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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.

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slide1

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

slide4

CL 210ms

210ms

238ms

248ms

258ms

Earlist LA

exist

Perfect PPI

slide6

Schematic of Common Lesion Sets Employed in AF Ablation

CH Sang ,CS Ma.

Heart Rhythm, 2010, 7: S332

Europace 2012:14: 528–606

slide8

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

无房颤生存率

72%

60%

广泛消融

42%

34%

28%

18%

10%

12%

slide9

再次消融房速机制

Mechanisms of ATs During Re-do

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

slide10

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)

JACC 2007;50:1781

slide11

长程持续性房颤导管消融

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%

Haissaguerre M, et al. J CE. 2005;16: 1125-1137

slide12

Mechanisms of ATs during CAF Abl. by Stepwise Approach

  • 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)

Ning M, Ma CS. CMJ 2010

slide13

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 mi cti roof 2c3l

PVI基础上三线(MI、CTI、Roof)消融(2C3L)是否有效?PVI基础上三线(MI、CTI、Roof)消融(2C3L)是否有效?

slide15

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
slide16

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

J ThoracCardiovascSurg 1995;110:473 & 2007;133:389

slide17

MAZEIII 术式对慢性房颤消融策略的启示

Implications of former experiences

  • 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 ThoracCardiovascSurg 2003;126:1822-8

slide19

“2C3L” Approach for CAF

  • 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

Sang CH,Ma CS, Heart Rhythm, 2010, 7: S332

slide20

2C3L病例 60M CAF 5 years

Activation Mapping Only After Endpoints/203L Achieved

slide22

病例6 心衰房颤(房颤导致心衰)

55F CAF 4年, CHF 6 月, 无高血压、无糖尿病、无瓣膜病

LVED:58mm EF:28%

203L策略: PVIs 、 Roof、MI、CTI

slide24

6 months

post ablation

3 days

post ablation

slide25

“2C3L” VS. Stepwise

  • “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)
slide27
持续性房颤的导管消融

成功率%

Heart Rhythm 2010;7:835

slide30

左房间隔部过度消融的危害

(间隔线、CFAE、FIRM)

slide31

LAA Delay

Incidence :26% ------ 11% ----- 0%

2006 2007 2009

slide32

LAA Delay

P QRS

A V

Jiang CX , Ma CS. PACE 2010; 33:652

slide33

LAA Delay: ECG

Narrow P, Pseudo △, Pseudo ε

slide35

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

slide36

导管消融

下壁导联 P 波后半部分负向波

slide42

关于FIRM

Sanjiv M. Narayan, UC, San Diego

slide44

pro-arythmia

or

bridge to sinus rhythm

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