心房颤动与充血性心力衰竭房室结消融加起搏治疗的地位课件

Atrial Fibrillation and Congestive Heart Failure: Role of AVN Ablation and Pacing CP1053942-2 GW-ICC, Beijing 2003GW-ICC, Beijing 2003 Win K. Shen, M.D.Win K. Shen, M.D. “Two new epidemics of cardiovascular disease are emerging: Heart failure and atrial fibrillation.” CP1053942-2 Shattuck Lecture, NEJM, 1997Shattuck Lecture, NEJM, 1997 “Cardiovascular Disease in the “Cardiovascular Disease in the New Millennium”New Millennium” Eugene Eugene BraunwaldBraunwald Objectives AF and CHF, a vicious cycle Clinical outcomes following AVN ablation and pacing Symptoms, functional capability Survival Evolving pacing methods in AF and CHF Questions and challenges Atrial Fibrillation and CHF Rapid ratesRapid rates IrregularityIrregularity LV dysfunctionLV dysfunctionLV dysfunctionLV dysfunction Increased filling Increased filling pressurespressures MarkerMarker Cause or Consequence?Cause or Consequence? CP1000536-6 80-Year-Old Female80-Year-Old Female Grogan M: AJC 69:1573, 1992 Grogan M: AJC 69:1573, 1992 Serial Changes in EFSerial Changes in EF *Heart rate 140 one week earlier*Heart rate 140 one week earlier 0 0 2020 4040 6060 AF 120AF 120AF 70AF 70AF 76AF 76AF 70AF 70 60606060 EFEF (%)(%) 4040 Heart rate (Heart rate (bpmbpm) ) 3030 CP1000536-4 AFAdverse Effect of Irregular Rate VVIVVIVVIVVIVVTVVTVVTVVT VVI = regular rate at mean AF rate VVT = irregular rate tracking AF Clark et al: JACC, 1997 L/minL/min 0 0 2 2 4 4 6 6 8 8 Cardiac OutputCardiac Output P50% 131 (47%) EF 40% 105 (37%) EF 41-50% (16%) 282 Patients EF 40% at baselineEF 40% at baseline 2626 8% 8% 3434 13% (P0.001)13% (P0.001) UnchangedUnchanged 9 (16%)9 (16%) EF nearly normalized in 16/56 (29%)EF nearly normalized in 16/56 (29%) Mild-moderateMild-moderate LV LV dysfdysf ProbablyProbably commoncommon AFibAFib-Induced LV Dysfunction-Induced LV Dysfunction FrequencyFrequency CommonCommon AF mediates AF mediates additional LV additional LV dysfunction dysfunction Under-Under- recognized recognized Preexisting LVPreexisting LV dysfunctiondysfunction SevereSevere LV LV dysfdysf AFib-inducedAFib-induced cardiomyopathycardiomyopathy No preexisting structuralNo preexisting structural heart diseaseheart disease UncommonUncommon but not rarebut not rare CP1000536-10 AFib and CHF Temporal Relations and Mortality Framingham Study CP1119361-1 MenMen Impact of incident CHF Impact of incident CHF on mortality (RR+CI)on mortality (RR+CI) WomenWomen 2.72.7 (1.9-3.7)(1.9-3.7) 3.13.1 (2.2-4.2)(2.2-4.2) MenMen Impact of incident Impact of incident AFibAFib on mortality on mortality WomenWomen 1.61.6 (1.2-2.1)(1.2-2.1) 2.72.7 (2.0-3.6)(2.0-3.6) Benjamin: Circ, 2003 Development of CHF in Pt with AFib Years Cumulative incidence of CHF Development of AFib in Pt with CHF Years Cumulative incidence of AF Prevalence of AF in CHF Trials Percent with AF CP1068448-3 SOLVD-P SOLVD-T VeHFT CHF-STAT GESICA CONSENSUS 5 10 13 15 25 50 NYHA INYHA II-IIINYHA III-IV Cumulative survivalCumulative survival free from NVAF (%)free from NVAF (%) Follow-up (years)Follow-up (years) NormalNormal Diastolic Dysfunction and Development of NRAF Tsang T: JACC, 2002Tsang T: JACC, 2002 Log rank P0.001Log rank P0.001 RestrictiveRestrictive PseudonormalPseudonormal Abnormal relaxationAbnormal relaxation Subsequent AFib 9.8% 840 patients840 patients Aged Aged 65 yr65 yr Olmsted CountyOlmsted County No prior No prior AFibAFib Adjusted for Age CP1103556-5 Atrial Fibrillation and Heart Failure Arrhythmogenic Substrate Initiation and Trigger Neuro-humoral fluctuation Bradycardia Tachycardia Stretch APCs, PV, SVC Ischemia Maintenance Structure Hemodynmics Electrophysiology Bio-energetics Molecular Atrial Fibrillation and CHF CHF AFCHF AF AtrialAtrial dilatation dilatation Stretch receptor activationStretch receptor activation Neuro-humoralNeuro-humoral modulation modulation Signal transduction/bioenergeticsSignal transduction/bioenergetics ElectropysiologicElectropysiologic remodeling remodeling FibrosisFibrosis AutomaticityAutomaticity RefactorinessRefactoriness ConductionConduction A viciousA vicious cyclecycle Loss of Loss of atrialatrial contraction contraction Impaired ventricular fillingImpaired ventricular filling High heart ratesHigh heart rates EF EF perfusion perfusion NeurohormonalNeurohormonal activation activation Sympathetic stimulationSympathetic stimulation Use of negative Use of negative inotropicinotropic drugs drugs TriggeredTriggered activityactivity CHFCHF AtrialAtrial fibrillationfibrillation CP1110819-1 AFAF CHFCHF 2.5 sec2.5 sec 185 185 bpmbpm Radiofrequency Ablation of AV Junction CP1048425-13 8.6 sec 1200 ms AVN Ablation and AVN Ablation and AtrialAtrial FibillationFibillation Wood: Circ, 2000Wood: Circ, 2000 WorsenedWorsenedImprovedImproved 0.40.40.20.2 0 0 0.20.20.40.40.60.6 ActivityActivity Severity Severity SxSx PalpitationsPalpitations Exercise intoleranceExercise intolerance Frequency Frequency SxSx 0.80.81.01.0 Effort Effort dyspneadyspnea Rest Rest dyspneadyspnea Well-beingWell-being QOLQOL CP968148-6 AVN Ablation and AVN Ablation and AtrialAtrial FibillationFibillation Wood: Circ, 2000Wood: Circ, 2000 WorsenedWorsenedImprovedImproved 4 4 2 2 0 0 2 2 4 4 6 6 FractionalFractional shortening (%)shortening (%) NYHANYHA EjectionEjection fraction (%)fraction (%) Visits (no.)Visits (no.) Admissions (no.)Admissions (no.) Drugs (no.)Drugs (no.) CP968148-5 Long Term Survival AVN Ablation vs Drug Therapy P=0.51P=0.51 OzcanOzcan, NEJM 2001, NEJM 2001 Follow-up (yr)Follow-up (yr) Survival (%) CP1048425-34 Ablation therapy (n=350) Drug therapy (n=229) Long Term Survival Following AVN Ablation Pts (No CHF, MI, or Cardiac Drugs) vs Normal Population Follow-up (yr)Follow-up (yr) ExpectedExpected ObservedObserved Survival (%) CP1048425-35 OzcanOzcan, NEJM 2001, NEJM 2001 n = 121 p = 0.43 Long Term Survival Following AVN Ablation EF 40% vs Normal Population 0 20 40 60 80 100 01234567 Follow-up, year Event free survival, % Observed (n = 56) Expected P0.001 OzcanOzcan, AJC 2003, AJC 2003 Long Term Survival Following AVN ablation Near Normalization of EF vs Normal Population 0 20 40 60 80 100 01234567 Follow-up, year Event free survival, % Observed (n = 16) Expected P=0.37 OzcanOzcan, AJC 2003, AJC 2003 Role of Cardiac Resynchronization in Patients with CHF and RV Pacing Is Iatrogenic LBBB Analgous to Spontaneous LBBB? 20 patients with chronic AF and CHF Prior AVN RF and RV apical pacing EF 22 % LVEDd 68 mm LV pacing lead added and “Y” adapted to VVIR pulse generator Leon, AR JACC 2002;39:1258Leon, AR JACC 2002;39:1258 CP1060489-1 NYHA class Pre-BVPPost-BVP Ejection fraction (%) Pre-BVPPost-BVP P0.001P0.001 Effects of BiV Pacing on Functional Status and EF in RV Paced Patients After AVN Ablation Leon, AR JACC 2002;39:1258Leon, AR JACC 2002;39:1258 3.4+ 0.5 2.4+ 0.6 21.5+ 6.9 30.9+ 11.5 MUSTIC 12-Month Follow-Up CP1077281-5 Linde: JACC, 2002 131 patients included131 patients included Sinus rhythm groupSinus rhythm group n=67n=67 n=48n=48 BiVBiV n=46 n=46 VVI n=2VVI n=2 n=45n=45 BiVBiV n=45 n=45 n=42n=42 BiVBiV n=42 n=42 AtrialAtrial fibrillation group fibrillation group n=64n=64 n=41n=41 BiVBiV n=35 n=35 VVIR n=6VVIR n=6 n=37n=37 BiVBiV n=32 n=32 VVIR n=6VVIR n=6 n=33n=33 BiVBiV n=29 n=29 VVIR n=4VVIR n=4 End of 6 months crossover phase, start of long term Sudden deathn=1 Heart failure death n=1 Septicaemia death n=1 End of 9 months follow-up End of 12 months follow-up n=75 Still in study Sudden deathn=1 Stroke deathn=1 ICDn=1 Sudden deathn=1 ICD implantationn=1 Cancern=1 Lost to follow-upn=1 Sudden deathn=1 Heart failure death n=1 Heartn=1 transplantation Heart transplantn=1 list The Evolution of the 6-Minute Walked Distance, Peak VO2 QoL and NYHA Class at M6, M9, and M12 CP1077281-9 RandomizationM6M9M12 6-min walked distance (m)33887 (n=37)363101 (n=37) 32082 (n=27)36897 (n=97) 31580 (n=27)37087 (n=37) P=0.004 Peak VO2 (mL/kg/min)12.84.7 (n=37) 14.34.1 (n=37)NA 12.83.6 (n=24)13.93.5 (n=24) P=0.004 QoL score (0-105)4422 (n=40)3420 (n=40) 4522 (n=31)3422 (n=31) 4523 (n=28)3117 (n=28) P=0.002 NYHA (I-IV)3.00 (n=38)2.30.5 (n=38) 3.00 (n=29)2.10.4 (n=29) 3.00 (n=28)2.20.5 (n28) P=0.0001 Atrial fibrillation group PAVE Study Design High Rate Pacing -4WksHigh Rate Pacing -4Wks Note: Baseline = 6 Weeks post ablation Prevention of Atrial Fibrillation CP1048425-12 Physiologic pacing Physiologic pacing vsvs VVI pacing VVI pacing Anatomy-based investigationAnatomy-based investigation New pacing algorithmsNew pacing algorithms Atrial FibrillationManagement AFFIRM-completed*AFFIRM-completed* RACE-completed*RACE-completed* PIAF-completed*PIAF-completed* STAF (pilot)-completed*STAF (pilot)-completed* AF-CHF-beginningAF-CHF-beginning TrialsTrials * *No difference between strategiesNo difference between strategies Resolving IssuesResolving Issues Rate controlRate controlMaintenance of sinus rhythmMaintenance of sinus rhythm PatientsPatients Normal LVNormal LVCHFCHF CP1000536-14 CP1096645-23 AFFIRM: Adverse Events EventNo.%No.%No.% P Primary endpoint (death) 66626.331025.935626.70.08 Secondary endpoint 86132.341632.744532.00.33 (composite of death, disabling stroke, disabling anoxic encephalopathy, major bleeding, and cardiac arrest)