心臟電生理檢查內(nèi) 容電生理撿查目的電生理撿查方法及原理電生理撿查在心律失常中應(yīng)用術(shù)前準備及術(shù)后護理電生理檢查目的明確心律失常診斷了解心律失常機制明確心律失常起源檢驗藥物抗心律失常效果選擇射頻消融適應(yīng)證起搏器及ICD適應(yīng)證暈厥原因撿查電生理撿查方法及原理心電圖(ECG)及心內(nèi)電圖(EGM)記錄技術(shù)心臟程序電刺激技術(shù)刺激+記錄體外除顫器Hardwired

pulsetimerSoftware

pulsetimer脈沖刺激器示波器計算機Preamplifiers

atthetable病人記錄器放大器TypicalCatheterPlacement(H)RA前后位側(cè)位右前斜(RAO)左前斜(LAO)導(dǎo)管電活動Recording1-2Recording3-4雙極:

激動時間

4321記錄紙速50-100mm/sIV1HRAHisCSCSCSRV濾 波ECG(0.05-2500Hz)(30-100Hz)EGM(30-500Hz)(0.05-2500Hz)EffectoffilteringonthesignalsandinterpretationBurstRamp50HzPacing程序電刺激遞增刺激掃描刺激程序早搏刺激St =Stimulus

R =ResponseS2S2S1S1S1S1S1S1S2StRStRStRStRStRS1S1S1S1S1S1S2StR基礎(chǔ)刺激S1早搏刺激S2,S3S1S1S1S1S2AS1S1S1S1S2AAAA400260AAAA400250V1V5HRARARVV1V5HRARARVPVVHRACSHBEAH激動順序傳導(dǎo)時間不應(yīng)期折返RADCSPCSHBIAVFV1AAVAAVAVAVAVHAVH750PA=50AH=80HV=45HRAHisLVPRTI不同部位記錄EGMHRAEGMseptumEGMCSP-waveTimingrelationshipoftheactivationofdifferentsites激動順序激動順序IaVraVfV1HRAAVJCSpCSmCSd正常竇律 房早NSRAAHVAAAPACSNAAVNBHECG最小值最大值5010055PQRSP-A:A-H:H-V:255035AHV正常傳導(dǎo)間期正常HV間期ECG-V1HRAHisRVHV50msAHVVHV延長HRAAHAVJAVJHV=

90msAHVVHV阻滯心房起搏(350ms)HRAAVJAVJSSSSSAHAHVAHVAHVA逆?zhèn)鞑粦?yīng)期SSREFRACTORYREFRACTORYREFRACTORY刺激閾值引起心肌細胞興奮的最小能量全或無概念閾值奪獲不奪獲心房不應(yīng)期S1S1S1S1S2AS1S1S1S1S2AAAA400260AAAA400250V1V5HRARARVV1V5HRARARV心室不應(yīng)期260270S1S1S1S2S1S1S1S2不奪獲奪獲房室結(jié)特性正常情況下心房遞增刺激時房室結(jié)(AH)傳導(dǎo)時間會相應(yīng)延長，房內(nèi)傳導(dǎo)及室內(nèi)傳導(dǎo)時間不變ECG-V1HR1HisRVCyclelength:450Cyclelength:360SSSSAAHVV90655020909050AHVV20AAaVfaVrV1V5HRAAVJRVIAVJS1S1S1S2300400AAAHAHHVHV激動傳導(dǎo)心房: 穩(wěn)定心室: 穩(wěn)定AV結(jié): 隨心率加快傳導(dǎo)減慢電生理撿查在心律失常中應(yīng)用過緩型心律失常SSSAV阻滯室內(nèi)阻滯過速型心律失常SVTVT暈厥待查選擇心律失常治療適應(yīng)證病態(tài)竇房結(jié)綜合征(SSS)竇律下記錄竇房結(jié)恢復(fù)時間竇房傳導(dǎo)時間竇房結(jié)電圖心房竇房結(jié)房室傳導(dǎo)阻滯體表心電圖希氏束電圖心房程序電刺激定位診斷定量診斷ECGMinimumvaluesMaximumvalues5010055PQRSP-A:A-H:H-V:255035AHV心室內(nèi)傳導(dǎo)阻滯體表心電圖希氏束電圖心房程序電刺激阻滯數(shù)量阻滯部位預(yù)后評價ECGMinimumvaluesMaximumvalues5010055PQRSP-A:A-H:H-V:255035AHV心動過速大多為折返性室上性心動過速陣發(fā)性室上性心動過速竇性、房性、房室結(jié)、旁道房撲、房顫室性心動過速HPS分支折返(a)(b)(c)(d)AVNRT正路前傳型AVRT旁路前傳型AVRT雙旁路AVRTAVNI型II型III型Wolff-Parkinson-WhiteSyndrome房室旁道—一種快傳導(dǎo)纖維束(隨心率加快不減慢)心室預(yù)激波—delta波構(gòu)成折返途經(jīng)慢徑房室結(jié)(AV-node)快徑旁道(Kentbundle)觸發(fā)因素:早搏—誘發(fā)+終止隱匿性旁道房室旁道無前傳良好逆?zhèn)鳂?gòu)成心動過速IaVraVfV1HRAAVJCSpCSmCSdRV左側(cè)旁路折返SVTAAAAA誘發(fā)SVTSSSSSVT200bpmIaVraVfV1HRAAVJCSpCSmCSdRV心室刺激終止SVTSSSSSSSSVTVentricularpacingNSR房室結(jié)雙徑路房室結(jié)的一種電生理特性見于10%的人群形成心動過速的基礎(chǔ)，購成約一半的PSVT電生理特征心電圖上兩種PR間期心房刺激時A-H間期出現(xiàn)跳躍(>50ms)能誘發(fā)PSVTBA心房刺激周期縮短10ms，A-H增加超過50ms，(B-A>50ms)心動過速室性心動過速HPS分支折返電藥理學(xué)abcdAB1243誘發(fā)VTS1S1S2S1S1S2IaVfaVrV1V5HRAAVJAVJRVIIIIIIaVrV5V1HRARVS1S1S1S1S2S3S1S1S1S1S2S3InductionofVT早搏刺激終止VTaVfIaVrV1V5HRARV320190S快速終止VTaVfaVrV1V5HRARVOTRVA270SSSSSSSSSS190暈厥待查機械電生理過緩過速暈厥待查測定竇房結(jié)功能測定房室結(jié)功能測定室內(nèi)傳導(dǎo)功能測定旁道不應(yīng)期--誘發(fā)房顫—觀察心室反應(yīng)誘發(fā)室性心動過速—觀察血流動力學(xué)選擇心律失常治療適應(yīng)證進一步明確病竇--植入起搏器明確傳導(dǎo)阻