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慢性房颤 机制及导管消融策略中的哲学. 董建增 首都医科大学北京安贞医院. PVI 是房颤导管消融的基石是否已经动摇?. CL 210ms 210ms 238ms 248ms 258ms. Earlist LA. exist. Perfect PPI. Possible Macro-Reentrant Substrates. CTI. Schematic of Common Lesion Sets Employed in AF Ablation. CH Sang , CS Ma. - PowerPoint PPT Presentation
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慢性房颤机制及导管消融策略中的哲学
董建增 首都医科大学北京安贞医院
PVI是房颤导管消融的基石是否已经动摇?
existEarlist LA
Perfect PPI
CL 210ms
210ms
238ms
248ms
258ms
CTI
Possible Macro-Reentrant Substrates
Europace 2012 : 14 : 528–606
Schematic of Common Lesion Sets Employed in AF Ablation
CH Sang , CS Ma.Heart Rhythm, 2010, 7: S332
PVI是否充分?
广泛消融
Proven Isolation Of The PV Versus Extended PV Antrum And Posterior Wall Isolation In Patients With
Long Standing Persistent Atrial Fibrillation --- Rong Bai , HRS 2012
全部患者 3 次操作
消融内容完全相同
34%
18%
12% 10%
72%
60%
42%
28%
无房颤生存率
Jais Chae基础资料 N 128 78 ATs 246 155 平均 AT 数 1.92 1.99房颤类型 PAF 20% 73% Persistent 80% 27% 初始消融策略 segmental+ Circ.+规律房速机制 折返 83% 88% 大折返 44% 75% 局部折返 39% 13% 局灶 14% 12% Jais P, et al. JCE 2009; 20: 480 Chae S, et al. JACC 2007;50:1781
再次消融房速机制Mechanisms of ATs During Re-do
JACC 2007;50:1781
慢性房颤术后复发 OAT主要原因消融径线未实现阻滞或传导恢复MI+CTI+ROOF= 78% ( 91/116 )
Haissaguerre M, et al. J CE. 2005;16: 1125-1137
方法 PVI + SVCI + CS + Defrag + CTI,ROOF,MI ( 60pts.
)
结果 房颤中止 87%(52/60)
直接中止 11.7%(7/60) 经房扑中止75%(45/60)
38 个局灶房速 平均 2个规律房速 49 个大折返
CAF 成功率 : 95%
长程持续性房颤导管消融
Ning M, Ma CS. CMJ 2010
• CAF 86
• Turned to sinus rhythm through 179ATs ( average 2 ) in 80% (69/86) pts.
• Mechanism of AT
- Macroreentry 81%(145/179)
perimitral 65, CTI 48, roof 32
- Localized reentry 12%(21/179)
- Focal 7%(13/179)
Mechanisms of ATs during CAF Abl. by Stepwise Approach
慢性房颤线性消融的必要性
消融过程中经过 > 2 个房速(多为大折返)
复发的心动过速类似机制
80% 需要多线消融PVI + 直接线性消融
减少标测
减少增加食管瘘风险的消融
减少不必要而且可能影响心房功能的消融
PVI基础上三线( MI、 CTI、 Roof
)消融( 2C3L)是否有效?
动物实验研究对慢性房颤消融策略的启示Implications of former experiences
动物实验研究( 1912 年)
• 心脏颤动与心肌组织体积直接相关• 心肌内在环路是颤动的基础• 内在环路存在于大容积心肌,在较小容积的心肌不足以形成
Physiology , Washington University in St. Louis
Garrey WE , Journal of Physiology 1914
J Thorac Cardiovasc Surg 1995;110:473 & 2007;133:389
MAZE III 术式对慢性房颤消融策略的启示Implications of former experiences
First MAZE on Sep 25, 1987 Cox JL, Surgery Depart , Washington University in St. Louis
• 1988~2001 年 lone ( n=112 ) : PAF/PTAF=72/40 Concomitant ( n=86 ) : PAF/PTAF=45/41
• 平均随访: 5.4±2.9 年• 无房颤: 96.6% (172/178 ) lone : 95.9% ( 79.6%+16.3%AAD ) concomitant :97.5% ( 73.4%+24%AAD )
Prasad SM, J Thorac Cardiovasc Surg 2003;126:1822-8
MAZEIII 术式对慢性房颤消融策略的启示Implications of former experiences
PVI基础上三线( MI、 CTI、 Roof
)2C3L策略
2008
• PVIs -------------------------- “2C”
• Roof 、 MI 、 CTI ----------- “3L”
• DC (whether afib. or organized AT)
• Ensure PVI & linear block during sinus
• Iso 、 Burst stimulation at ≥180ms
• Mapping & abl. of the induced ATs
(SVC isolation if afib. induced)
• CAFÉ abl. limit to sinus couldn’t maintain
“2C3L” Approach for CAF
Sang CH , Ma CS, Heart Rhythm, 2010, 7: S332
Activation Mapping Only After Endpoints/203L Achieved
2C3L 病例 60M CAF 5 years
“2C3L” Is Physiologic
MI
CTI
RoofPVI
203L 策略 : PVIs 、 Roof 、 MI 、 CTI
55F CAF 4 年 , CHF 6 月 , 无高血压、无糖尿病、无瓣膜病
LVED : 58mm EF : 28%
病例 6 心衰房颤(房颤导致心衰)
E A99cm/s 77cm/s
病例 6 心衰房颤(房颤导致心衰)消融后
3 dayspost ablation
6 monthspost ablation
• “2C3L” approach
1. Initial abl : PVI + ROOF + MI + CTI
2. Cardioversion ( routinely )
3. Ensure the endpoints of 2C3L
4. Inducement, mapping and abl. of the induced ones (SVC)
• “ Stepwise” approach 1. Initial abl. : PVI + ROOF + MI + CTI
2. Try best to terminate afib. by aggressive abl. at CFAE
3. Try best to terminate ATs by detailed mapping and abl.
4. Cardioversion ( selectively)
5. Ensure the endpoints of 2C3L
6. Inducement, mapping and abl. of the induced ones (SVC)
“2C3L” VS. Stepwise
2C3L策略之外的消融为什么也能维持窦律?
持续性房颤的导管消融
Heart Rhythm 2010;7:835
成功率 %
不同消融窦律的质量是否相同?
左房间隔部过度消融的危害(间隔线、 CFAE 、 FIRM )
LAA Delay
Incidence : 26% ------ 11% ----- 0% 2006 2007 2009
P QRS
A V
LAA Delay
Jiang CX , Ma CS. PACE 2010; 33:652
LAA Delay: ECG
Narrow P, Pseudo , Pseudo △ ε
LAA Delay MV Doppler
In the editorial , Dr. Chugh and Oral says:…………stepwise ablation represents a major
advance in the treatment of patients with persistent AF, the timely contribution by Jiang et al. reminds us that there may be unintended consequences of
extensive ablation…………
Jiang CX , Ma CS . PACE 2010; 33:652
导管消融
下壁导联 P 波后半部分负向波
假预激波
EpsilonWave JCE 2007; 18:1114-1115
Rotor和最快 DF是不是驱动?
Sanjiv M. Narayan, UC, San Diego
关于 FIRM
“环形运动” ≠ 折返
CS CS
pro-arythmia
or
bridge to sinus rhythm
谢谢
Antrum
LA
Relationship Between the Histological traits and Local Electrogram (CX43×200)
Anatomic → Electrophysiological Heterogeneity