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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

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



Schematic of Common Lesion Sets Employed in AF Ablation

CH Sang ,CS Ma.

Heart Rhythm, 2010, 7: S332

Europace 2012:14: 528–606


PVI是否充分?


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%


再次消融房速机制 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

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


慢性房颤术后复发 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial FibrillationOAT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


长程持续性房颤导管消融 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

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


Mechanisms of ATs during CAF Abl. by Stepwise Approach Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

  • 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


慢性房颤线性消融的必要性 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

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 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation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 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

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


MAZE III Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation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


MAZEIII Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation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 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation基础上三线(MI、CTI、Roof)2C3L策略

2008


“2C3L” Approach for CAF Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

  • 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


2C3L Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation病例 60M CAF 5 years

Activation Mapping Only After Endpoints/203L Achieved


“2C3L” Is Physiologic Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

Roof

PVI

MI

CTI


病例 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation6 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


病例 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation6 心衰房颤(房颤导致心衰)

消融后

E A

99cm/s 77cm/s


6 months Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

post ablation

3 days

post ablation


“2C3L” VS. Stepwise Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

  • “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 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation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 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

成功率%

Heart Rhythm 2010;7:835


不同消融窦律的质量是否相同? Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation


左房间隔部过度消融的危害 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

(间隔线、CFAE、FIRM)


LAA Delay Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

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

2006 2007 2009


LAA Delay Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

P QRS

A V

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


LAA Delay: ECG Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

Narrow P, Pseudo △, Pseudo ε


LAA Delay MV Doppler Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation


In the editorial Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation, 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 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

下壁导联 P 波后半部分负向波


假预激波 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation


EpsilonWave Posterior Wall Isolation In Patients With Long Standing Persistent Atrial FibrillationJCE 2007; 18:1114-1115


Rotor Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation和最快DF是不是驱动?


关于 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial FibrillationFIRM

Sanjiv M. Narayan, UC, San Diego


Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation环形运动” ≠ 折返

CS

CS


pro-arythmia Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation

or

bridge to sinus rhythm


谢谢 Posterior Wall Isolation In Patients With Long Standing Persistent Atrial Fibrillation




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