手术消融手术技术和临床试验结果及东西方比较（中英文）

手术消融 : 手术技术 和临床试 验结果及东西方比较 : Dr James Wong Chief Surgeon, Heart, Lung J Thorac Cardiovasc Surg 2008;136:419-423 两例左冠脉优势型病例 Copyright 2008 The American Association for Thoracic Surgery Castella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423 射频双极钳在左心耳切口至二尖瓣瓣环间形成消融线 Castella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423 补体 C9免疫组化染色显示，消融后 8小时左房后壁 透壁性坏死 (放大倍数： 20倍 ) Copyright 2008 The American Association for Thoracic Surgery Castella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423 双极射频钳顶端位于三尖瓣瓣环附近 发展中国家医疗费用问题 0 5 10 15 20 25 30 35 40 中国 日本 新加坡 马来西亚 印度尼西亚 越南 泰国 US Dollars 34312 35163 6948 1925 818 37372461 人均国民生产总值 在中国，使用可形成 Cox 迷宫 III手术消融线单极设备的费用与普 通居民一年的收入相当 . 由于医疗费用问题很重要，发展中国家患者仅能支付一种设备的 费用。 使用单极进行笔式射频消融 时，如何保证其透壁性？ 冲洗式单极射频消融 确保透壁性的技术 心内膜和心外膜联合消融 确保透壁性 在同一消融线上， 对心内膜和心外膜 消融。 f g 左心房 Click on picture to start movie Transmurality 从左肺静脉至二尖 瓣瓣环消融线的透 壁性 左心房 Click on picture to start movie c d 序贯心内膜和心外膜冲洗式单极消融以确保消融 线的透壁性 q 我们希望得到什么结果 研究时限 : 2002年 10月 2003年 12月 44 例患者 : 30 例二尖瓣反流 /修复术 , 10 例二尖瓣反流主动脉瓣反流 , 2 例冠脉搭 桥 , 2例房间隔缺损 死亡率 : (2 例患者 ) 1例二尖瓣反流 , 1例 二尖瓣反流 + 主动脉瓣反流 平均年龄 : 45 岁 ( 范围： 22 60 岁 ) 平均左房直径 : 51mm ( 范围： 45 62 mm ) 房颤类型 : 所有患者均为慢性房颤（大于 1 年） 随诊时间 : 4 5 年 结果 : 34/42 恢复窦律 ( 81%). 心房收缩 ( M-超声 ): LA 70%, RA 90% 无中风发生，无晚期死亡病例 失败患者 : 6 例，其中有 4名患者为累及左心房峡部的房扑 谢谢 ! Surgical Ablation: Techniques and Trial Results, Comparison of East and West: Dr James Wong Chief Surgeon, Heart, Lung J Thorac Cardiovasc Surg 2008;136:419-423 Two examples of left dominant coronary circulation Copyright 2008 The American Association for Thoracic Surgery Castella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423 Radiofrequency bipolar clamp positioned to carry out the ablation line from the left auriculotomy to the mitral annulus Castella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423 Complement C9 immunostaining of the posterior wall of the left atrium showing transmural necrosis approximately 8 hours after ablation was performed (original magnification x20) Copyright 2008 The American Association for Thoracic Surgery Castella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423 The radiofrequency clamp is positioned to reach the tricuspid annulus COST ISSUES IN DEVELOPING COUNTRIES 0 5 10 15 20 25 30 35 40 Greater Japan Singapore Malaysia Indonesia Vietnam Thailand China US Dollars 34312 35163 6948 1925 818 37372461 GPD ( nominal) per capital In China the monopolar device which can create all the lines of the Cox Maze III can cost up to almost a year of personal income. Because of cost consideration can be important, only one device is affordable in developing countries The issue then if the monopolar RF pen is to be used, how can one ensure transmurality with it Unipolar Irrigated RF Technique To Ensure Transmurality Endocardial & Epicardial Combined Lesions Ensuring Transmurality Apply ablation to both surfaces along the same line. f g LEFT ATRIUM Click on picture to start movie Transmurality Transmurality of line of block from LPV to MA LEFT ATRIUM Click on picture to start movie c d Sequential Endocardial and Epicardial Irrigated Monopolar Ablation to ensure transmurality q What type of results one expect to get Study interval: Oct 2002 Dec 2003 44 patients: 30 MVR/Repair, 10 MVR + AVR, 2 CABG, 2 ASD Mortality: (2 patients ) 1 MVR, 1 MVR + AVR Average age: 45 years ( range 22 60 years ) Average LA diameter: 51mm ( range 45 62 mm ) AF type: All chronic and 1 year Follow up duration: 4 5 years Result: 34/42 in SR ( 81%). Atria