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左房食管瘘的识别与处理

左房食管瘘的识别与处理. 李毅刚 上海交通大学 新华医院. 房颤介入治疗方法. Segmental PV Isolation Circumferential Ablation Circumferential Isolation Cafes. Haissaguerre. SCV. 环肺静脉消融＋线性消融. LUPV. RUPV. LLPV. RLPV. ICV. Pappone. SCV. LUPV. RUPV. LLPV. RLPV. ICV. IRAAF. SCV. LUPV. RUPV. LLPV. RLPV. ICV.

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左房食管瘘的识别与处理

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  1. 左房食管瘘的识别与处理 李毅刚 上海交通大学 新华医院

  2. 房颤介入治疗方法 • Segmental PV Isolation • Circumferential Ablation • Circumferential Isolation • Cafes

  3. Haissaguerre SCV 环肺静脉消融＋线性消融 LUPV RUPV LLPV RLPV ICV Pappone SCV LUPV RUPV LLPV RLPV ICV IRAAF SCV LUPV RUPV LLPV RLPV ICV

  4. 房颤消融治疗主要的并发症-- 左房食管瘘--肺静脉狭窄-- 房性心律失常-- 心包填塞-- 脑卒中

  5. 左房食管瘘的识别：临床表现 • 数天之后才发生 • 不具有特异性 • 胸痛 • 发热 • 惊厥 • 系统性栓塞 • 败血症 • 白细胞升高 • CRP升高

  6. 左房食管瘘的识别：临床表现 Calkins H. et al. Heart Rhythm 2006;10:1162-1163 • 发生率：〉60例 (0.05-1%) • 死亡率：〉75%

  7. 目前最大病例数报道 Cummings JE. et al. Ann Intern Med. 2006;144:572-574

  8. Cummings JE. et al. Ann Intern Med. 2006;144:572-574

  9. Cummings JE. et al. Ann Intern Med. 2006;144:572-574

  10. Cummings JE. et al. Ann Intern Med. 2006;144:572-574

  11. 左房食管瘘的识别：影像特征 Preis O. J Thorac Imaging 2007;22:283-285

  12. Preis O. J Thorac Imaging 2007;22:283-285

  13. Preis O. J Thorac Imaging 2007;22:283-285

  14. Preis O. J Thorac Imaging 2007;22:283-285

  15. Malamis AP. J Thorac Imaging 2007;22:188-191

  16. Malamis AP. J Thorac Imaging 2007;22:188-191

  17. Schley P. Europace 2006;8189-190

  18. Schley P. Europace 2006;8189-190

  19. Schley P. Europace 2006;8189-190

  20. 左房食管瘘的诊断与处理 • 当怀疑本病存在时，即禁忌行内窥镜以及食管内超声等检查。 • 推荐行无创检查，如CT,MRI增强检查。 • 一经发现，立即手术。

  21. 肺静脉、左房和食管的解剖关系

  22. Anatomic Relationship of the Esophagus and Left Atrium Although the anatomic relationship between the esophagus and LA posterior wall varied widely, two major patterns of esophageal routes could be depicted Tsao HM Chest. 2005;128:2581-2587

  23. Anatomic Relationship of the Esophagus and Left Atrium Sanchez-Quintana D, et al. Circulation., 2005;112:1400-5

  24. Anatomic Relationship of the Esophagus and Left Atrium Sanchez-Quintana D, et al. Circulation., 2005;112:1400-5

  25. Anatomic Relationship of the Esophagus and Left Atrium Sanchez-Quintana D, et al. Circulation., 2005;112:1400-5

  26. Anatomic Relationship of the Esophagus and Left Atrium Sanchez-Quintana D, et al. Circulation., 2005;112:1400-5

  27. Anatomic Relationship of the Esophagus and Left Atrium Sanchez-Quintana D, et al. Circulation., 2005;112:1400-5

  28. 左房食管瘘的预防

  29. 预防与对策 -- 了解食管走形 食管造影 CT, MRI，心内超声（ICE） CARTO-Merge, Navix -- 放电前食管标测 -- 食管内温度监测 -- 低能量输出 -- 不同能源：冷凝 -- 食管内冷盐水灌注球囊

  30. 术前影像检查－了解食管走形

  31. 食管造影

  32. Good E. JACC 2005;46:2107-2110

  33. ≥ 2cm 67% ≥ 4cm 4% Good E. JACC 2005;46:2107-2110

  34. Good E. JACC 2005;46:2107-2110

  35. 实时检测食道的位置更为重要 Good E. JACC 2005;46:2107-2110

  36. CARTO-Merge

  37. Navix

  38. 改变消融策略 • Pappone:左房后壁 • 温度低于55°C • 射频能量应低于50W • 左房消融线应移至左房顶壁 • Ren:临近食管处 • 温度低于55°C • 射频功率应在30-50W • 10－30 S：微泡形成/早期超声可见的损伤形成 • 我们消融方案:左房后壁 • 温度低于45°C • 射频能量应低于30W • 左房顶部消融线前移

  39. 食管内温度监测 Perzanowski C, et al. JCE, 2006;17:166-170

  40. 食管内温度监测 Perzanowski C, et al. JCE, 2006;17:166-170

  41. 食管内温度监测 Cummings JE, et al. Circulation., 2005;112:459-64

  42. 食管内温度监测 温度探测电极 Cummings JE, et al. Circulation., 2005;112:459-64

  43. 食管内温度监测 Cummings JE, et al. Circulation., 2005;112:459-64

  44. 食管内温度监测 Cummings JE, et al. Circulation., 2005;112:459-64

  45. 食管内温度监测 Cummings JE, et al. Circulation., 2005;112:459-64

  46. 食管内温度监测 Cummings JE, et al. Circulation., 2005;112:459-64

  47. 食管内温度监测 Cummings JE, et al. Circulation., 2005;112:459-64

  48. 不同能源：冷凝

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