“Terapia medica o ablazione per le più comuni aritmie.

Presentazione sul tema: "“Terapia medica o ablazione per le più comuni aritmie."— Transcript della presentazione:

1 “Terapia medica o ablazione per le più comuni aritmie.
Bruciare o ingoiare pillole amare?” Pietra Ligure 12 Aprile 2008

2 Fisiopatologia e clinica del Flutter Atriale
Dott.Paolo Sartori A.O. Universitaria San Martino Genova

3 Definizione del Flutter Atriale
Aritmia sopraventricolare da rientro il cui circuito è nella maggior parte dei casi intorno alla valvola tricuspide che lo delimita anteriormente; posteriormente da barriere anatomiche . Il ciclo di tale aritmia, in assenza di farmaci antiaritmici, varia dai msec. Il rapporto A/V è > = a 1

4 Barriere anatomiche delimitanti il circuito
Crista Terminalis SVC TV CS Eustachian ridge Point out right atrial structures relevant to atrial flutter ablation: 1. SVC 2. IVC 3. Thebesian valve (sinus venarium minimarum) of coronary sinus 4. Septal (medial) leaflet of the tricuspid valve and the annulus of tricuspid valve 5. Eustachian ridge (crescent shaped valve) Atrial portion of the membranous septum- also the inter-atrial septum: posterior-medial aspect of the right atrium 6. Crista terminalis- posterior barrier of reentrant circuit in atrial flutter. Poor transverse conduction properties of CT may be a requisite substrate for clinical occurrence of atrial flutter. a. Anterior free wall- pectinate muscle. Highly trabeculated. ( runs anterior to the IVC) b. Posterior wall- sinus venarium Also, the Fossa Ovalis, true atrial septum IVC

5 Barriere anatomiche delimitanti il circuito
LAO RAO

6 Classificazione del Flutter atriale
Type II ? Typical Reverse flutter Type IC Atypical Isthmus dependent Macro reentry Antidromic Type I Non Isthmus dependent 1.The proliferation of descriptive terminology has resulted in some confusion and the need to better clarify and more accurately define atrial flutter and related arrhythmia's. Clockwise Proliferation of descriptive terminology confusing in the literature; therefore a simple definition was required to avoid confusion Orthodromic Usual Counter clockwise Type I Classic Common Orthodromic CCW isthmus dependent Typical CCW Type A Type II Atypical Uncommon Rare Antidromic Clockwise Reverse typical CW Lesion flutter Left atrial flutter

7 Criterio di classificazione
Substrato anatomico Attivazione Caratteristiche dell’entrainment NASPE position paper defined atrial flutter based on compilation of current knowledge. Atrial flutter is classified as an macro reentrant tachycardia Reentry is around a large central obstacle Central obstacle may be fixed, functional, or a combination of the two Defined relative to atrial anatomy In this presentation we will focus on typical and reverse typical AFL Both are Isthmus dependent Both are “using” the same “circuit”, however in opposite directions Both are amenable to anatomic ablation technique Others: (not in the scope of this presentation) Lesion Macro reentrant tachycardia Right free-wall macro-reentry without atriotomy Left atrial macro- reentry tachycardia Type 1-C antiarrhythmic (drug) mediated tachycardia 4. Saoudi, N. et. al. “Classification of Atrial Flutter and Regular Tachycardia According to Electrophysiologic Mechanism and Anatomic Bases: A Statement from a Joint Expert Group from the Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Electrophysiology.” JCE, volume 12, No. 7, pp July 2001. 2001 NASPE Proposed AFL Classification4

8 Classificazione

9 Flutter Atriale Tipico
Circuito di rientro anatomico Flutter atriale comune Flutter atriale non comune

10 Flutter Atriale Tipico comune
+DI +V1 +DII,DIII,aVF

11 Flutter Atriale Tipico non comune
+DI +V1 +II,III,aVF

12 ECG FLUTTER ATRIALE TIPICO COMUNE
Sawtooth pattern The incidence of A-V block makes the P wave sawtooth pattern easier to see. Isthmus dependent Typical AFL (CCW) Atrial rhythm: regular and very stable ( bpm) P wave: Characteristic saw tooth pattern with a predominantly negative deflection in, II and III, and/or aVf (inferior axis) and positive in V1 (but may be negative or biphasic). Leads I and aVL show low-voltage deflections 3:1 A-V Block

13 ECG FLUTTER ATRIALE TIPICO NON COMUNE

14 Posizione dei cateteri

15 Proiezioni radiologiche
RAO

16 Proiezioni radiologiche
LAO

17 Segnali endocavitari Flutter atriale comune Flutter atriale non comune
DD1-2 DD1-2 DD3-4 DD3-4 DD5-6 DD5-6 DD7-8 DD7-8 DD9-10 DD9-10 DD11-12 DD11-12 DD13-14 DD13-14 DD15-16 DD15-16 DD17-18 DD17-18 DD19-20 DD19-20 Flutter atriale comune Flutter atriale non comune

18 MAPPAGGIO DURANTE FLUTTER ATRIALE

19 Attivazione del FL. A comune
Activation sequence typical counterclockwise right atrial isthmus dependent atrial flutter

20 MAPPAGGIO DURANTE RITMO SINUSALE
HRA HRA LRA LRA

21 Entrainment

22 SINTOMATOLOGIA A seconda del rapporto A/V
Asintomatico  Segni obiettivi di scompenso Cardiopalmo Dispnea Lipotimie Sincope Angina

23 Grazie della cortese attenzione