室性心动过速消融何时进行？消融？WinKShen.ppt

Win K.Shen,M.D.Win K.Shen,M.D.Professor of MedicineProfessor of MedicineMayo Clinic College of MedicineMayo Clinic College of MedicineGW-HRS Joint Symposium,Beijing 2009GW-HRS Joint Symposium,Beijing 2009CP1063458-1室性心动过速的消融：室性心动过速的消融：何时进行？如何消融？何时进行？如何消融？?声明声明声明声明Relevant Financial Relationship(s)Relevant Financial Relationship(s)NoneNoneOff Label UsageOff Label UsageNoneNone 室性心动过速的机制室性心动过速的机制室性心动过速的机制室性心动过速的机制 折返、拖带、隐匿性拖带的基本概念折返、拖带、隐匿性拖带的基本概念折返、拖带、隐匿性拖带的基本概念折返、拖带、隐匿性拖带的基本概念 稳定的，单形性室速稳定的，单形性室速稳定的，单形性室速稳定的，单形性室速 不稳定或多折返环室速不稳定或多折返环室速不稳定或多折返环室速不稳定或多折返环室速 高级方法和技术高级方法和技术高级方法和技术高级方法和技术内容内容内容内容CP1323528-2室速消融室速消融室速消融室速消融指南建议指南建议指南建议指南建议I I类适应证类适应证类适应证类适应证 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，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猝死低危患者猝死低危患者(C)(C)束支折返室速束支折返室速束支折返室速束支折返室速(C)(C)ICDICD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)(C)Circ 2006室性心律失常室性心律失常室性心律失常室性心律失常CP1206111-1“局灶局灶局灶局灶”“多发性多发性多发性多发性”流出道流出道流出道流出道分支分支分支分支瓣上瓣上瓣上瓣上RVRVLVLV普肯普肯普肯普肯野野野野折返折返折返折返解剖靶点解剖靶点解剖靶点解剖靶点心肌病心肌病心肌病心肌病疤痕疤痕疤痕疤痕二尖瓣二尖瓣二尖瓣二尖瓣电生理策略电生理策略电生理策略电生理策略P.P.刺激刺激刺激刺激拖带拖带拖带拖带影像影像影像影像电生理电生理电生理电生理损伤损伤损伤损伤解剖解剖解剖解剖室速标测和消融步骤室速标测和消融步骤室速标测和消融步骤室速标测和消融步骤潜在的心脏机制，病史潜在的心脏机制，病史潜在的心脏机制，病史潜在的心脏机制，病史潜在的心脏机制，病史潜在的心脏机制，病史 缺血性心脏病缺血性心脏病缺血性心脏病缺血性心脏病缺血性心脏病缺血性心脏病 特发性扩心病特发性扩心病特发性扩心病特发性扩心病特发性扩心病特发性扩心病 其它其它其它其它其它其它根据心电图判断心动过速的起源根据心电图判断心动过速的起源根据心电图判断心动过速的起源根据心电图判断心动过速的起源根据心电图判断心动过速的起源根据心电图判断心动过速的起源程序性刺激，方法程序性刺激，方法程序性刺激，方法程序性刺激，方法程序性刺激，方法程序性刺激，方法 重整重整重整重整重整重整 拖带拖带拖带拖带拖带拖带 隐匿性拖带隐匿性拖带隐匿性拖带隐匿性拖带隐匿性拖带隐匿性拖带高级标测技术高级标测技术高级标测技术高级标测技术高级标测技术高级标测技术 电压标测电压标测电压标测电压标测电压标测电压标测 电解剖标测电解剖标测电解剖标测电解剖标测电解剖标测电解剖标测 影像影像影像影像影像影像 心外膜标测心外膜标测心外膜标测心外膜标测心外膜标测心外膜标测 其它其它其它其它其它其它标测的概念标测的概念折返性室速折返性室速双电位双电位疤痕疤痕Scars0.5 mV2 mV潜在折返环潜在折返环CP1176527-5CP1233975-13ECGECGECGECGECGECGQRSQRSQRS起始起始起始起始起始起始共同通路共同通路共同通路共同通路共同通路共同通路(CP)(CP)(CP)CPCPCP入口入口入口入口入口入口内环内环内环内环内环内环疤痕疤痕疤痕疤痕疤痕疤痕外环外环外环外环外环外环疤痕疤痕疤痕疤痕疤痕疤痕通道盲端通道盲端通道盲端通道盲端通道盲端通道盲端CP CP CP 出口出口出口出口出口出口折返环和相关术语折返环和相关术语折返环和相关术语折返环和相关术语该室速折返环出口位置可能是该室速折返环出口位置可能是该室速折返环出口位置可能是该室速折返环出口位置可能是:A.LV/A.LV/A.LV/前壁前壁前壁前壁前壁前壁/基底部基底部基底部基底部基底部基底部/侧壁侧壁侧壁侧壁侧壁侧壁 B.LV/B.LV/B.LV/后壁后壁后壁后壁后壁后壁/心尖心尖心尖心尖心尖心尖/侧壁侧壁侧壁侧壁侧壁侧壁 C.LV/C.LV/C.LV/后壁中部后壁中部后壁中部后壁中部后壁中部后壁中部/间隔部间隔部间隔部间隔部间隔部间隔部 D.LV/D.LV/D.LV/后壁后壁后壁后壁后壁后壁/心尖心尖心尖心尖心尖心尖/间隔部间隔部间隔部间隔部间隔部间隔部标测示意图标测示意图标测示意图标测示意图横断面横断面横断面横断面基地部基地部基地部基地部心尖心尖心尖心尖长轴切面长轴切面长轴切面长轴切面间隔间隔间隔间隔侧壁侧壁侧壁侧壁12126 69 93 3前壁前壁前壁前壁后壁后壁后壁后壁CP1060083-4A AB BC CD DE EQRSQRS形态提示室速的出口位置形态提示室速的出口位置形态提示室速的出口位置形态提示室速的出口位置V4V4基底部基底部基底部基底部心尖心尖心尖心尖AVRAVRCP1060083-1AVRV4II,III,aVFII,III,aVFQRS QRS 形态提示室速的出口形态提示室速的出口形态提示室速的出口形态提示室速的出口CP1060083-2前壁前壁前壁前壁后壁后壁后壁后壁II,III,aVFII,III,aVFQRSQRS形态提示室速的出口形态提示室速的出口形态提示室速的出口形态提示室速的出口I,aVLI,aVL间隔部间隔部间隔部间隔部侧壁侧壁侧壁侧壁II,III,aVFII,III,aVFCP1060083-3该室速的折返环出口位置可能是该室速的折返环出口位置可能是该室速的折返环出口位置可能是该室速的折返环出口位置可能是:A.LV/A.LV/A.LV/前壁前壁前壁前壁前壁前壁/基底部基底部基底部基底部基底部基底部/侧壁侧壁侧壁侧壁侧壁侧壁 B.LV/B.LV/B.LV/后壁后壁后壁后壁后壁后壁/心尖心尖心尖心尖心尖心尖/侧壁侧壁侧壁侧壁侧壁侧壁 C.LV/C.LV/C.LV/后壁后壁后壁后壁后壁后壁/中部中部中部中部中部中部/间隔部间隔部间隔部间隔部间隔部间隔部 D.LV/D.LV/D.LV/后壁后壁后壁后壁后壁后壁/心尖心尖心尖心尖心尖心尖l/l/l/间隔间隔间隔间隔间隔间隔*CP1233975-13折返环路与拖带折返环路与拖带折返环路与拖带折返环路与拖带A,B,C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=265VTCL=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=265室速终止室速终止室速终止室速终止CP1201033-1%0-100-100-10n=46n=46n=4611-3011-3011-30n=18n=18n=1831-6031-6031-60n=24n=24n=24606060n=64n=64n=64PPI-VTCL(msec)PPI-VTCL(msec)PPI-VTCL(msec)CP1270284-4VT#5VT 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男性，男性，男性，男性，男性，男性，55 55 55 岁，扩张型心肌病岁，扩张型心肌病岁，扩张型心肌病岁，扩张型心肌病岁，扩张型心肌病岁，扩张型心肌病,EF 27%,EF 27%,EF 27%ICDICDICD频繁放电，既往消融失败频繁放电，既往消融失败频繁放电，既往消融失败频繁放电，既往消融失败频繁放电，既往消融失败频繁放电，既往消融失败左心室辅助装置左心室辅助装置左心室辅助装置左心室辅助装置 Low-speed Low-speed Low-speed centrifugal centrifugal centrifugal continuous flow continuous flow continuous flow pump pump pump Low blood surface Low blood surface Low blood surface area contact area contact area contact 21 Fr Left atrial 21 Fr Left atrial 21 Fr Left atrial cannulacannulacannula 19 Fr femoral 19 Fr femoral 19 Fr femoral arterial cannulaarterial cannulaarterial cannula Up to 4L/min FlowUp to 4L/min FlowUp to 4L/min FlowThiele et al Circ 2001左心室支持下诱发室速左心室支持下诱发室速左心室支持下诱发室速左心室支持下诱发室速左心室辅助支持下心内膜及心外膜标测左心室辅助支持下心内膜及心外膜标测左心室辅助支持下心内膜及心外膜标测左心室辅助支持下心内膜及心外膜标测LAALACannulaEndoEpi经心外膜途径消融经心外膜途径消融Schweikert et al.Circulation.2003;108:1329-1335.Eduardo Sosa,JACC 2000 室速合并冠心病的患者经心外膜消融是可行的室速合并冠心病的患者经心外膜消融是可行的室速合并冠心病的患者经心外膜消融是可行的室速合并冠心病的患者经心外膜消融是可行的.5353例中发生了例中发生了例中发生了例中发生了4 4例右心室穿孔及心脏压塞例右心室穿孔及心脏压塞例右心室穿孔及心脏压塞例右心室穿孔及心脏压塞 对其它心律失常亦有效对其它心律失常亦有效对其它心律失常亦有效对其它心律失常亦有效(VT(VT 伴或不伴伴或不伴SHD,WPW,RVOT SHD,WPW,RVOT VT,AT)VT,AT)，尤其是经心内膜消融失败的患者，尤其是经心内膜消融失败的患者，尤其是经心内膜消融失败的患者，尤其是经心内膜消融失败的患者 无并发症报道无并发症报道无并发症报道无并发症报道左心室心内膜和心内膜消融左心室心内膜和心内膜消融左心室心内膜和心内膜消融左心室心内膜和心内膜消融Mitral Valve 多数情况下为折返机制多数情况下为折返机制多数情况下为折返机制多数情况下为折返机制多数情况下为折返机制多数情况下为折返机制 根据拖带的反应识别传导的关键区域根据拖带的反应识别传导的关键区域根据拖带的反应识别传导的关键区域根据拖带的反应识别传导的关键区域根据拖带的反应识别传导的关键区域根据拖带的反应识别传导的关键区域 多形性室速和多环路折返较常见多形性室速和多环路折返较常见多形性室速和多环路折返较常见多形性室速和多环路折返较常见多形性室速和多环路折返较常见多形性室速和多环路折返较常见 通常需要电压通常需要电压通常需要电压通常需要电压通常需要电压通常需要电压/把横标测把横标测把横标测把横标测把横标测把横标测 部分病人可能需要心外膜标测部分病人可能需要心外膜标测部分病人可能需要心外膜标测部分病人可能需要心外膜标测部分病人可能需要心外膜标测部分病人可能需要心外膜标测 为防止为防止为防止为防止为防止为防止ICDICDICD反复放电，多数患者应接受姑息性反复放电，多数患者应接受姑息性反复放电，多数患者应接受姑息性反复放电，多数患者应接受姑息性反复放电，多数患者应接受姑息性反复放电，多数患者应接受姑息性VTVTVT消融消融消融消融消融消融疤痕依赖基质的室速消融疤痕依赖基质的室速消融疤痕依赖基质的室速消融疤痕依赖基质的室速消融GW-ICC HRS Joint SymposiumBeijingBeijingOct.11,2009Oct.11,2009Win K.Shen,M.D.Win K.Shen,M.D.Professor of MedicineProfessor of MedicineMayo Clinic College of MedicineMayo Clinic College of MedicineGW-HRS Joint Symposium,Beijing 2009GW-HRS Joint Symposium,Beijing 2009CP1063458-1Ventricular Tachycardia Ablation When and How?DISCLOSUREDISCLOSURERelevant Financial Relevant Financial Relationship(sRelationship(s)NoneNoneOff Label UsageOff Label UsageNoneNone Spectrum of VT mechanismsSpectrum of VT mechanisms Basic concept of reentry,entrainment,Basic concept of reentry,entrainment,and concealed entrainment and concealed entrainment Stable,Stable,monomorphicmonomorphic VT VT Unstable VT or multiple circuitsUnstable VT or multiple circuits Advanced technology and techniquesAdvanced technology and techniquesObjectivesObjectivesCP1323528-2VT AblationVT AblationRecommendationsRecommendationsClass IClass I Ablation is indicated in patients who are otherwise at low Ablation is indicated in patients who are otherwise at low risk for SCD and have sustained predominantly risk for SCD and have sustained predominantly monomorphic VT that is drug resistant,who are drug monomorphic VT that is drug resistant,who are drug intolerant,or who do not wish long-term drug therapy intolerant,or who do not wish long-term drug therapy(level of evidence:C)(level of evidence:C)Ablation is indicated in patients with bundle-branch Ablation is indicated in patients with bundle-branch reentrant VT(level of evidence:C)reentrant VT(level of evidence:C)Ablation is indicated as adjunctive therapy in patients with Ablation is indicated as adjunctive therapy in patients with an ICD who are receiving multiple shocks as a result of an ICD who are receiving multiple shocks as a result of sustained VT that is not manageable by reprogramming or sustained VT that is not manageable by reprogramming or changing drug therapy or who do not wish long-term drug changing drug therapy or who do not wish long-term drug therapy(level of evidence:C)therapy(level of evidence:C)Circ 2006Ventricular ArrhythmiasVentricular ArrhythmiasCP1206111-1“Focal”Focal”“Diffuse”Diffuse”Outflow tractOutflow tractFascicularFascicularSupra-Supra-valvularvalvularRVRVLVLVPurkinjePurkinjeReentryReentryAnatomic targetAnatomic targetMyopathicMyopathicScarsScarsMitral valveMitral valveEP maneuversEP maneuversP.StimulationP.StimulationEntrainmentEntrainmentImagingImagingElectrophysiologyElectrophysiologyLesion creationLesion creationAnatomyAnatomySteps in Mapping and Ablating VT Steps in Mapping and Ablating VT Underlying cardiac substrate,historyUnderlying cardiac substrate,history Ischemic heart disease Ischemic heart disease Idiopathic dilated Idiopathic dilated cardiomyopathycardiomyopathy OthersOthersECG recognition of tachycardia originECG recognition of tachycardia originProgrammed stimulation,maneuversProgrammed stimulation,maneuvers ResetReset EntrainmentEntrainment Concealed entrainmentConcealed entrainmentAdvanced mappingAdvanced mapping Voltage mapping Voltage mapping Electro-anatomical correlationElectro-anatomical correlation ImagingImaging EpicardialEpicardial approach approach OthersOthersConcepts of MappingReentrant Ventricular TachycardiaDoublepotentialsScarsScars0.5 mV2 mVPotentialcircuitsCP1176527-5CP1233975-13ECGECGECGECGECGECGQRSQRSQRSonsetonsetonsetCommon pathwayCommon pathwayCommon pathway(CP)(CP)(CP)CPCPCPentranceentranceentranceInner loopInner loopInner loopScarScarScarOuter loopOuter loopOuter loopScarScarScarDead-endDead-endDead-endpathwaypathwaypathwayCP exitCP exitCP exitReentrant Circuit and TerminologyReentrant Circuit and TerminologyThis VT circuit exit site is likely:This VT circuit exit site is likely:A.LV/anterior/basal/lateralA.LV/anterior/basal/lateral B.LV/posterior/apical/lateralB.LV/posterior/apical/lateral C.LV/posterior/mid/C.LV/posterior/mid/septalseptal D.LV/posterior/apical/D.LV/posterior/apical/septalseptalMapping SchemeMapping SchemeCross SectionCross SectionBaseBaseApexApexLongitudinal SectionLongitudinal SectionSeptalSeptalLateralLateral12126 69 93 3AnteriorAnteriorPosteriorPosteriorCP1060083-4A AB BC CD DE EQRS Morphology Clues to VT Exit SiteQRS Morphology Clues to VT Exit SiteV4V4BaseBaseApexApexAVRAVRCP1060083-1AVRV4II,III,II,III,aVFaVFQRS Morphology Clues to VT Exit SiteQRS Morphology Clues to VT Exit SiteCP1060083-2AnteriorAnteriorPosteriorPosteriorII,III,II,III,aVFaVFQRS Morphology Clues to VT Exit SiteQRS Morphology Clues to VT Exit SiteI,I,aVLaVLSeptalSeptalLateralLateralII,III,II,III,aVFaVFCP1060083-3This VT circuit exit site is likely:This VT circuit exit site is likely:A.LV/anterior/basal/lateralA.LV/anterior/basal/lateral B.LV/posterior/apical/lateralB.LV/posterior/apical/lateral C.LV/posterior/mid/C.LV/posterior/mid/septalseptal D.LV/posterior/apical/D.LV/posterior/apical/septalseptal*CP1233975-13Reentrant Circuit and EntrainmentReentrant Circuit and EntrainmentA,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 manifested 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 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 alley”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 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 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“dead end alley”C.Pacing in an outer loopD.Pacing outside of the circuitE.Non capturePPITCL*PPI=395S-QRS=265VTCL=395E-QRS=265Termination of VTTermination of VTCP1201033-1%0-100-100-10n=46n=46n=4611-3011-3011-30n=18n=18n=1831-6031-6031-60n=24n=24n=24606060n=64n=64n=64PPI-VTCL(PPI-VTCL(PPI-VTCL(msecmsecmsec)CP1270284-4VT#5VT 1VT 2VT 3VT 3CP1270284-17Voltage Map Guided VT Ablation55 year-old man with DCM,EF 27%55 year-old man with DCM,EF 27%Frequent ICD shocks,failed previous ablationFrequent ICD shocks,failed previous ablationLeft Ventricular SupportLeft Ventricular Support Low-speed Low-speed centrifugal centrifugal continuous flow continuous flow pump pump Low blood surface Low blood surface area contact area contact 21 Fr Left atrial 21 Fr Left atrial cannulacannula 19 Fr femoral 19 Fr femoral arterial cannulaarterial cannula Up to 4L/min FlowUp to 4L/min FlowThiele et al Circ 2001Induction of VT on LV SupportInduction of VT on LV SupportEndocardial and Epicardial Mapping Endocardial and Epicardial Mapping with Left Ventricular Supportwith Left Ventricular SupportLAALACannulaEndoEpiEpicardial ApproachSchweikert et al.Circulation.2003;108:1329-1335.Eduardo Sosa,JACC 2000Epicardial approach shown to be feasible for VT ablation in patients with CAD.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 AblationEndocardial and Epicardial LV AblationMitral Valve Reentry mechanism is most commonReentry mechanism is most common Response to entrainment maneuvers determines Response to entrainment maneuvers determines the critical zone of conductionthe critical zone of conduction Multiple Multiple VTsVTs and circuits are frequently present and circuits are frequently present Voltage/scar mapping is often required Voltage/scar mapping is often required EpicardialEpicardial approach may be required in selected approach may be required in selected patientspatients Most patients undergo“palliative”VT ablation for Most patients undergo“palliative”VT ablation for recurrent ICD shocks recurrent ICD shocks VT Ablation in Scar Dependent SubstrateVT Ablation in Scar Dependent SubstrateGW-ICC HRS Joint SymposiumBeijingBeijingOct.11,2009Oct.11,2009