A conduction is diagnostic of an accessory Continued V-A conduction is diagnostic of an accessory pathwaypathwayAdenosine can break some non-WPW tachycardiasAdenosine does
56、 not work on every patientObjectiveModify the slow pathway of the AV node in order that it will no longer conduct.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 unsucce
57、ssful, the catheter is moved anterior and superior in a stepwise fashion until successful.RAOLAOSlow Pathway ModificationSlow Pathway Modification Inability to reinduce tachycardia Loss of dual AVN physiology Prolongation of AH interval Complete heart block *RF Ablation Endpoints* Not a desirable en
58、dpoint for slow-pathway ablation.Potential ComplicationsPotential Complications3rd degree AV block-rare when targeting slow pathway10% when targeting fast pathwayOther EP study related complications62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 ConclusionsEasy to diagnoseEasy to treatHigh success rate with RFA64 Thank You
