多道電生理培訓(xùn)2心臟與心電圖34心律失常心電圖SinusRhythmsSinusTachycardiaSinusBradycardiaTheEPLab5耗材射頻消融導(dǎo)管標(biāo)測導(dǎo)管穿刺針，鞘電纜線電生理刺激儀電生理記錄儀電生理導(dǎo)管室臺設(shè)備配置射頻消融儀電生理工作站備注：除顫器；心肺復(fù)蘇設(shè)備；血壓、氧飽和度監(jiān)護儀等7RealTimeReview電生理基礎(chǔ)學(xué)習(xí)目的:熟悉基本的電生理術(shù)語理解基本EP手術(shù)流程理解導(dǎo)管手術(shù)中在CardioLab和Mac-Lab記錄的信息ReasonsforanEPStudy心律失常的評估心臟電生理傳導(dǎo)系統(tǒng)異常的診斷起博器,ICD的評估心臟傳導(dǎo)系統(tǒng)SANode竇房結(jié)AVNode房室結(jié)HISBundle希氏束BundleBranches束枝Purkingeefibers普肯野氏纖維心臟傳導(dǎo)竇房結(jié)心房傳導(dǎo)

房室結(jié)

希氏束左,右束枝蒲肯野氏纖維蒲肯野氏纖維竇房結(jié)激動心率的起始自主性70Beats/minuteP波開始心房激動右房RightAtrium房間隔InteratrialSeptum左房LeftAtriumP波持續(xù)房室結(jié)AVNode調(diào)節(jié)器Regulator自主節(jié)律50bpm延遲100msA-H間隔40-140msHISECGAH快速傳導(dǎo)路徑HISBundleBranchesPurkinjeFibersH-VInterval心室激動室間隔右，左室游離壁房室間溝A-VGrooveQRS持續(xù)期復(fù)極Repolarization不應(yīng)期RefractoryPeriod休眠期RestPhase無激動性Non-excitabilityQT持續(xù)期心內(nèi)電信號Intra-CardiacSignalsBasicEPStudy患者準(zhǔn)備PatientPrepped插入導(dǎo)管CatheterInsertions基線測量BaselineMeasurements起博/刺激Pacing/Stimulator(Bloom)診斷Evaluationofinformation治療/消融治療Intervention/AblationGenerator心臟傳導(dǎo)的解剖RightVentricleRightAtriumLeftAtriumLeftVentricleSANodeAVNodePurkinjeFibersBundleofHisPulmonaryVein電傳導(dǎo)ElectricPropagation70Beats/MinuteA-V順序激動SequentialActivationRV/LV同步激動不應(yīng)期RefractoryRestPeriod電－機械耦合Electro-MechanicalCoupling有效的心輸出量EfficientCardiacOutput電－機械耦合心室同步收縮心肌收縮，相當(dāng)于不應(yīng)期250-450msArterialPressureTechniquesforRecording12導(dǎo)ECG雙極腔內(nèi)心電BipolarCatheterElectrogramsHRAHISRVCSMapping動脈壓ArterialPressure12導(dǎo)ECG4個肢6個胸導(dǎo)聯(lián)作為電活動的無創(chuàng)參考Non-InvasiveReferenceofElectricalActivity定位心律失常的來源Locatethesourceofarrhythmias室速VentricularTachycardia旁道Pathways12導(dǎo)ECG體表記錄RecordedfromBodySurface無創(chuàng)Non-InvasiveECG電極Electrodes總體觀察心電活動ElectricalOverviewEPCatheters雙極心電BipolarElectrogram記錄波形傳導(dǎo)RecordsPropagatingWaves電極距離較近CloselySpacedElectrodes檢測局部激動DetectsLocalActivation雙相波單極心電UnipolarElectrogram用于研究目的ResearchApplication細胞表面記錄Extra-cellularRecording較遠的參考電極RemoteReference雙向波術(shù)前檢查Pre-ProcedureTestingWBC白細胞評估有無感染RiskofSepsisifElevatedPlateletCount血小板計數(shù)評估有無出血趨向RiskofBleedingifLowHemoglobin&Hematocrit血紅蛋白及紅血球PossiblealternatecauseofSyncopeSodiumandPotassiumLevels電解質(zhì)Na+&K+CommoncauseofDysrhythmiaAnti-ArrhythmicMedicationsStoppedorLevelsDrawn停用抗心律失常藥物12LeadECGSomehomemedsmayaltertheECG手術(shù)部位ProcedureSitesVTStudies室速GroinorArmApproachSVTStudies室上速GroinApproach股動，靜脈插管PossibleArmApproach肘動，靜脈插管PossibleSubclavianorInternalJugular鎖骨下靜脈插管ICDFollowupsareusuallynon-invasiveICD隨訪通常用無創(chuàng)方法插管CatheterInsertion局麻LocalanesthesiaSeldingertechnique通常采用靜脈插管Generallyvenoussideonly左鎖骨下靜脈插管常用于插入冠狀靜脈竇導(dǎo)管HRA導(dǎo)管起博Pace:遠端Distal1,2前傳測試AntegradeConductionTesting記錄Record:近短Proximal3,4HIS導(dǎo)管記錄Record:近端Prox3,4中端Mid2,3遠端Dist1,2RVA導(dǎo)管起博Pace:遠端Distal1,2逆?zhèn)鳒y試RetrogradeConductionTesting記錄Record:近端Prox3,4心室激動VentricularActivationCS導(dǎo)管記錄Record:CS7,8CS5,6起博Pace:標(biāo)測左側(cè)旁路MappingofLeftSidePathways激動順序SequenceofActivation基線傳導(dǎo)記錄BaselineConductionRecordings12LeadHRA,HIS,RV起博HRA(前傳AntegradeConduction)竇房結(jié)恢復(fù)SinusNodeRecovery遞增心房刺激IncrementalAtrialPacing(Wenkebach)房性期前刺激AtrialExtra-Stimulus起博RVA(逆?zhèn)鱎etrogradeConduction)遞增心室刺激IncrementalVentricularPacing室性期前刺激VentricularExtra-StimulusEPProtocol方案術(shù)中Procedure在記錄基線測量后，采用在8個刺激后增加房性早搏或室性早搏的方法檢測心律失常的性質(zhì)及部位AfterBaselineMeasurementsaretakenandrecorded,PacingisDonefor8beats,thenPVC’sorPAC’sareadded.房性早搏通常用于研究源于心房的心律失常PAC’sareusedforstudyofArrhythmiasoriginatingfromtheAtria室性早搏通常用于研究源于心室的心律失常PVC’sareusedforstudyofArrhythmiasoriginatingfromtheVentricles術(shù)中Procedure通過各種刺激方案可確定心律失常的類型及部位AvarietyofpacingprotocolswillrevealthearrhythmiatypeanditsbasiclocationInducingthearrhythmiathroughpacingwillhelptopinpointthearrhythmiaCathetermappingintheareaofarrhythmiainductionwillindicatethebestpositionforRadiofrequency(RF)catheterablation竇房結(jié)恢復(fù)時間SinusNodeRecoveryTime:SNRT基于超速抑制BasedonOverdriveSuppression30秒起博30secondspacingSNRT=IntervalbetweenpacingandrecoverybysinuscSNRT=SNRTminusintrinsicheartrate房性早搏AtrialExtra-Stimulus典型的Typical:8個刺激(S1ms)1個早搏(decreasingS2ms)AH傳導(dǎo)間隔延長，最終阻滯脫落intervalextension,andeventualblock(depicted)尋找慢徑Seekingslowpathway心律失常Arrhythmias室上速SupraventricularTachycardia(SVT)AVNodalReentryAVReentryWolff-Parkinson-WhiteAtrialTachycardiaAtrialFlutterAtrialFibrillation室速VentricularTachycardia(VT)房室結(jié)折返性心動過速AVNodalReentry(AVNRT)Causes:CongenitalAging–SVTCharacteristics:ReentrantActivationAroundAVNodeAtrial/VentricularActivationFastPathway(longrefractoryperiod)SlowPathway(shortrefractoryperiod)LongerP-RintervalatonsetV-AactivationonECG房室折返性AVReentry(AVRT)Causes:CongenitalCharacteristics:AccessoryPathwayatA-VGrooveRight,Left,Posterior,orSeptalAccessoryPathwayWPW綜合癥SyndromeCauses:CongenitalCharacteristics:AtrialArrhythmiaandAntegrade-ConductingAccessoryPathwayAccessoryPathwayatA-VGrooveRight,Left,Posterior,orSeptalShortP-Rinterval(<0.12sec)ProlongedQRSinterval(>0.1sec)SlurringoftheupstrokebyadeltawaveAccessoryPathway房撲AtrialFlutterTheFlutteringAtriaproduceasawtooth-typecharacterfortheAtrialWaveformTheAratehasa4:1ratiototheVrateTheAVNodepreventsalloftheAtrialbeatsfromreachingtheVentricles房顫AtrialFibrillationTherearenoidentifiableP-waveformsTheVentricularresponseisirregularMostoftheAtrialimpulsesareblockedbytheAVnodeAtrialrateof350-600BPMAtriumbeatsirregularlylikeJello!

室速VentricularTachycardiaCauses:MyocardialInfarctionCongenitalCardiomyopathyCharacteristics:OnlyinVentricleUni-orMultifocalSustainedorIntermittentAverageHRof150–250BPMLifeThreatening治療Treatments/Therapies藥物Anti-ArrhythmicDrugs起博器/除顫起博Pacemaker/ICDImplant射頻RFAblation標(biāo)測Mapping找出心律失常部位的方法Requiresameansoflocatingthesourceofthearrhythmia:用一根導(dǎo)管環(huán)繞心臟Moveasinglecatheteraroundtheheart使用高密度電極Useacatheterwithahighdensityofelectrodes其他Othertechnologies標(biāo)測電極導(dǎo)管MappingCatheterRecordPaceAblateHalo電極導(dǎo)管BasketCatheter籃狀電極導(dǎo)管SteerableAblationCatheter

大頭電極導(dǎo)管消融Ablation通過發(fā)放射頻能量進行消融AblationsareusuallyperformedbydeliveringRFenergy.射頻產(chǎn)生的高溫可破壞局部組織Thehightemperaturecreatedbytheenergykillsthelocaltissue.射頻通過類似普通標(biāo)測電極導(dǎo)管的大頭電極進行消融RFenergyisdeliveredbyaspecialcatheterthatissimilartoanormalEPcatheter.也可用超聲，微波，激光及低溫的方法進行消融Alternativeformsofablationsarebeingconsidered:ultrasound,microwave,laser,andcryogenic.消融Ablation射頻消融時，需實時標(biāo)測及測試以確保相應(yīng)的組織已被阻斷OnceRFEnergyisdirectedtoarrhythmiasite,morepacingandtestingisdonetoensureresponsibletissuehasbeendestroyed如心律失常可被再次誘發(fā)，則需在相應(yīng)組織周圍反復(fù)消融Ifarrhythmiaisre-induced,mo