電生理及血液動力學(xué)簡介完整版

InvasiveCardiology電生理及血液動力學(xué)簡介GEMS－ITPrucka應(yīng)用培訓(xùn)教程血液動力學(xué)學(xué)習(xí)目的:心臟基礎(chǔ)解剖學(xué)熟悉基本的血液動力學(xué)術(shù)語理解常見的心臟血動手術(shù)流程心臟解剖

為什么要進(jìn)行血液動力學(xué)監(jiān)測？在導(dǎo)管手術(shù)中提供實時而精確的壓力和ECG監(jiān)測及記錄結(jié)合影像資料可進(jìn)一步確診心血管疾病導(dǎo)管手術(shù)中需監(jiān)測哪些指標(biāo)？不同心臟腔室及血管壓力的監(jiān)測瓣膜兩側(cè)的壓力/壓力差值測量（壓力梯度）心排量(用于心功能評價)正常壓力值RV25/0/4RA6/5/3LA10/12/8PA(肺動脈)25/9/15LV左室120/5/10

AO(主動脈）120/80/95PCW肺毛壓11/12/9左心導(dǎo)管并冠脈檢查基線測量選擇性冠脈造影用豬尾導(dǎo)管進(jìn)行LV左室基本功能測量LV造影LV導(dǎo)管回撤壓測量（連續(xù)測壓）心電及左心系統(tǒng)壓力波形P-波-心房收縮(除極)***A-waveofLAQRS–心室收縮(心臟收縮)***AO舒張,LVEDP(舒末壓)ST段–壓低(缺血)抬高(損傷)T-波–復(fù)極或心肌舒張(舒張)***V-waveofLA,AO/LV

收縮左、右心導(dǎo)管并冠脈檢查通常使用兩根導(dǎo)管

豬尾導(dǎo)管–冠脈

Swan-ganz漂浮導(dǎo)管右心系統(tǒng)壓力Fick法CO–TDCO（熱稀釋法心排量）CommonMeasurementsobtained左心導(dǎo)管,豬尾導(dǎo)管同步實時壓力測量LV/PCWLV/AO冠脈注射心電及右心系統(tǒng)壓力波形P-wave-Contraction(depolarization)oftheatria***A-waveofPCWandRAQRS–Ventricularcontraction(systole)***PAdiastole,RVEDPSTsegment–Depression(ischemia)Elevation(injury)T-wave–RepolarizationorMyocardialrelaxation(diastole)***V-waveofPCWandRAPAsystole,RVsystole正常O2飽和度(+/-5%)RV75%RA75%LA95%PA75%LV95%

AO95%PCW97%SVC70%IVC75%LV至AOPullback連續(xù)測壓電生理基礎(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-CardiacSignals

TheEPLabComponentsHardware可移動操作臺ComputerAmplifier&StimulatorDisplayPrinterKeyboardandmouseRFablationdeviceIsolatedpowersupplyHardware(cont.)英特爾?至強(qiáng)?處理器E3-1225v2

4GB(2x2GB)DDR3UDIMM內(nèi)存,1600MHz500GB7200RPM3.5‘’SATA3硬盤x2

1GBNVIDIAQuadro600(1個DP與1個DVI-I)16X最大可變速DVD-ROM刻錄光驅(qū)

Video1forreal-timeVideo2fornon-real-time(optional)ComputerHardware(cont.)TOOP-2001AmplifierWhatis16/32/64/96channels?

PowerTOOP-2001:ExternalPowercontrols220vLineFrequency(Notchfilters)TOOP-2001:ManufacturebuildsuniqueamptospecificationCLabIIPlus:Autorecognitionof50Hzor60HzTOOP-2001B(16導(dǎo))TOOP-2001C(32導(dǎo))TOOP-2001D(64導(dǎo))TOOP-2001E(96導(dǎo))CatheterInputs16326496IntracardiacChannels0164864ECG12121212Inv.Pressure4444Hardware(cont.)AmpliferHardwareECGIECG1/2/3BP1/2MAP50HzbuttonResetbuttonPowerbuttonHardware(cont.)AmplifierPOWERGNDUSBportNetworkportStimControlCOM心臟電生理檢查及射頻消融手術(shù)常用儀器射頻消融手術(shù)實況圖BasicEPStudy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(jī)械耦合Electro-MechanicalCoupling有效的心輸出量EfficientCardiacOutput電－機(jī)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(xì)胞表面記錄Extra-cellularRecording較遠(yuǎn)的參考電極RemoteReference雙向波術(shù)前檢查Pre-ProcedureTestingWBC白細(xì)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(yuǎn)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(yuǎn)端Dist1,2RVA導(dǎo)管起博Pace:遠(yuǎn)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SequenceofActivationEPProtocol方案基線傳導(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-Stimulus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(jìn)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(jìn)行消融RFenergyisdeliveredbyaspecialcatheterthatissimilartoanormalEPcatheter.也可用超聲，微波，激光及低溫的方法進(jìn)行消融Alternativeformsofablationsarebeingconsidered:ultrasound,microwave,laser,andcryogenic.