房颤导管消融---适应证选择.ppt

房颤导管消融 -适应证选择,上海交通大学附属胸科医院 上海交通大学房颤中心 刘旭,房颤患病率逐年增加,%,36,37,53,Year,Proportion Aged 80 Yr,Go: JAMA, 2001：2370,中国1000万,国内房颤的流行病学研究,房颤患者脑中风 风险17.5% 瓣膜病房颤患者 脑中风风险26.88% 非瓣膜病房颤患者 脑中风风险24.15%,Hu DY, Chin J Intern Med 2003;42:15761. Wen-Hang QI. Int J Cardiol 2005;105:2837. Zhang S. Heart 2009 Jul;95(13):1052-5 .,结论：导管消融治疗房颤合并心衰患者，在不使用药物治疗的情况下，维持窦性心律，能显著改善心功能、症状、运动耐量及生活质量。,Li-Fern Hsu,et al. N Engl J Med 2004;351:2373-83.,房颤导管消融适应症,2012ESC-房颤导管消融指南,指南提出，对于不伴有或者伴有轻微心脏疾 的阵发性房颤患者，导管消融是一线治疗。,2012ESC-房颤导管消融指南 成功标准:术后12个月 阵发:50% 持续:40% 长程:30%,慢性房颤消融 -适应证的个体化策略,临床病例,病例 2 71岁，女性 AF病史83个月 高血压 糖尿病 LA 56mm RA 56x46mm MR、TR 中度返流,病例 1 43岁，男性 AF病史14个月 LA 41mm,不同特点的患者 - 完全相同的术式？,适应证的个体化,依据何在,临床特征 病史 合并疾病 心脏超声,电生理特征 肺静脉电位 碎裂电位 双心房电学差异,预后与复发 复发时间 复发类型 复发次数,依据何在,* Yuanglong w, Xu L, et al. The evalution of left and atrial atrium lines ablation for longstanding atrial fibrillation.PACE.onlines,适应证的个体化,适应证的个体化,220 patients with LS-AF Group I ：CPVI+CFAEs Group II : I+Lines(roof+mitral ismuths) Group III : II+Lines(roof+mitral ismuths+thricuspid ismuths) Current ablation endpoints: CPVI+CFAEs+Lines(roof+mitral ismuths) (CCL),步骤1 环肺静脉电隔离,步骤2 碎裂电位消融,步骤3 必要的线性消融,AF终止,AF终止,AF未终止,AF未终止,电复律,本中心慢性房颤CCL消融策略探索 CPVI+CFAEs+Lines(CCL),Wang YY, Liu Xu, et al. Evaluation of linear lesions in the left and right atrium in ablation of longstanding atrial fibrillation. Pacing and Clinical Electrophysiology. 2013. Acceptted.,依据-临床特征-年龄,258 patients with LS-AF Current ablation endpoints - CCL Group I (55 yrs), Group II (5665 yrs) ,Group III (66 years),follow-up of 18.1 5.1 months,* Xiaodong Z, Liang Z, Xu L, et al. The impact of age on the efficacy and safety of catheter ablation. Int J Cardiol , online.,SR group and recurrent ATa group,适应证的个体化,* Xiaodong Z, Liang Z, Xu L, et al. The impact of age on the efficacy and safety of catheter ablation. Int J Cardiol , online.,依据-临床特征-年龄,适应证的个体化,* Xiaodong Z, Liang Z, Xu L, et al. The impact of age on the efficacy and safety of catheter ablation. Int J Cardiol , online.,依据-临床特征-年龄,适应证的个体化,依据-临床特征-性别,220 patients with LS-AF Current ablation endpoints - CCL 147 males and 73 females,follow-up of 19 5.0 months,* Xiaodong Z, Liang Z, Xu L, et al. Efficacy and safety of catheter ablation for long-standing persistent atrial fibrillation in women. PACE, accepted.,SR group and recurrent ATa group,适应证的个体化,依据-临床特征-性别,* Xiaodong Z, Liang Z, Xu L, et al. Efficacy and safety of catheter ablation for long-standing persistent atrial fibrillation in women. PACE, accepted.,适应证的个体化,依据-临床特征-性别,* Xiaodong Z, Liang Z, Xu L, et al. Efficacy and safety of catheter ablation for long-standing persistent atrial fibrillation in women. PACE, accepted.,适应证的个体化,依据-临床特征-COPD,550 patients with AF and COPD Current ablation endpoints - CPVI/CCL With COPD (n=54) and without COPD (n=496),follow-up of 31.4 4.8months,* Gu J, Xu L, et al. Impact COPD on Procedural Outcomes and Quality of life. J Cardiovasc Electrophysiol. 2013,24:148-54,SR group and recurrent ATa group,适应证的个体化,The presence of COPD predicted higher recurrence after single-catheter ablation in AF patients,依据-临床特征-COPD,* Gu J, Xu L, et al. Impact COPD on Procedural Outcomes and Quality of life. J Cardiovasc Electrophysiol. 2013,24:148-54,适应证的个体化,依据-临床特征-RHD,99 patients with LS-AF and RHD Valvular operation + CPVI vs. valvualr operation + Maze procedure,follow-up of 15 5 and 20 8 months,* Xu L, et al. Efficacy of catheter ablation and surgical CryoMaze procedure in patients with LS-AF and RHD. Euro Heart J. 2010,31:2633-41.,SR group and recurrent ATa group,适应证的个体化,* Xu L, et al. Efficacy of catheter ablation and surgical CryoMaze procedure in patients with LS-AF and RHD. Euro Heart J. 2010,31:2633-41.,The concomitant Cox Maze procedure using SICTRA is more effective than subsequent CPVI combined with substrate modification in treating patients with LS-AF and RHD.,依据-临床特征-RHD,适应证的个体化,依据-临床特征-VR,216 patients with LS-AF Current ablation endpoints - CCL Valvular regurgitation (VR) on ablation outcomes,follow-up of 18.9 2.7 months,SR group and recurrent ATa group,* Liang Z, Xu L, et al. The Role of Valvular Regurgitation in Catheter Ablation Outcomes Europace, online,适应证的个体化,* Liang Z, Xu L, et al. The Role of Valvular Regurgitation in Catheter Ablation Outcomes. Europace, online,依据-临床特征-VR,适应证的个体化,In three types of VR MR was associated with recurrent ATa ATa recurrence increased with the grades of MR severity.,* Liang Z, Xu L, et al. The Role of Valvular Regurgitation in Catheter Ablation Outcomes. Europace, online.,依据-临床特征-VR,适应证的个体化,依据-临床特征-终点达标,208 patients with LS-AF Obtaining Current ablation endpoints - CCL 67 of 208 (32.2%) patients undergoing 2 procedures,follow-up of 19.9 4.1 months,AF recurrence group non-AF recurrence group (including SR and AT),* Liang Z, Xu L, et al. Why Atrial Fibrillation Recurs in Patients Obtained Current Ablation Endpoints. JICE, accepted.,适应证的个体化,* Liang Z, Xu L, et al. Why Atrial Fibrillation Recurs in Patients Obtained Current Ablation Endpoints. JICE, accepted.,依据-临床特征-终点达标,适应证的个体化,* Liang Z, Xu L, et al. Why Atrial Fibrillation Recurs in Patients Obtained Current Ablation Endpoints. JICE, accepted.,AF recurrence group patients with 2 procedures greater RA enlargement (90.0% vs. 35.7%,p=0.001) longer AF duration (97.3 42.9 months vs. 65.3 36.9 months, p=0.031).,依据-临床特征-终点达标,适应证的个体化,依据-临床特征-复发,222 patients undergoing 2nd procedure Current ablation endpoints - CCL Recurrent AT(R-AT) vs. recurrent AF (R-AF),follow-up of 17.7 4.0 months,SR group and recurrent ATa group,* Liang Z, Xu L, et al. Recurrence as Atrial Tachycardia versus Atrial Fibrillation,适应证的个体化,* Liang Z, Xu L, et al. Recurrence as Atrial Tachycardia versus Atrial Fibrillation.,依据-临床特征-复发,适应证的个体化,* Liang Z,