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慢性房颤 机制及导管消融策略中的哲学 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?. 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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慢性房颤 机制及导管消融策略中的哲学

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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


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PVI是房颤导管消融的基石是否已经动摇?


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CL 210ms

210ms

238ms

248ms

258ms

Earlist LA

exist

Perfect PPI


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Possible Macro-Reentrant Substrates

CTI


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Schematic of Common Lesion Sets Employed in AF Ablation

CH Sang ,CS Ma.

Heart Rhythm, 2010, 7: S332

Europace 2012:14: 528–606


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PVI是否充分?


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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%


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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


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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


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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


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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


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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?


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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


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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


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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


Pvi mi cti roof 2c3l1

PVI基础上三线(MI、CTI、Roof)2C3L策略

2008


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“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


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2C3L病例 60M CAF 5 years

Activation Mapping Only After Endpoints/203L Achieved


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“2C3L” Is Physiologic

Roof

PVI

MI

CTI


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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


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病例6 心衰房颤(房颤导致心衰)

消融后

E A

99cm/s 77cm/s


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6 months

post ablation

3 days

post ablation


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“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)


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2C3L策略之外的消融为什么也能维持窦律?


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持续性房颤的导管消融

成功率%

Heart Rhythm 2010;7:835


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不同消融窦律的质量是否相同?


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左房间隔部过度消融的危害

(间隔线、CFAE、FIRM)


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LAA Delay

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

2006 2007 2009


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LAA Delay

P QRS

A V

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


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LAA Delay: ECG

Narrow P, Pseudo △, Pseudo ε


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LAA Delay MV Doppler


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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


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导管消融

下壁导联 P 波后半部分负向波


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假预激波


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EpsilonWave JCE 2007; 18:1114-1115


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Rotor和最快DF是不是驱动?


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关于FIRM

Sanjiv M. Narayan, UC, San Diego


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“环形运动” ≠ 折返

CS

CS


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pro-arythmia

or

bridge to sinus rhythm


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谢谢


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Relationship Between the Histological traits and Local Electrogram (CX43×200)

LA

Antrum


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Anatomic → Electrophysiological Heterogeneity


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