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慢性房颤 机制及导管消融策略中的哲学

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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  1. 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

  2. PVI是房颤导管消融的基石是否已经动摇？

  3. CL 210ms 210ms 238ms 248ms 258ms Earlist LA exist Perfect PPI

  4. Possible Macro-Reentrant Substrates CTI

  5. Schematic of Common Lesion Sets Employed in AF Ablation CH Sang ，CS Ma. Heart Rhythm, 2010, 7: S332 Europace 2012：14： 528–606

  6. PVI是否充分？

  7. 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%

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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？

  14. 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

  15. 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

  16. 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

  17. PVI基础上三线（MI、CTI、Roof）2C3L策略 2008

  18. “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

  19. 2C3L病例 60M CAF 5 years Activation Mapping Only After Endpoints/203L Achieved

  20. “2C3L” Is Physiologic Roof PVI MI CTI

  21. 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

  22. 病例6 心衰房颤（房颤导致心衰） 消融后 E A 99cm/s 77cm/s

  23. 6 months post ablation 3 days post ablation

  24. “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)

  25. 2C3L策略之外的消融为什么也能维持窦律？

  26. 持续性房颤的导管消融 成功率% Heart Rhythm 2010;7:835

  27. 不同消融窦律的质量是否相同？

  28. 左房间隔部过度消融的危害 （间隔线、CFAE、FIRM）

  29. LAA Delay Incidence ：26% ------ 11% ----- 0% 2006 2007 2009

  30. LAA Delay P QRS A V Jiang CX , Ma CS. PACE 2010; 33:652

  31. LAA Delay: ECG Narrow P, Pseudo △, Pseudo ε

  32. LAA Delay MV Doppler

  33. 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

  34. 导管消融 下壁导联 P 波后半部分负向波

  35. 假预激波

  36. EpsilonWave JCE 2007; 18:1114-1115

  37. Rotor和最快DF是不是驱动？

  38. 关于FIRM Sanjiv M. Narayan, UC, San Diego

  39. “环形运动” ≠ 折返 CS CS

  40. pro-arythmia or bridge to sinus rhythm

  41. 谢谢

  42. Relationship Between the Histological traits and Local Electrogram (CX43×200) LA Antrum

  43. Anatomic → Electrophysiological Heterogeneity

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