嘉義長庚心臟內科潘國利

Cardiac Anatomy From view of Interventional

Electrophysiologists

Anderson R H et al. Heart 2001;85:716-720

Short axis

Cardiac Orientation

Posterior Anterior

Superior

Inferior

Cardiac Orientation

Right Lateral

Left Lateral

Superior

Inferior

QRS Complex )QRS Complex )

P-R IntervalP-R Interval

P-WaveP-Wave

Relationship of the Surface 12 lead Electrogram to the Activation Sequence

Arrythmia-PSVT

Eletrophysiology Study

Intracardiac ECG

• Bradycardia

- Sick sinus syndrome

- AV conduction block

• Tachycardia

- Supraventricular tachycardia

- Ventricular tachycardia

The Normal Conduction System

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

Cardiac Structure

H.

Position of EP catheter

AP view LAO view

HRHRAA His

RVA

CS

His

CS

HRA

RVA

Intracardiac Electrogram Recordings – Catheter Placement

CS

HRA

RVA

His

HRA Catheter Characteristics

HIS Catheter Specifications

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.

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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.

AV Node

His Bundle His Bundle RegionRegion

Tricuspid Tricuspid AnnulusAnnulus

CS Catheter Specifications

RVA Catheter Specifications

Intracardiac Electrogram Recordings

Supraventricular tachycardia

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

AP View of the Heart

AP View with View Inside Ventricles

RAO View of the Heart

RAO View with View Inside RA and RV

LAO View of the Heart

LAO View with View Inside Ventricles

Position of EP catheter

AP view LAO view

HRHRAA His

RVA

CS

AP View of LV and Ao

LAO View of LV and Ao

RAO View of LV and Ao

• HRA

• His

• RV

• CS

How about right site accessory pathway and typical flutter ?

Crista TerminalisCrista Terminalis SVCSVC

Eustachian ridgeEustachian ridge

TVTV

IVCIVC

CSCS

Cardiac Anatomy Related to Isthmus Dependent Flutter

Catheter Positions

His

A

V

MV

TV

CS

Hallo

LOCATIONMAPPING

Fluoroscopic Positions

CSCS

DuoDecDuoDec

RVRV

HISHIS

RVRV

HISHIS

CSCS

DuoDecDuoDec

LAORAO

那如何描述左心房心律不整 (Af, AT)

AP View of the LA

PA View of the LA

PV Mapping CathetersSpiral HP

Reflexion VR

Left atrium venogram

Left atrium venogram

LAO

LIPV

LSPV

CRD-1

Fluoroscopy and MRI views of the Pulmonary veins

Cardiac Venous Anatomy

4545

Besides, coronary sinus is important

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)

Venous structures

AP View of the RA,LA and CS

LAO View of the RA,LA and CS

結論 1

His

A

V

MV

TV

CS

Hallo

結論 2

謝謝聆聽