1、2018/7/9,HF 重塑和静脉造影的重要性,Large K9 Heart(approximately the size of normal human heart),Heart from MIRACLE study patient,Autopsied Hearts,Right Atrial Anatomical Features,Tricuspid annulus三尖瓣环Fossa ovalis卵圆窝Eustachian ridge欧氏脊Coronary sinus冠状窦Thebesian valve冠状窦瓣Eustachian fossa欧氏窝Inferior vena cava下腔静脉
2、,心衰导致解剖变化的X线影像Fluoroscopic Views of Anatomical Changes Due to Congestive Heart Failure,Click to Play Movie,CRT手术中普遍遇到的苦难,CS开口位置较高 ostium located higher on atrial wall due to lower floor in RACS 成角锐利steeply angulated in HF pts瓣膜阻挡鞘管或电极导线推送Valves obstructing catheter or lead advancement,1. Niazi NASPE
3、 2002 presentation,CS解剖 高度上的变异Variations in Height over the RA Floor,1. Niazi NASPE 2002 presentation,HF pts.较非心衰患者CS起源更高 tended to have higher CS origin than non-HF pts. (p0.001)CS 起源的高度在心衰患者中变异稍大origin slightly more variable in HF pts.,Anatomy of The CS 垂直成角Variations in Vertical Angulation,1. Nia
4、zi NASPE 2002 presentation,CS 成角程度在心衰中更陡angulation was more steep in HF pts (p=0.001)起始部位的成角会影响鞘管进入冠状窦及推送Initial angulation impacts ability to cannulate CS and advance catheter,瓣膜结构Valve Structures,Thebesian瓣 膜性瓣，覆盖在CS开口的后下部位membranous valve covering postero-inferior aspect of CS ostium In 10-20% 的病
5、例中，会影响冠状窦插管of cases, can impede CS cannulationVieussens瓣 通常冠状窦的远端接近第一个大分支usually in distal portion of CS near the first large transference branch在侧支中有静脉瓣Venous valves in side branches,1. Niazi NASPE 2002 presentation,人类CS开口的影像,v Thebesian ValveO CS Ostium,由于心衰导致解剖结构的改变Anatomical Changes due to Conge
6、stive Heart Failure,Click to Play Movie,2018/7/9,静脉造影Venograms,学习目标Learning Objective:,在X线影像下辨认静脉解剖并描述其与电极导线放置的相关性Identify venous anatomy in flouro images, and describe its relevance to lead placement,什么是静脉造影What is a Venogram?,两维X线静脉解剖影像，通常在不同角度观测2-dimentional x-ray image of venous anatomy often vi
7、ewed at various angles动态电影影像: 实时图像记录real time image recording,提供心脏静脉解剖的影像资料Provide a Visualization of Cardiac Venous Anatomy 增加电极导线植入的成功率 Increase Chance of Successful Lead Placement提供游离壁途径Access to lateral free wall提供静脉粗细和扭曲程度信息Insight into size and tortuosity of veins提供后备方案Provides a Back-Up Plan
8、提供理想左室电极位置的路线图Provides a roadmap to the optimal LV Lead position!,为什么要进行静脉造影Why perform a venogram?,静脉解剖Venous Anatomy,* Click on object to run clip,静脉解剖的3维图像3-D Perspective of Venous Anatomy,底部Base中部Mid心尖部Apex,减少血管重叠问题Reduce Vessel Overlap Issues 提供整体血管图像信息Provide Visualization of Entire Vessel 增进对
9、解剖的理解Increased understanding of anatomy确定后外侧位置Ensure posterior lateral position,在两个或多个切面上的静脉造影图像Venograms in TWO or more Views,多个切面的重要性Importance of Multiple Views,注意侧支靶血管的起源Notice the origin of the lateral target vessel,LAO View,RAO View,Images compliments of Dr. Seth Worley,目标侧支Target Lateral Bran
10、ch,目标侧支Target Lateral Branch,静脉造影Venograms A 3-维图像Dimensional Perspective,Click on image to Play Movie,Question: LV电极放置何处Where would you place the LV lead?,LAO View,Images compliments of Dr. Seth Worley,E,B,A,不同的切面提供不同的信息,AP最简单的观测切面Easiest perspective to see从前部到后部Shows front to backRAO可显示冠状窦的静脉分叉点Is
11、olates vessels point of bifurcation from coronary sinus可显示心尖部到心底部的分离程度Reveals apical to basal lead separation(RV Lead)LAO可发现哪些静脉位于左室壁Isolates which veins are on left ventricular wall揭晓室间隔与外侧电极导线的分离程度Reveals septal to lateral lead separationLV 电极导线的松弛性Lead slack,AP View (Ribs),From the AP view, ribs
12、curve away from the spine with the same angulation on both sides,* Click on object to run clip,RAO: 观测,脊柱在左侧 Spine on left 开胸手术后胸骨缝线在右侧Staples on right 脊突在左侧Spinal processes on left CS 在脊突右侧on right of spine 心影拉长Elongated heart shadow 电极导线位于脊柱右侧Leads to right of spine,RAO View (Ribs),From the RAO vi
13、ew, ribs can be seen sloping downward as shown by the arrow(negative slope),RAO Venogram,脊柱在右侧Spine on right 胸骨缝线在左侧Staples on left 脊突在右侧Spinal processes on right CS 横跨脊柱crosses spine 电极在脊柱左侧Leads left of spine,LAO: 观测What to look for,LAO View (Ribs),From the LAO view, ribs can be seen sloping upwar
14、d as shown by the arrow(positive slope),* Click on object to run clip,LAO Venogram,通过画图使之更易于理解,LAO,Os,MCV,Post,Post Lat,Ant,Ant Lat,Lateral,RAO,Os,Ant,Ant Lat,Post Lat,Post,MCV,Lat,AP,RA,RV,MCV,Post,Post Lat,Ant Lat,Os,Ant,Lat,心大静脉,投影Projection?,RAO view,Shallow LAO view,LV 电极导线在两个切面上都在2:00-5:00 位置上
15、？,投影Projection?,RAO View,投影Projection?,LAO View,投影举例Projection Example:,AP View,静脉造影解释,Guide Catheter,CS 开口,模型与影像的对应,D,Middle Cardiac,Postero-Lateral,AIV,你可以标记吗?,LAO View,B,A,C,D,CS,Lateral,Great Cardiac,AIV,Venogram,LAO View,B,A,D,C,E,A=后静脉,Venogram,F,B=CS,C=心前静脉,D=侧静脉,E=心中静脉,F=CS 开口,AP View,B,A,D,
16、C,E,F,AP Venogram,A= CS,B= 后静脉,C = 心前静脉？,D = 侧静脉？,E=心中静脉,F=心大静脉,心脏静脉的侧支交通支充盈Collateral filling of cardiac veins,CRT电极导线植入选择静脉Selecting Vein for CRT Lead Placement,A. 心脏侧静脉 (marginal) cardiac veinB. 后外侧静脉Postero-lateral cardiac veinC. 后静脉Posterior cardiac veinD. 心中静脉Middle cardiac veinE. 心大静脉Great ca
17、rdiac vein,A,B,C,D,E,目标: 左室游离壁 (侧，后外侧，前外侧) 1,2,3,1. Ansalone et al. JACC. 2002;39:489-499 2. Butter et al. CIRCULATION. 2001;104:3026-3029 3. Auricchio et al. AJC. 1999;83:136D-142D,A,B,C,D,E,LAO View,在左室后外侧游离壁对数个靶静脉进行选择排序Prioritize Several Target Veins on the Left Postero-Lateral Free Wall,选择血管Sele
18、ct vessels that:左右室电极导线分离最大Maximize separation between RV and LV leads避免膈神经刺激和梗死心肌Avoid infarcted myocardium and phrenic nerve stimulation血管细小以确保电极头端能稳定嵌入Are small enough to securely wedge lead tip,临床证据显示Clinical Evidence Suggests that 外侧或后外侧静脉Lateral or Postero-Lateral Cardiac Veins 可以提供与右室的分离程度和电极
19、导线稳定性Provide Both Separation From RV And Lead Stability,能允许与RV有最大电学分离的左室部位Left Ventricular Anatomy That Allows The Greatest Electrical Separation From RV,理想起搏部位Optimal Pacing Site,膈神经与目标电极部位Phrenic Nerve and Target Lead Sites,电极导线必须避免膈神经以预防膈肌起搏Leads must avoid phrenic nerve to prevent diaphragmatic pacing,2018/7/9,案例研究,Ex. 6: 选择何种电极导线Which LV lead would you choose?,A,D,E,C,B,LAO View,Images compliments of Dr. Seth Worley,Time to stretch,
