cardiac anatomy_20120916_南區
TRANSCRIPT
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嘉義長庚心臟內科潘國利
Cardiac Anatomy From view of Interventional
Electrophysiologists
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Anderson R H et al. Heart 2001;85:716-720
Short axis
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Cardiac Orientation
Posterior Anterior
Superior
Inferior
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Cardiac Orientation
Right Lateral
Left Lateral
Superior
Inferior
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QRS Complex )QRS Complex )
P-R IntervalP-R Interval
P-WaveP-Wave
Relationship of the Surface 12 lead Electrogram to the Activation Sequence
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Arrythmia-PSVT
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Eletrophysiology Study
Intracardiac ECG
• Bradycardia
- Sick sinus syndrome
- AV conduction block
• Tachycardia
- Supraventricular tachycardia
- Ventricular tachycardia
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The Normal Conduction System
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V Wave = CS (LBB) V Wave = CS (LBB) & RVa (RBB)& RVa (RBB)
His potential = HisHis potential = His
A-Wave = HRAA-Wave = HRA
Relationship of the Intracardiac Electrogram to the Activation Sequence
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Cardiac Structure
H.
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Position of EP catheter
AP view LAO view
HRHRAA His
RVA
CS
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His
CS
HRA
RVA
Intracardiac Electrogram Recordings – Catheter Placement
CS
HRA
RVA
His
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HRA Catheter Characteristics
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HIS Catheter Specifications
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Koch’s Triangle
An imaginary area called Koch’s triangle extends from the tricuspid annulus to the tendon of Todaro to the CS ostium. Two tracts of atrial fibers within Koch’s triangle form anatomically distinct conduction pathways to the compact AV node. • His bundle and compact AV node are at the apex of Koch’s triangle (thus must be avoided
during ablation) and define the anterior aspect of the atrial septum.•CS ostium is at the base and forms the posterior portion of the atrial septum.• Tricuspid annulus defines the third face of Koch’s triangle. • The anterior/superior tract, which lies along the tendon of Tadaro near the compact AV node,
is the fast pathway. The posterior/inferior tract, which lies along the tricuspid valve annulus near the CS ostium, is the slow pathway of the AV node. The slow pathway is farther away from the AV node and can usually be safely ablated.
1515
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Right Atrial Anatomy
The triangle in the picture is called the “Triangle of Koch” and has one face made up of the tricuspid annulus, another the “Tendon of Todaro” and the last the base of the CSos. At the tip of the triangle is the AV node. Thus EP doctors have this in mind when they ablate in the RA in order to avoid ablating the AV node and causing complete heart block requiring a pacemaker implantation.
Nakagawa et al., Circulation, 1996;94
At the base of the CSos is the At the base of the CSos is the Thesbian Valve (ThV). This can Thesbian Valve (ThV). This can be quite large and completely be quite large and completely cover the CSos making it very cover the CSos making it very difficult to insert a CS catheter. difficult to insert a CS catheter. Some patients also have a Some patients also have a diverticulum, which is a huge diverticulum, which is a huge pouch just inside the CSos. This pouch just inside the CSos. This too makes advancing the CS too makes advancing the CS catheter difficult after accessing catheter difficult after accessing the CSos. the CSos.
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AV Node
His Bundle His Bundle RegionRegion
Tricuspid Tricuspid AnnulusAnnulus
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CS Catheter Specifications
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RVA Catheter Specifications
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Intracardiac Electrogram Recordings
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Supraventricular tachycardia
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所以
心房 , 心室相關的空間位置的了解在心臟電生理檢查是重要的
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AP View of the Heart
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AP View with View Inside Ventricles
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RAO View of the Heart
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RAO View with View Inside RA and RV
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LAO View of the Heart
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LAO View with View Inside Ventricles
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Position of EP catheter
AP view LAO view
HRHRAA His
RVA
CS
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AP View of LV and Ao
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LAO View of LV and Ao
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RAO View of LV and Ao
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• HRA
• His
• RV
• CS
How about right site accessory pathway and typical flutter ?
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Crista TerminalisCrista Terminalis SVCSVC
Eustachian ridgeEustachian ridge
TVTV
IVCIVC
CSCS
Cardiac Anatomy Related to Isthmus Dependent Flutter
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Catheter Positions
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His
A
V
MV
TV
CS
Hallo
LOCATIONMAPPING
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Fluoroscopic Positions
CSCS
DuoDecDuoDec
RVRV
HISHIS
RVRV
HISHIS
CSCS
DuoDecDuoDec
LAORAO
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那如何描述左心房心律不整 (Af, AT)
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AP View of the LA
PA View of the LA
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PV Mapping CathetersSpiral HP
Reflexion VR
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Left atrium venogram
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Left atrium venogram
LAO
LIPV
LSPV
CRD-1
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Fluoroscopy and MRI views of the Pulmonary veins
Cardiac Venous Anatomy
4545
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Besides, coronary sinus is important
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Cardiac Venous Anatomy
Coronary Sinus (CS) – Great Cardiac Vein (GCV)Vein (Ligament) of Marshall (VOM or LOM)Left and Right Superior and Inferior Pulmonary Veins (RSPV, RIPV, LSPV, LIPV) Superior Vena Cava (SVC)Inferior Vena Cava (IVC) Pulmonary artery (PA)Middle Cardiac Vein (MCV)Posterior Descending Artery (PDA)
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Venous structures
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AP View of the RA,LA and CS
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LAO View of the RA,LA and CS
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結論 1
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His
A
V
MV
TV
CS
Hallo
結論 2
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謝謝聆聽