血液动力学

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1、血液动力学,学习目的: 心脏基础解剖学 熟悉基本的血液动力学术语 理解常见的心脏血动手术流程,心脏解剖,为什么要进行血液动力学监测？,在导管手术中提供实时而精确的压力和ECG监测及记录 结合影像资料可进一步确诊心血管疾病 导管手术中需监测哪些指标？ 不同心脏腔室及血管压力的监测 瓣膜两侧的压力/压力 差值测量（压力梯度） 心排量 (用于心功能评价),正常压力值,RV 25/0/4,RA 6/5/3,LA 10/12/8,PA(肺动脉) 25/9/15,LV左室 120/5/10,AO(主动脉） 120/80/95,PCW肺毛压 11/12/9,左心导管并冠脉检查,基线测量 选择性冠脉造影 用猪

2、尾导管进行 LV 左室基本功能测量 LV造影 LV 导管回撤压测量（连续测压）,心电及左心系统压力波形,P-波 - 心房收缩(除极) * A-wave of LA QRS 心室收缩(心脏收缩) *AO 舒张, LV EDP(舒末压) ST 段 压低 (缺血) 抬高 (损伤) T-波 复极 或心肌舒张 (舒张) * V-wave of LA, AO/LV 收缩,左、右心导管并冠脉检查,通常使用两根导管 猪尾导管 冠脉 Swan-ganz 漂浮导管 右心系统压力 Fick 法CO TDCO（热稀释法心排量） Common Measurements obtained 左心导管, 猪尾导管 同步实时压

3、力测量 LV / PCW LV / AO 冠脉注射,心电及右心系统压力波形,P-wave - Contraction(depolarization) of the atria *A-wave of PCW and RA QRS Ventricular contraction (systole) *PA diastole, RV EDP ST segment Depression (ischemia) Elevation (injury) T-wave Repolarization or Myocardial relaxation (diastole) * V-wave of PCW and R

4、A PA systole, RV systole,正常 O2 饱和度 (+/- 5%),RV 75%,RA 75%,LA 95%,PA 75%,LV 95%,AO 95%,PCW 97%,SVC 70%,IVC 75%,LV 至 AO Pullback连续测压,电生理基础,学习目的: 熟悉基本的电生理术语 理解基本EP 手术流程 理解导管手术中在CardioLab和 Mac-Lab记录的信息,Reasons for an EP Study,心律失常的评估 心脏电生理传导系统异常的诊断 起博器, ICD 的评估,心脏传导系统,SA Node 窦房结 AV Node 房室结 HIS Bundle

5、希氏束 Bundle Branches 束枝 Purkingee fibers 普肯野氏纤维,心脏传导,窦房结,心房传导,房室结,希氏束,左,右束枝,窦房结激动,心率的起始 自主性 70 Beats/minute P波开始,心房激动,右房Right Atrium 房间隔Interatrial Septum 左房Left Atrium P 波持续,房室结AV Node,调节器Regulator 自主节律 50 bpm 延迟 100 ms A-H 间隔,快速传导路径,HIS Bundle Branches Purkinje Fibers H-V Interval,心室激动,室间隔 右，左室游离壁

6、房室间沟A-V Groove QRS 持续期,复极Repolarization,不应期Refractory Period 休眠期Rest Phase 无激动性Non-excitability QT持续期,心内电信号Intra-Cardiac Signals,The EP Lab,Components,Hardware,可移动操作台 Computer Amplifier&Stimulator Display Printer Keyboard and mouse RF ablation device Isolated power supply,Hardware (cont.),英特尔 至强 处理器

7、 E3-1225 v2 4GB (2x2GB) DDR3 UDIMM 内存, 1600MHz 500GB 7200 RPM 3.5 SATA3 硬盘 x2 1 GB NVIDIA Quadro 600 (1个DP与1个DVI-I) 16X 最大可变速DVD-ROM 刻录光驱 Video 1 for real-time Video 2 for non-real-time(optional),Computer,Hardware (cont.),TOOP-2001 Amplifier,What is 16/32/64/96 channels?,Power TOOP-2001: External Po

8、wer controls 220 v Line Frequency (Notch filters) TOOP-2001: Manufacture builds unique amp to specification CLab II Plus: Auto recognition of 50 Hz or 60 Hz,Hardware (cont.),Amplifer Hardware,ECG IECG1/2/3 BP1/2 MAP 50Hz button Reset button Power button,Hardware (cont.),Amplifier,POWER GND USB port

9、Network port Stim Control COM,心脏电生理检查及射频消融手术常用仪器,射频消融手术实况图,Basic EP Study,患者准备Patient Prepped 插入导管Catheter Insertions 基线测量Baseline Measurements 起博/刺激Pacing / Stimulator (Bloom) 诊断Evaluation of information 治疗/消融治疗Intervention / Ablation Generator,心脏传导的解剖,电传导Electric Propagation,70 Beats/Minute A-V 顺序

10、激动Sequential Activation RV/LV 同步激动 不应期Refractory Rest Period 电机械耦合Electro-Mechanical Coupling 有效的心输出量Efficient Cardiac Output,电机械耦合,心室同步收缩 心肌收缩，相当于不应期,Techniques for Recording,12 导ECG 双极腔内心电Bipolar Catheter Electrograms HRA HIS RV CS Mapping 动脉压Arterial Pressure,12 导ECG,4 个肢 6 个胸导联 作为电活动的无创参考Non-Inv

11、asive Reference of Electrical Activity 定位心律失常的来源Locate the source of arrhythmias 室速Ventricular Tachycardia 旁道Pathways,12 导 ECG,体表记录Recorded from Body Surface 无创Non-Invasive ECG 电极Electrodes 总体观察心电活动Electrical Overview,EP Catheters,双极心电Bipolar Electrogram,记录波形传导Records Propagating Waves 电极距离较近Closely

12、 Spaced Electrodes 检测局部激动Detects Local Activation 双相波,单极心电Unipolar Electrogram,用于研究目的Research Application 细胞表面记录Extra-cellular Recording 较远的参考电极Remote Reference 双向波,术前检查Pre-Procedure Testing,WBC白细胞 评估有无感染Risk of Sepsis if Elevated Platelet Count血小板计数 评估有无出血趋向Risk of Bleeding if Low Hemoglobin & Hema

13、tocrit血红蛋白及红血球 Possible alternate cause of Syncope Sodium and Potassium Levels电解质Na+ &K+ Common cause of Dysrhythmia Anti-Arrhythmic Medications Stopped or Levels Drawn停用抗心律失常药物 12 Lead ECG Some home meds may alter the ECG,手术部位Procedure Sites,VT Studies室速 Groin or Arm Approach SVT Studies室上速 Groin A

14、pproach股动，静脉插管 Possible Arm Approach肘动，静脉插管 Possible Subclavian or Internal Jugular锁骨下静脉插管 ICD Follow ups are usually non-invasive ICD随访通常用无创方法,插管Catheter Insertion,局麻Local anesthesia Seldinger technique 通常采用静脉插管Generally venous side only 左锁骨下静脉插管常用于插入冠状静脉窦导管,HRA 导管,起博Pace: 远端Distal 1,2 前传测试Antegrad

15、e Conduction Testing 记录Record: 近短Proximal 3,4,HIS 导管,记录Record: 近端Prox 3,4 中端Mid 2,3 远端Dist 1,2,RVA导管,起博Pace: 远端Distal 1,2 逆传测试Retrograde Conduction Testing 记录Record: 近端Prox 3,4 心室激动Ventricular Activation,CS 导管,记录Record: CS 7,8 CS 5,6 起博Pace: 标测左侧旁路Mapping of Left Side Pathways,激动顺序Sequence of Activa

16、tion,EP Protocol方案,基线传导记录Baseline Conduction Recordings 12 Lead HRA, HIS, RV 起博HRA (前传Antegrade Conduction) 窦房结恢复Sinus Node Recovery 递增心房刺激Incremental Atrial Pacing (Wenkebach) 房性期前刺激Atrial Extra-Stimulus 起博RVA (逆传Retrograde Conduction) 递增心室刺激Incremental Ventricular Pacing 室性期前刺激Ventricular Extra-St

17、imulus,术中Procedure,在记录基线测量后，采用在8个刺激后增加房性早搏或室性早搏的方法检测心律失常的性质及部位After Baseline Measurements are taken and recorded, Pacing is Done for 8 beats, then PVCs or PACs are added. 房性早搏通常用于研究源于心房的心律失常PACs are used for study of Arrhythmias originating from the Atria 室性早搏通常用于研究源于心室的心律失常PVCs are used for study o

18、f Arrhythmias originating from the Ventricles,术中Procedure,通过各种刺激方案可确定心律失常的类型及部位A variety of pacing protocols will reveal the arrhythmia type and its basic location Inducing the arrhythmia through pacing will help to pinpoint the arrhythmia Catheter mapping in the area of arrhythmia induction will in

19、dicate the best position for Radiofrequency (RF) catheter ablation,窦房结恢复时间Sinus Node Recovery Time: SNRT,基于超速抑制Based on Overdrive Suppression 30秒起博30 seconds pacing SNRT = Interval between pacing and recovery by sinus cSNRT = SNRT minus intrinsic heart rate,房性早搏Atrial Extra-Stimulus,典型的Typical: 8 个刺

20、激(S1ms) 1个早搏(decreasing S2ms) AH传导间隔延长，最终阻滞脱落 interval extension, and eventual block (depicted) 寻找慢径Seeking slow pathway,心律失常Arrhythmias,室上速Supraventricular Tachycardia (SVT) AV Nodal Reentry AV Reentry Wolff-Parkinson-White Atrial Tachycardia Atrial Flutter Atrial Fibrillation 室速Ventricular Tachyca

21、rdia (VT),房室结折返性心动过速AV Nodal Reentry (AVNRT),Causes: Congenital Aging SVT Characteristics: Reentrant Activation Around AV Node Atrial/Ventricular Activation Fast Pathway (long refractory period) Slow Pathway (short refractory period) Longer P-R interval at onset V-A activation on ECG,房室折返性AV Reentry

22、 (AVRT),Causes: Congenital Characteristics: Accessory Pathway at A-V Groove Right, Left, Posterior, or Septal,WPW 综合症Syndrome,Causes: Congenital Characteristics: Atrial Arrhythmia and Antegrade-Conducting Accessory Pathway Accessory Pathway at A-V Groove Right, Left, Posterior, or Septal Short P-R i

23、nterval (0.1 sec) Slurring of the upstroke by a delta wave,房扑Atrial Flutter,The Fluttering Atria produce a sawtooth-type character for the Atrial Waveform The A rate has a 4:1 ratio to the V rate The AV Node prevents all of the Atrial beats from reaching the Ventricles,房颤Atrial Fibrillation,There ar

24、e no identifiable P-waveforms The Ventricular response is irregular Most of the Atrial impulses are blocked by the AV node Atrial rate of 350-600 BPM Atrium beats irregularly like Jello!,室速Ventricular Tachycardia,Causes: Myocardial Infarction Congenital Cardiomyopathy Characteristics: Only in Ventri

25、cle Uni- or Multifocal Sustained or Intermittent Average HR of 150 250 BPM Life Threatening,治疗Treatments/Therapies,药物Anti-Arrhythmic Drugs 起博器/除颤起博Pacemaker/ ICD Implant 射频RF Ablation,标测Mapping,找出心律失常部位的方法Requires a means of locating the source of the arrhythmia: 用一根导管环绕心脏Move a single catheter arou

26、nd the heart 使用高密度电极Use a catheter with a high density of electrodes 其他Other technologies,标测电极导管Mapping Catheter,Record Pace Ablate,Halo 电极导管,Basket Catheter篮状电极导管,Steerable Ablation Catheter大头电极导管,消融Ablation,通过发放射频能量进行消融Ablations are usually performed by delivering RF energy. 射频产生的高温可破坏局部组织The high

27、 temperature created by the energy kills the local tissue. 射频通过类似普通标测电极导管的大头电极进行消融RF energy is delivered by a special catheter that is similar to a normal EP catheter. 也可用超声，微波，激光及低温的方法进行消融Alternative forms of ablations are being considered: ultrasound, microwave, laser, and cryogenic.,消融Ablation,射频

28、消融时，需实时标测及测试以确保相应的组织已被阻断Once RF Energy is directed to arrhythmia site, more pacing and testing is done to ensure responsible tissue has been destroyed 如心律失常可被再次诱发，则需在相应组织周围反复消融If arrhythmia is re-induced, more RF energy will be applied in surrounding tissue 需等待一段时间以反复进行刺激而不能诱发出心律失常There is a waiting

29、 period once no arrhythmia can be maintained and pacing will be done again 当消融后测量及记录成功并经再测试后不能诱发心律失常，手术结束Case end is reached when post-ablation measurements are recorded successfully and retesting reveals no arrhythmia,术后Post Procedure,卧床休息Bedrest for invasive procedures 静脉插管术后约3小时Approximately 3 ho

30、urs for femoral venous 动脉插管术后约6小时Approximately 6 hours for arterial access 定期检查Frequent procedure site checks 12 Lead 应该无变化，除了Should be unchanged, except WPW 预激综合症消融后 房室结消融术后,并发症Complications,出血和/ 或淤血Bleeding and/or Bruising 感染Infection 传导阻滞，植入永久起博器Unplanned Permanent Pacemaker 心包填塞Tamponade 末梢血栓Distal Thrombosis 肺静脉狭窄Pulmonary Vein Stenosis (Afib RFA) This is not a complete listing,