乳头肌起源室早/室速的特征与消融 VT/PVC Originating From the Papillary Muscle 杨新春 首都医科大学附属北京朝阳医院心脏中心

乳头肌相关室性心律失常的实验研究 1999年Kim等 含乳头肌的离体猪右心室进行计算机多电极阵列标测 2003年Pak等 兔离体心脏前壁进行室颤光学标测 2006年 Pak等开胸犬或猪 心内多电极阵列球囊非接触式标测或心外膜高密度标测 2008 年 Pak等开胸室猪 左心室后壁临近后乳头肌处，延后降支做从心底到心尖行心肌切开-缝合术 2010年郭雷生等开胸猪超声引导下注射酒精消融左心室后乳头肌

VA Originating from the Posterior Papillary Muscle in LV Circ Arrhythmia Electrophysiol. 2008;1:23-29

VA Originating from the Anterior Papillary Muscle in LV J Cardiovasc Electrophysiol, 2009. 20, 866-872

VA Originating From the Papillary Muscles in the LV Circ Arrhythm Electrophysiol. 2010;3:324-331

VA Originating from the Posterior Papillary Muscle in LV J Cardiovasc Electrophysiol, 2010. 21. 62-69

VA Originating from the Posterior Papillary Muscle in LV J Cardiovasc Electrophysiol, 2010. 21. 62-69

VA Originating From the Anterior Papillary Muscles in the LV J Cardiovasc Electrophysiol, 2010. 21. 62-69

VA Originating From the Anterior Papillary Muscles in the LV J Cardiovasc Electrophysiol, 2010. 21. 62-69

VA Originating From the Papillary Muscle (1) a normal baseline ECG and intracardiac conduction intervals with normal LV systolic function; (2) right bundle-branch block; (3) lack of inducibility with programmed ventricular and atrial stimulation; (4) absence of criteria for transient entrainment; (5) inducibility of VT or PVCs with intravenous isoproterenol or epinephrine; (6) earliest ventricular activation at the PM in the LV; (7) Absence of high-frequency potentials at the site of origin (8）Irrigated RF current was required，which suggests that the site of origin may be deep beneath the endocardium. Circ Arrhythmia Electrophysiol. 2008;1:23-29

Papillary Muscle Arrhythmias≠ Fascicular Arrhythmias Heart Rhythm 2008;5:1530 –1537

IFVT ≠ PAP VA Heart Rhythm 2008;5:1530 –1537

Image of PM VA: X-ray Circ Arrhythmia Electrophysiol. 2008;1:23-29

Image of PM VA: X-ray J Cardiovasc Electrophysiol, 2009. 20, 866-872

Image of PM VA: 3D EAM & MR Low Voltage and Delayed Enhancement in PM Heart Rhythm 2008;5:1530 –1537

Image of PM VA Activation mapping of PVC superimposed on the CT images J Cardiovasc Electrophysiol, 2010. 21, 214-215

Image of PM VA: Echocardiography Inter Med 49: 2010, 1863-1866

Image of PM VA: TEE J Interv Card Electrophysiol.2009,24:143–145

Image of PM VA: ICE Heart Rhythm 2009;6:389 –392

Image of PM VA: ICE Circ Arrhythm Electrophysiol. 2010;3:324-331

Image of PM VA: MR Heart Rhythm 2010;7:1654 –1659

Image of PM VA: MR Heart Rhythm 2010;7:1654 –1659 An oblique reformatted image of the mid-left ventricle (left) and a longaxis view (right) on delayed enhancement (DE) cardiovascular magnetic resonance imaging 41 months after ablation in a patient with failed ablation of an arrhythmia originating from the posteromedial papillary muscle (PAP). The majority of the lesion is confined to the free wall surrounding the PAP. Heart Rhythm 2010;7:1654 –1659

Activation mapping & Pace mapping Circ Arrhythmia Electrophysiol. 2008;1:23-29

V-potential Circ Arrhythm Electrophysiol. 2010;3:324-331

Spontaneous change in the QRS morphology Circ Arrhythm Electrophysiol. 2010;3:324-331

Spontaneous change in the QRS morphology Circ Arrhythm Electrophysiol. 2010;3:324-331

Pace mapping J Interv Card Electrophysiol.2009,24:143–145

Activation mapping J Interv Card Electrophysiol.2009,24:143–145 Cardiac tracings exhibiting the successful ablation site (left panel) and successful ablation of the VT (right panel). The arrowheads indicate the high frequency potentials which might have represented the activity of the Purkinje fibers. ABL the ablation catheter; CS 1 to 5 the first to fifth electrode pair of the coronary sinus catheter, HB His bundle, RV right ventricle, Xd, p the distal and proximal electrode pairs of the relevant catheter J Interv Card Electrophysiol.2009,24:143–145

A Purkinje potential ? Heart Rhythm 2010;7:1654 –1659

Catheter Ablation of VT Originating in the Left Anterior Papillary Muscle J Cardiovasc Electrophysiol, 2010. 21, 214-215

经皮导管酒精消融猪左心室后乳头肌 Ao LA LV PPM

术后程序期前刺激未能诱发室颤 (S1S2S3S4S5S6: 350/280/240/220/180/160)

PPM消融后，诱发非持续性多形性室速

部分动物术前可在左室记录到P电位

术前窦律下左室电极记录到P电位

术后P电位消失

小结 PM相关VA可发生于无器质性心脏病的患者，也可发生于心肌梗死后患者或心肌病患者。 可能由于PM相关VA发生的基础疾患不同，VA起源部位与深度的差异，使EP标测和消融靶点不同 导管贴靠和消融效果密切相关，ICE是定位PM和评价导管贴靠的重要手段 起源于PM深部的VA需要灌注导管多点消融 PM相关VA有效可靠的消融手段仍需不断探索

谢谢！