Triệt đốt loạn nhịp thất ở vị trí không điển hình - Phạm Trường Sơn

TRIỆT ĐỐT LOẠN NHỊP THẤT Ở VỊ TRÍ KHÔNG ĐIỂN HÌNH
BỆNH VIỆN TRUNG ƯƠNG QUÂN ĐỘI 108
VIỆN TIM MẠCH
TS. Phạm Trường Sơn
IDIOPATHIC VENTRICULAR TACHYCARDIA
PVC LOCATION 
RV (80%) LV (20%)
- RVOT
- TV annulus
- RV septum
- RV free wall
- LVOT
- MV annulus
- Left fascicle: posterior, anterior
- Papillary muscle
Our results 2016 2017 2018 Sum
RV
(n= 133) 
(78,2%) 
Non RVOT 1 3 5 9 
(6,8%)
RVOT 47 55 22 124 
(93,2%)
LV
(n=37) 
(21,8%)
Valsava PVC 13 6 5 24 
(64,9%)
Non valsava
PVC
1 6 6 13
(35,1%)
PVC LOCALITY 
ATYPICAL RV - PVC 
Năm Tác giả Số
BN
3D 
(%)
Thường
(%)
Không đốt
(gần His)
Success
(%)
Recurre-
nce
2013 Lian-
Pin W 
29 75.9 24.1 6.9 93.1 3.4%
2018 Chúng
tôi
9 22.2 77.8% 0 100 0
RV – PVC ABLATION 
RV PVC
it concludes 9 distinct anatomic segments 
 3 anatomic segments: 
- Superoseptum: from top to the His bundle 
- Midseptum: from the His bundle to coronary sinus
- Inferoseptum: from the coronary sinus to bottom
 3 regions: 
- Valvular region: from the tricuspid valve to 2 cm anterior of the valve 
- Basal and apical region: 2 equal portions between valve and RV apex
RV SEPTUM
Author RV septum (%) RV free 
wall (%)
TVA Basal Apical
Van herendael
29/187 
(10%)
27 28 24 31
Chúng tôi
9/133
(6,8%)
77.8 0 0 22.2
RV - PVC
- PVC at the septum: The initial ventricular force is much 
greater in the LV than in the RV
- QRS vector directed to the left posterior and away from V1: 
result in a QS pattern.
PVC FROM FREE WALL
Characteristic RV 
septum 
(78%)
RV free wall
(22%)
Transition Earlier 
(V3)
Late (V4)
V1 QS Small R 
wave
V2, V3 Deeper S 
wave
QRS in
inferior leads 
narrow Wide, 
notching
PVC: FREE WALL RV
PVC: INFERIOR FREE WALL RV
PVC: INFERIOR FREE WALL RV
RV septum
(n= 29/581)
(5%)
Supero
septum
Mid
septum
Infero
septum
TV- RV 
(69%)
3 
(10,3%)
15 
( 51,7%)
2 
(6,9%)
Basal RV 
(31%) 
1
(3,5%)
4
(13,8%)
4
(13,8%)
Catheter Ablation of Idiopathic Premature Ventricular Contractions and Ventricular Tachycardias 
Originating from Right Ventricular Septum. PLoS ONE 8(6): e67038
RV septum
(n=7/133) 
(5,3%)
Supero
septum
Mid
septum
Infero
septum
TV- RV 
region 
1
(14,3%)
5
(71,4%)
1 
(14,3%)
RV SEPTUM- PVC
 PVC at TV septum is more posterior portion of the RV
than the basal septum: more distant from the pre
cordial electrodes and depolarized toward these
electrodes.
+ Earlier precordial R-wave transition (≦V4) : from TV –
RV septum
+ later precordial R-wave transition (>V4): from the basal
RV septum:
 The earlier precordial R-wave transition (≦V4) has a
Se: 100%, Sp: 100%, NPV: 100%, and PPV: 100% to
predict the TV RV septal origin.
PVC FROM TV – RV SEPTUM
 When PVC originated from TV- RV septum regions,
the ratio of the A:V electrograms <1 and: the
amplitudes of the atrial and ventricular electrograms
were ≧0.03 and >0.35 mV at the ablation site,
respectively;
 When PVC originated from the basal and apical
regions of RV septum: only V electrograms and no A
electrograms were recorded.
PVC FROM TV – RV SEPTUM
 PVC from the RV superoseptum
At the right superior side of the heart :
- Depolarized toward the inferior leads:
Greater R wave, smaller S wave
at these leads
- Away from aVR and aVL, so:
Greater QS amplitude in: aVR,
Smaller R: aVL
PVC FROM SUPEROSEPTUM 
PVC FROM HIS REGION
- Narrow QRS duration, QS in V1
- Transition < V4
- Low R wave in leads II and aVF
- Particularly, lower R wave in lead III than in lead II
- A monophasic tall R pattern in lead I
- R wave in lead aVL
PVC FROM HIS REGION
 Away from the inferior leads: QRS negative, lower
R wave and greater S wave amplitude in the
inferior leads
 Depolarized in a direction toward aVL: greater R
wave amplitude in the lead aVL
PVC FROM INFERIOR SEPTUM
LVOT - PVC
CLASSIFICATION OF LVOT
Idiopathic LVOT-VAs have 3 groups:
- Aortic sinus cusps (ASC): Left coronary cusp (LCC), right
coronary cusp (RCC), non-coronary cusp (NCC).
- Endocardial origin: the aorto-mitral continuity (AMC), the
anterior site around the mitral annulus (MA), superior basal
septum (adjacent to the His),
- Epicardial origin: LV summit, coronary venous system
LOẠN NHỊP THẤT NGUYÊN PHÁT ĐƯỜNG RA THẤT TRÁI
 Success rate of RFCA for VAs with RVOT and 
pulmonary artery: 90–92%
 Idiopathic VAs with LVOT, ASC, and
epicardial origins: 55–60%
LVOT - PVC
Parameters 2016 2017 2018 Sum
LV
(n=37) 
(21,8%)
Valsava PVC 13 6 5 24 
(64,9%)
Non valsava
PVC
1 6 6 13
(35,1%)
LOẠN NHỊP THẤT NGUYÊN PHÁT ĐƯỜNG RA THẤT TRÁI
 R/S transition ≥ V4: RVOT (100% Spe)
 R/S ≥ V3 , then the V2 transition ratio (R/S) is measured.
- < 0.6: RVOT, some cases are ASC (due to insulated myocardial
fibers across to Ventricular septum)
- > 0.6: LVOT origin (Se 95% and Sp100%) 
 Timing R/QRS > 50%
DIFERENTIATION : RVOT AND LVOT
 Xoang vành trái hay gặp nhất: 50-60%
 Xoang vành phải: 25%
 Giữa lá xoang vành trái và phải: 15%
 Xoang không vành:5%
ORIGIN OF VAS
VỊ TRÍ XOANG VÀNH
 RCC: r or m in DI, QS in V1 (near 
septum)
 LCC: rS in DI, notch in V1 (transeptal
conduction),
 RCC/LCC commissure: qrS in V1
or QS V1
 NCC: notched R in DI
 Van ĐMC và van hai lá kết nối với nhau qua vòng tam 
giác xơ
 Vùng tam giác xơ bao quanh van hai lá: tổ chức xơ
không hoàn toàn, có tế bào cơ lạc chỗ xen lẫn: tạo ổ
phát nhịp
VỊ TRÍ DƯỚI XOANG VÀNH
PHÂN BIỆT VÙNG TIẾP GIÁP VAN ĐMC VÀ VAN HAI LÁ
 AMC: monophasic R waves with no S waves in almost all
precordial leads (located in the most posterior LVOT,
directed only in the anterior direction)
 Anterior MA: had S waves (Rs or RS) in many of the
precordial leads other than lead V6: a right bundle-branch
block pattern, usually present LV endocardial origin. IDT >
85 ms identified anterior MA-Vas: 75% Se and 83% Sp
AMC - PVC
AMC - PVC
 R wave: all precordial lead, no S wave at V6
ANTERIOR MV - PVC
 R wave: all precordial lead, S wave at V3- V6
VỊ TRÍ THƯỢNG TÂM MẠC: EPICARDIAL SITES
 LV summit: the most common site of idiopathic
epicardial LV,
 coronary sinus: much higher within the GCV (great
cardiac vein) and AIVV (Anterior Interventricular Vein)
than on the epicardial surface of either side of these
veins.
THE SUMMIT OF LV
 The region on the 
epicardial surface of the 
LV: 
+ near the bifurcation of the 
LM, bounded by an arc 
+ from the superior LAD to 
the first septal branch
+ anteriorly and laterally to 
the LCx. 
-
Papillary musscle
(35%)
Fasicular PVC 
(29%)
MV PVC 
(36%)
Origin Al PaP PM PaP LAF LPF Anterior 
MV
other
Tác giả
(n=52)
17.5 17.5 5,9 23.1 28.9 7.1
Chúng tôi
(n=13)
7.7 0 7.7 15.4 69,2 0
LV - PVC
 MV: accounted for 5 % of idiopathic VTs .
 Classified into 3 categories
- Anterolateral : 58%
- Posterior: 11%
- Posteroseptal: 21%
 Endocardial ablation is usually used; occasionally,
an approach via CS: may be necessary
MV - PVC
 Impulse from left fascicles, RBB is the last activated: rSR’
Type of 
PVC
axis QRS
DII,III,AVF
QRS
DI
V1
Anterior 
fascular
inferior , 
rightward 
direction 
positive negative: 
rSR’
Posterior 
fascular
superior 
leftward 
direction
negative positive: 
FASICULAR - PVC
LV - PVC
LEFT ANTERIOR FASCICULAR PVC
PAPILLARY MUSCLE- PVC
HIGH LEFT POSTERIOR FASCULAR (NEAR LBB): PVC
POSTERIOR MV - PVC
KẾT LUẬN
 NTTT nguyên phát thường xuất phát từ đường ra thất
phải, sau đó đến đường ra thất trái
 NTTT thất phải có thể xuất phát từ vị trí khác: đặc
biệt hay gặp ở vùng vách van ba lá, gần his
 NTT thất trái ngoài xuất phát từ xoang Valsava, còn
có thể xuất phát từ lá trước van hai lá, phân nhánh trái
bó his và cơ nhú.
 Việc triệt đốt các vị trí không điển hình cho tỷ lệ
thành công cao, nhất là khi có 3D hỗ trợ
THANK YOU