avrt房室折返型心動(dòng)過(guò)速

房室折返型心動(dòng)過(guò)速

AVRT學(xué)習(xí)目標(biāo)定義“旁道”解釋旁道的機(jī)制描述WPW的心電圖特征描述旁道的標(biāo)測(cè)與消融講述在旁道電生理檢查導(dǎo)管的選擇講述如何驗(yàn)證旁道消融是否成功房室折返型心動(dòng)過(guò)速的簡(jiǎn)介AVRT介紹另一種折返類(lèi)型，陣發(fā)型室上速,

(占室上速35-40%,占總?cè)丝诘?.1-0.3%)心電圖竇性心電圖中Discrete

P波能夠診斷部分病例癥狀心悸,頭昏眼花,憂心男性患者更多，與女性患者比例是,更多是年輕時(shí)候發(fā)病適當(dāng)?shù)脑绮渴艺鄯敌托膭?dòng)過(guò)速的機(jī)制房室折返型心動(dòng)過(guò)速!AVNRALARVAPLV房室折返型心動(dòng)過(guò)速的機(jī)制心室與心房之間有兩條通路:房室結(jié)(正常)旁道(異常)旁道心房與心室除正常傳導(dǎo)系統(tǒng)外心內(nèi)膜組織有額外的肌束房室交接處發(fā)育異常，可以出現(xiàn)在瓣環(huán)任意一點(diǎn)沒(méi)有遞減傳導(dǎo),比房室結(jié)傳導(dǎo)速度更快Kent

Bundle,

Bypass

Tract兩種類(lèi)型旁道顯性/WPW可以順向傳導(dǎo)（心房到心

室），也可以逆向傳導(dǎo)（心室到心房）異常的心電圖基線預(yù)激程度不同伴房顫高危險(xiǎn)性隱匿性只有逆向傳導(dǎo)（心室到心房）正常的心電圖基線沒(méi)有預(yù)激房顫不會(huì)并發(fā)WPW:

Wolff-Parkinson-White

Preexcitation

Syndrome旁道部位旁道能夠出現(xiàn)在任何位置，二尖瓣，三尖瓣環(huán)的后壁和側(cè)壁.右側(cè)游離壁左側(cè)游離壁后間隔前間隔竇率下顯性旁道（WPW）心電圖–PR間期<120

ms–正常P波向量后面出現(xiàn)delta波(預(yù)激)–QRS波持續(xù)>100

msWPW綜合征:12-導(dǎo)聯(lián)心電圖預(yù)激這個(gè)病例,左側(cè)預(yù)激后伴隨著一個(gè)正常的激動(dòng)，通過(guò)右束支，產(chǎn)生融合波房室折返型心動(dòng)過(guò)速:WPW:心動(dòng)過(guò)速的發(fā)生一個(gè)房性早搏能觸發(fā) 旁道阻滯后仍可以通過(guò)房室結(jié)傳導(dǎo)通過(guò)旁道逆向傳導(dǎo) 逆向傳導(dǎo)形成在下壁導(dǎo)聯(lián)可見(jiàn)倒置P波房室折返型心動(dòng)過(guò)速機(jī)制AccessorypathwayAAVNVHAP?

Biosense

Webster,

Inc.2008房室折返型心動(dòng)過(guò)速:12-導(dǎo)聯(lián)心電圖WPW:房顫伴預(yù)激發(fā)作快速心室率Patients

with

WPW

are

at

risk

of

sudden

cardiac

death

due

to

atrialarrhythmias,

such

as

atrial

flutter

and

atrial

fibrillation

that

conduct

rapidlyover

the

accessory

pathway,

and

elicit

extremely

rapid

ventricular

rates.

Asthis

continuous

tracing

shows,

it

can

degrade

into

ventricular

fibrillation.WPW:房顫伴預(yù)激發(fā)作快速心室率WPW患者伴有房撲，房顫有非常高的心臟猝死幾率，因?yàn)橥ㄟ^(guò)旁道快速心房激動(dòng)傳導(dǎo)到心室激動(dòng)，形成快速的心室率房室折返型心動(dòng)過(guò)速的診斷房室折返型心動(dòng)過(guò)速的診斷心電圖竇律(WPW)房室折返型心動(dòng)過(guò)速發(fā)作旁道的診斷心室-心房逆向傳導(dǎo):沒(méi)有遞減傳導(dǎo),His束不早房室折返型心動(dòng)過(guò)速誘發(fā)AVRT診斷竇律下心電圖短PR間期<0.12s正常P波向量(排除交界心律)Delta波寬QRS>

100msI

+

andAVF

-AVFII,III,+旁道定位Thefirst

25

ms

of

the

manifest(Pre-excited)

QRScomplexAVRT診斷:心動(dòng)過(guò)速下心電圖The

P

wave

produced

by

retrograde

conduction

during

AV

reentrytachycardia

is

inverted

in

the

inferior

ECG

leads,

since

atrialdepolarization

begins

in

the

lower

rightatrium

andproceedssuperiorly

and

leftward. Rapid

retrograde

conduction

over

theaccessory

pathway

results

in

a

short

R-P

interval,

usually

less

thanone-half

of

the

R-R

interval.AVRT診斷:竇率&心室起搏竇率心室起搏AVRT誘發(fā)AVRT診斷:發(fā)作時(shí)AVRT:房波或者心室起搏終止房室折返型心動(dòng)過(guò)速的治療AVRT的治療房室折返型心動(dòng)過(guò)速治療可以使用Beta受體阻滯劑或者Ca離子拮抗劑(5藥物治療可以導(dǎo)致疲勞和心動(dòng)過(guò)緩另一個(gè)選擇是射頻導(dǎo)管消融治療(>90%有效率)–治療后不需要其他長(zhǎng)期治療AVRT導(dǎo)管消融旁道射頻消融旁道針對(duì)患者顯 性預(yù)激患者，伴有突然死 亡的風(fēng)險(xiǎn)射頻消融后預(yù)激delta波 消失.AVRT導(dǎo)管消融治療左側(cè)旁道逆向?qū)Ч芟赗AO右側(cè)旁道導(dǎo)管消融AVRT旁道定位Precise

location

of

the

accessory

pathway

is

determined

by

therovecatheter. Retrograde

conduction

over

the

AP

is

seen

as

a

small

spikebetween

theV

and

A

waves. These

"Kent

potentials"

are

so

namedbecause

ofthe

original

denomination

ofaccessory

pathways

as"Kentbundles,"

after

the

investigator

Stanley

Kent,

who

first

proposed

theexistence

of

accessory

AV

connections.AVRT導(dǎo)管消融Radio

frequency

ablation

of

the

accessory

pathway

is

oftenindicated

in

patients

with

WPW

who

are

at

risk

ofsuddendeath

due

to

atrial

fibrillation

with

a

rapid

ventricularresponse

via

the

bypass

tract.Note

the

disappearance

of

the

preexcitation

delta

wave

inthe

QRS

with

catheter

ablation.Pre-Post

V-AConduction房室折返型心動(dòng)過(guò)速:導(dǎo)管消融AVRT導(dǎo)管消融CARTOENSITE

NAVXAVRT導(dǎo)管消融HRA:HIS:CS:RVA:Ablation

Catheter:Others房室折返型心動(dòng)過(guò)速消融驗(yàn)證AVRT