经皮间隔支化学消融治疗肥厚梗阻性心肌病英文课件(模板).pptx

1、 ventricular tachycardia,fibrillation Level any ages.there is a big difference in Natural history not sure.The more cardiac hypertrophy,the higher the pressure gradient,the greater the risk of sudden death.The outflow tract pressure gradient of the clinical importance of the issue remains controvers

2、ial,but it is generally considered an important clinical process indicators.Nnual mortality rate of 2-4%,the incidence of sudden death 1%Whether the obstruction produced the clinical symptoms?not only with the degree of outflow tract obstruction and outflow tract pressure gradient,as well as the obs

3、truction site.But also with ventricular diastolic function and the adequacy of venous return is also closely related.Increase the heart before and after load and myocardial contractility often cause noticeable clinical symptoms.Therefore,it will become more apparent after exercise.The patients shoul

4、d be treatment.All patients had diastolic dysfunction How the pressure gradient and symptoms And the extent and distribution of the hypertrophy has nothing to do.Whether normal or small ventricular cavity,due to increased heart weight,ventricular volume reduction,myocardial fibrosis,leaving ventricu

5、lar stiffness increased,compliance decreased and caused the diastolic function damage.Pulmonary venous pressure and end-diastolic pressure were increased and heart disfunction.systolic functionsystolic functionPTSMA indication (1)Clinical indicationNo dobutamine gradients(Drugs)Coronary angiographyV

6、erapamilRemove balloon should be emptying alcohol of the balloon catheter and stagnation injection alcoholOutflow tract obstruction sign in EchocardiographSeptal thicknessHypertrophic Cardiomyopathy Survival According to Outflow Tract GradientSystolic function is normal or supranormal in HCOMMCEMoro

7、phologic indicationBeta-blockersasymmetrical septal hypertrophy(ASH),2.Target vessel supply to non-obstruction other regions such as:papillary muscle,free wall,etc.CONCLUSIONSBeta-blockersCONCLUSIONSCharacteristicsHypertrophic cardiomyopathy Epidemiological characteristicsMyocardial ischemiaMyocardi

8、al ischemia Myocardial ischemia,the symptoms of angina pectoris are:High-power so that left ventricular myocardial oxygen consumption increased;Cardiac contraction strength of oppression the large myocardial coronary artery;Intramyocardial small coronary artery stenosis and intimal thickening abnorm

9、alities,leading to leading to cardiac hypertrophy and coronary artery oxygen cardiac hypertrophy and coronary artery oxygen required due to an imbalance of oxygen supplyrequired due to an imbalance of oxygen supply.sudden deathsudden death HOCM of patients with abnormal myocardial cells and the arra

10、ngement of disorder provides a basis for the arrhythmia.However,abnormal myocardial arrangement and spontaneous arrhythmias and ventricular fibrillation threshold,the precise relationship is unclear.About 25%of patients may have non-sustained ventricular tachycardia,the arrhythmia is sudden death of

11、 a good predictor,and negative and negative predictive accuracy is 97%.predictive accuracy is 97%.The purpose of the treatment PTMSA The PTMSA treatment of HOCM is a obstruction by blocking a the supply blood of parts of the septal hypertrophy of myocardial and myocardial injury in the region,leadin

12、g to the area of myocardial necrosis,myocardial contractile function disappeared,Widened the left ventricular outflow tract,while lowering the outflow tract obstruction and the cardiac output increase.And improve clinical symptoms and hemodynamics.The pressure gradient at rest 50mmHg or 100mmHg with

13、 provocation.In 2008 ESC meeting,Seggewise that BJ Maron et al;JAMA 281:650-655,1999Outflow tract obstruction sign in EchocardiographM-mode echocardiogram in obstructive hypertrophic cardiomyopathy showing systolic anterior motion of the mitral valve(SAM)(arrows indicating septum and mitral valve le

14、aflet contact)Our classfication in PTSMA Our typing in the I-type and in the I-typing was the same as suitable for PTSMA treatment and Marons II-type includes the type II and type III of our model,it is suitable PTSMA treatment.Therefore,our IV-type classification is the first made by ultrasound ima

15、ging features of HOCM,according to its characteristics in line with PTSMA treatment.Arrhythmia and sudden deathClinical indicationSeptal Ablation in HOCMAcute Results/Ablation TechniquePathophysiologic and clinical characteristics of HOCMCharacteristics(post-PTSMA 6months)The vessel can not thorough

16、 or incomplete ablation (remaining smaller branches),self-revascularization.Septal thicknessCharacteristicsTransitory trifascicular blocks occurred at a rate of 52.(PG=80mmHg)DiltiazemThe vessel can not thorough or incomplete ablation (remaining smaller branches),self-revascularization.Results of PT

17、SMASeptal thicknessHypertrophic Cardiomyopathy Survival According to Outflow Tract GradientIncrease the heart before and after load and myocardial contractility often cause noticeable clinical symptoms.Complications in our patientsasymmetrical septal hypertrophy(ASH),2.Merge other needs surgery hear

18、t disease Mitral valve abnormalities and their own form of papillary muscles involved in the formation of pressure gradient,or mitral valve prolapse and regurgitation.PTSMA contraindicationssubaortic 1.Injection of a small amount of dye(1-2ml)through the guidewire lumen of the inflated balloon cathe

19、ter angiographically2.Prior to alcohol injection 1-2ml of echo contrast medium is administered through the central lumen of the balloon catheter under UCG.determines the supply area of the target septal branch.Ensure that no areas involving non-obstructive,such as the papillary muscles and ventricul

20、ar free wall and other parts.Avoid LAD ballooningExclude LAD leakageLevovist In the interval of contrast agent injected into the branch to observe the distribution of vascular contrAlcohol Shadow Levovist shadowMCEN=222No MCEn=30PSeptal branches(n)1.00.11.30.20.0001Alcohol(ml)2.90.93.92.40.0001Ballo

21、on size(mm)1.90.42.40.20.0001CK max(U/l)5342487454200.001CK-MB max(U/l)623096620.0001p0.05p 30mmHg and increased risk of death directly related to,New Eng l J Med 2003;348:295-303)Functional class III or IVdetermines the supply area of the target septal branch.DDD-pacemaker:2-10%Results of PTSMAComp

22、lications in our patientsApical or Japanese HCM.CharacteristicsThe vessel can not thorough or incomplete ablation (remaining smaller branches),self-revascularization.Morophologic indicationSystolic function is normal or supranormal in HCOMThe more cardiac hypertrophy,the higher the pressure gradient

23、,the greater the risk of sudden death.Hypertrophic Cardiomyopathy Survival According to Outflow Tract GradientClinical indicationMust be inserted temporary pacemaker(to prevent the conduction block).(pre-PTSMA)LVAOLVAOHis LVOT gradient 6 months after His LVOT gradient 6 months after PTSMA(PTSMA(PG=1

24、5mmHg)PG=15mmHg)Echocardiography showed ventricular septal hypertrophy over 30 mm in HOCM,necessary to performeing PTSMA should be very cautious and careful.May be there were a thick septal branch,and control wide,and collateral-rich septal branch of support,treatment had a higher risk and improve t

25、he clinical symptoms and hemodynamics have difficulties,so surgery mytomce may be a better choice.Contrast echocardiography Over-the-wire balloon.The septal branch with good collateral circulation.Diastolic dysfunctionBeta-blockersThe vast majority of patients with no symptoms,PTSMA complications (2

26、)(post-PTSMA 3days)PTSMA indication(3)Echocardiographic observations plays an important role in that will help to finalize define the choice of septal ablation and the ablation efficacy and reduce risks and Long-term follow-up of treatment efficacy.Complications in our patientsPG120mmHg before proce

27、dureFunctional class II with objective limitation or risk factorsClinical indicationPatients(n=171)EchocariographyGenerally considered:more severe hypertrophy,outflow tract obstruction near the LVOT sit,the more higher the obstructive pressure gradient were the more obvious clinical symptoms and the

28、 greater the potential threat.DiltiazemHOCM MyectomyFor mitral and papillary muscle anomalies and abnormal septal hypertrophy the best choice the surgery59%)underwent permanent pacemaker implantation due to permanent complete AV block.VerapamilMyocardial-Contrast-Echo in HOCMHer LVOT gradient 10 min

29、utes after septal ablation（PG=12mmHg）Patient CharacteristicsCharacteristicsPatients(n=171)Age(yrs)45.3717.71 Men/women122/49 (71.35%/28.65%)Symptoms Dyspnea93 (54.39%)Angina73(42.69%)Syncope76 (44.44%)NYHA functional class（II/III/IV）136(79.53%)/32(18.72%)/3(1.75%)Family history42 (24.6%)Medication B

30、eta-blockers106 (62%)Verapamil52 (30.4%)Diltiazem38 (22.2%)Amiodanone13(7.6%)PTSMA(n=171)pSeptal thickness(pre-PTSMA)22.675.35mm Septal thickness(post-PTSMA 3days)20.684.61mm NS Septal thickness(post-PTSMA 6months)16.774.39mm 0.05LVOTPG(pre-PTSMA)97.5838.23mmHgLVOTPG(post-PTSMA 3days)52.3635.7mmHg 0

31、.001LVOTPG(post-PTSMA 6months)47.2638.62mmHg0.001LA Diameter(pre-PTSMA)43.787.33mm LA Diameter(post-PTSMA 3days)42.417.52mm NSLA Diameter(post-PTSMA 6months)32.7615.58mm 50mmHg or 100mmHg with provocation.In 2008 ESC meeting,Seggewise that BJ Maron et al;JAMA 281:650-655,1999 Contrast echocardiograp

32、hy Over-the-wire balloon.Patient CharacteristicsCharacteristicsPatients(n=171)Age(yrs)45.3717.71 Men/women122/49 (71.35%/28.65%)Symptoms Dyspnea93 (54.39%)Angina73(42.69%)Syncope76 (44.44%)NYHA functional class（II/III/IV）136(79.53%)/32(18.72%)/3(1.75%)Family history42 (24.6%)Medication Beta-blockers

33、106 (62%)Verapamil52 (30.4%)Diltiazem38 (22.2%)Amiodanone13(7.6%)PTSMA(n=171)pSeptal thickness(pre-PTSMA)22.675.35mm Septal thickness(post-PTSMA 3days)20.684.61mm NS Septal thickness(post-PTSMA 6months)16.774.39mm 0.05LVOTPG(pre-PTSMA)97.5838.23mmHgLVOTPG(post-PTSMA 3days)52.3635.7mmHg 0.001LVOTPG(p

34、ost-PTSMA 6months)47.2638.62mmHg0.001LA Diameter(pre-PTSMA)43.787.33mm LA Diameter(post-PTSMA 3days)42.417.52mm NSLA Diameter(post-PTSMA 6months)32.7615.58mm 0.058 ml alchoholAfter 3 months 40%of patients with pressure gradient completely reduced,a year later this value was promoted to 62%.Systolic

35、function is normal or supranormal in HCOMClinical indication17%）who underwent PTSMA in Fuwai Hospital.Comorbitiy with increased surgical risk.Septal Ablation in HOCMAcute Results/Ablation TechniqueCharacteristicsMorophologic indicationLA DiameterTarget vessel supply to non-obstruction other regions

36、such as:papillary muscle,free wall,etc.Therefore,our IV-type classification is the first made by ultrasound imaging features of HOCM,according to its characteristics in line with PTSMA treatment.No emergency CABGCONCLUSIONSPost extrasystole.Select ablation of regional importance,particularly in the

37、target vessel is not clear who the septal branch The first septal branch of the size and distribution are great variationHer LVOT gradient 10 minutes after septal ablation（PG=12mmHg）Intraoperative ultrasound monitoringPTSMA indication (1)Subaorrtic SAM-associated gradientSystolic function is normal or supranormal in HCOM