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心电生理临床研究的个人体会

心电生理临床研究的个人体会. 南京医科大学第一附属医院 心脏科 陈明龙. 电生理医生的素养. 四会 做 说 写 想. 心电生理临床研究的轴线. 问题. 临床疑点. 思考. 提出假说. 验证. 设计方案. 解答. 应用临床. 以往的临床研究. SCI 论文 15 篇 Circ-AE: 1; JCE: 4; Europace: 3; PACE: 3; IJC: 1; Circ-J: 1; et al. 中华心血管病杂志： 8 中华心律失常杂志： 14. 举例一：左室特发性室速. 问题： 反复复发 手术不成功 术中不诱发.

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心电生理临床研究的个人体会

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  1. 心电生理临床研究的个人体会 南京医科大学第一附属医院 心脏科 陈明龙

  2. 电生理医生的素养 • 四会 • 做 • 说 • 写 • 想

  3. 心电生理临床研究的轴线 问题 临床疑点 思考 提出假说 验证 设计方案 解答 应用临床

  4. 以往的临床研究 • SCI论文15篇 • Circ-AE: 1; • JCE: 4; • Europace: 3; • PACE: 3; • IJC: 1; • Circ-J: 1; et al. • 中华心血管病杂志：8 • 中华心律失常杂志：14

  5. 举例一：左室特发性室速 • 问题： • 反复复发 • 手术不成功 • 术中不诱发

  6. 机制的认识 诱发心动过速 窦律 心室S1S2刺激 Maruyama et al, JCE 2001;12:968–972

  7. Retro-PP Sinus rhythm

  8. Retro-PP Ante-PP Ventricular stimuli

  9. DP Earliest PP Tachycardia

  10. DP Earliest PP Tachycardia 电生理机制 • 左侧希浦系统内的折返激动，相对明确的出口 • ？？？ 前传支、逆传支、具体环路、上转折点

  11. Chen M, et al. Europace. 2005;7:138-144

  12. Chen M, et al. Europace. 2005;7:138-144

  13. Chen M, et al. Europace. 2005;7:138-144

  14. Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post I II III R L F V1 V2 V3 V4 V5 V6 病例1 病例2 病例3 病例4 病例5 病例6

  15. 研究的意义和临床应用 • 临床广为应用 • 2009欧洲和美国VT指南分别引用3次 • Brawnwald: Clinical Electrophysiology

  16. 第三方评价 • 该术式被国内外同行专家接受，学术论文被引用20次，是近5年左室特发性室速被引用最多的文献

  17. 被指南与教科书引用情况 • 2009年室速导管消融专家共识（Heart rhythm.2009;6:886-933）被引用达6次 • 被国外权威教科书Braunwald系列丛书《Clinical arrhythmology and electrophysiology》与《Textbook of Cardiovascular Medicine 3rd Edition》所引用

  18. Comparison of the Conduction Velocity in Different Regions along the TVA between T-AFL and S-AFL: Implications of the Surgical Incisions on the RAFW(JCE, 2012, online) 举例二：外科术后房扑和典型房扑的机制对比研究

  19. Background • Isthmus-dependent AFL (S-AFL) post atriotomy is the most common macroreentry late after RA surgical procedures • It has identical reentrant circuit with typical atrial flutter (T-AFL) • S-AFL and T-AFL may have different proarrhythmic substrates

  20. Crista Terminalis SVC TV CS Eustachian ridge IVC Anatomic Structure

  21. Possible mechanisms of T-AFL B A C

  22. Electrophysiological basis of S-AFL • Need a slow conduction zone to perpetuate the tachycardia? • Where is the slowest conduction area? • The isthmus conduction is the same as it is in T-AFL?

  23. Objective • To compare the conduction velocity (CV) in different regions of the TVA in patients with T-AFL and S-AFL • To further delineate the true electrophysiological differences between S-AFL and T-AFL

  24. Methods 17 S-AFL 17 T-AFL • Pre-procedure • January 1, 2006 - May 2010, 34 • AAD Ceased • ECHO • Mapping • Ablation Array/NavX Activation map Conduction Time Length Conduction Velocity

  25. Methods: The separation of the TVA

  26. Results: Baseline characteristics

  27. Results: comparison of F wave morphology

  28. Discussion: Looking into T-AFL Profile

  29. Discussion : S-AFL Profile

  30. Results: EP Data

  31. Results: Comparison of Conduction Time

  32. Results: Comparison of Conduction Velocity

  33. Discussion: Slow Conduction Property of CTI in T-AFL • The circuit of T-AFL: confined anteriorly by the TVA and posteriorly by the CT • CV in CTI: ~ 0.6 m/s (range: 0.56–0.81 m/s) Schilling RJ et al. J Am Coll Cardiol 2001; 38: 385-393 Chan DP et al. Circulation 2000; 102: 1283-1289 Sawa A et al. Circ J 2008; 72: 384-391

  34. Discussion: Previous Electrophysiological Insights for S-AFL • Sharing the same circuit with T-AFL • The incision scar acts as a obstacle preventing short circuit to maintain the reentry CSo IVC Why S-AFL develops only in some of the patients?

  35. Discussion: Implications for CA

  36. Conclusions • In S-AFL • The RAFW is the slowest conduction zone due to surgical impairments and plays an important role in AFL development • The CTI has a relatively normal conduction speed, serves only as an anatomic isthmus and has less proarrhythmic effects • In T-AFL • The CTI is the slowest conduction region of the circuit in most patients, and acts as a critical component both electrophysiologically and anatomically

  37. 举例三：慢性房颤的消融策略研究 • 问题： • 单纯肺静脉隔离治疗慢性房颤不足够 • 广泛的左房线性消融和碎裂电位消融： • 致心律失常作用 • 左心房功能损害 • 手术并发症增加 寻找真正的房颤基质，做个体化的电学基质改良？

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