Download - 慢性房颤 机制及导管消融策略中的哲学
![Page 1: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/1.jpg)
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
![Page 2: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/2.jpg)
PVI是房颤导管消融的基石是否已经动摇?
![Page 3: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/3.jpg)
![Page 4: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/4.jpg)
existEarlist LA
Perfect PPI
CL 210ms
210ms
238ms
248ms
258ms
![Page 5: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/5.jpg)
CTI
Possible Macro-Reentrant Substrates
![Page 6: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/6.jpg)
Europace 2012 : 14 : 528–606
Schematic of Common Lesion Sets Employed in AF Ablation
CH Sang , CS Ma.Heart Rhythm, 2010, 7: S332
![Page 7: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/7.jpg)
PVI是否充分?
![Page 8: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/8.jpg)
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
![Page 9: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/9.jpg)
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
![Page 10: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/10.jpg)
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 )
![Page 11: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/11.jpg)
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
![Page 12: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/12.jpg)
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
![Page 13: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/13.jpg)
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
![Page 14: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/14.jpg)
PVI基础上三线( MI、 CTI、 Roof
)消融( 2C3L)是否有效?
![Page 15: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/15.jpg)
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
![Page 16: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/16.jpg)
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
![Page 17: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/17.jpg)
• 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
![Page 18: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/18.jpg)
PVI基础上三线( MI、 CTI、 Roof
)2C3L策略
2008
![Page 19: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/19.jpg)
• 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
![Page 20: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/20.jpg)
Activation Mapping Only After Endpoints/203L Achieved
2C3L 病例 60M CAF 5 years
![Page 21: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/21.jpg)
“2C3L” Is Physiologic
MI
CTI
RoofPVI
![Page 22: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/22.jpg)
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)
![Page 23: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/23.jpg)
E A99cm/s 77cm/s
病例 6 心衰房颤(房颤导致心衰)消融后
![Page 24: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/24.jpg)
3 dayspost ablation
6 monthspost ablation
![Page 25: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/25.jpg)
• “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
![Page 26: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/26.jpg)
2C3L策略之外的消融为什么也能维持窦律?
![Page 27: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/27.jpg)
持续性房颤的导管消融
Heart Rhythm 2010;7:835
成功率 %
![Page 28: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/28.jpg)
![Page 29: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/29.jpg)
不同消融窦律的质量是否相同?
![Page 30: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/30.jpg)
左房间隔部过度消融的危害(间隔线、 CFAE 、 FIRM )
![Page 31: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/31.jpg)
LAA Delay
Incidence : 26% ------ 11% ----- 0% 2006 2007 2009
![Page 32: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/32.jpg)
P QRS
A V
LAA Delay
Jiang CX , Ma CS. PACE 2010; 33:652
![Page 33: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/33.jpg)
LAA Delay: ECG
Narrow P, Pseudo , Pseudo △ ε
![Page 34: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/34.jpg)
LAA Delay MV Doppler
![Page 35: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/35.jpg)
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
![Page 36: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/36.jpg)
导管消融
下壁导联 P 波后半部分负向波
![Page 37: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/37.jpg)
假预激波
![Page 38: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/38.jpg)
EpsilonWave JCE 2007; 18:1114-1115
![Page 39: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/39.jpg)
![Page 40: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/40.jpg)
![Page 41: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/41.jpg)
Rotor和最快 DF是不是驱动?
![Page 42: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/42.jpg)
Sanjiv M. Narayan, UC, San Diego
关于 FIRM
![Page 43: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/43.jpg)
“环形运动” ≠ 折返
CS CS
![Page 44: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/44.jpg)
pro-arythmia
or
bridge to sinus rhythm
![Page 45: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/45.jpg)
谢谢
![Page 46: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/46.jpg)
![Page 47: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/47.jpg)
Antrum
LA
Relationship Between the Histological traits and Local Electrogram (CX43×200)
![Page 48: 慢性房颤 机制及导管消融策略中的哲学](https://reader030.vdocuments.pub/reader030/viewer/2022012308/568134a3550346895d9ba636/html5/thumbnails/48.jpg)
Anatomic → Electrophysiological Heterogeneity