心肌梗死患者抢救消融电风暴英文

Electical Storms
Nov 2005- admitted after recurrent ICD shocks
Interrogations: 58 episodes of VT detected Most terminated with ATP Some accerlerated to fast VT which was then termianted with cardioversion shocks Early re-initiation of VT
Rescue Ablation of Electrical Storms in a Patient with
Remote Myocardial Infarction
Katherine Fan Grantham Hospital Hong Kong SAR
Patient Mr. L
M/64 History of inferior MI 1989- MVR for papillary
Composite Substrate Profile
Fixed Block
DSM Sinus Rhythm
Functional Block
Composite Substrate Map
DSM VT
Marked Lesions
RAO view
Inferior view
Another Marked Lesions
ICD (single-chamber) 1997
Amiodarone added in 2001 for PAF/ NSVT
Recurrent VT episodes in 3/2005 with increased dosage of amiodarone
Developed SOB- diagnosed amiodarone induced pulmonary fibrosis: Amiodarone stopped/ High dose steroids required
muscle rupture and severe MR Ischemic cardiomyopathy (EF 30%) VT 1997- ICD implanted / generator change
2002 Chronic smoker/ COPD
Ventricular Arrhythmias
RBBB/ Right superior axis
LBBB/Left superior axis
By virtue of its narrow dimension, the isthmus became the vulnerable point to interrupt this circumferential activation
Targets Critical isthmus Areas of slow conduction Exit sites- often located at the border of the scarred myocardium
Mitral Isthmus Ventricular Tachycarida
LBBB/LAD
RBBB/RAD
Critical zone of slow conduction activated parallel to mitral isthmus in either direction resulting in 2 distinct but characteristic QRS configurations
RAO view
Inferior view
Substrate-Orientated VT Ablation
A definite trigger or delineated scar has been characterized as a requirement for substrate orientated ablation of intractable unmappable VT
VT 1
VT 2
Lesions Created
Termination of VT (RF #38!)
on RF
Catheter Ablation of the Mitral Isthmus for VT associated with Inferior Infarction
Wilber Biblioteka Baidut al. Circulation 1995;92:3481-3489
-blockers / sotalol- not tolerated – exacerbation of COPD
Recurrent VT episodes- mexiletine started but complicated by neurological signs (limb tremor and gait instability)
VT Morphologies
LBBB/ Left superior axis QRS RBBB/ Right superior axis QRS
RBBB/R sup ATP
LBBB/ L sup RBBB/ R sup
RAO
INF
Mitral valve prothesis
Sinus Rhythm
Dynamic Substrate Map
Sinus Rhythm
RAO view
Low Voltage Zone
Inferior view
Dynamic Substrate Map
Ventricular Tachycardia
RAO view
Low Voltage Zone
Inferior view
LBBB with left superior axis- rS in V1 and aVR/ R in V6, I, aVL
RBBB with right superior axis- R in V1 and aVR/ QS in V6, I, aVL
Wilber et al. Circulation 1995