左房食管瘘的识别与处理.ppt

左房食管瘘的识别与处理,李毅刚上海交通大学新华医院,SegmentalPVIsolationCircumferentialAblationCircumferentialIsolationCafes,房颤介入治疗方法,LUPV,LLPV,RUPV,RLPV,SCV,ICV,IRAAF,SCV,ICV,RUPV,RLPV,LUPV,LLPV,Pappone,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,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,左房食管瘘的识别：临床表现,CalkinsH.etal.HeartRhythm2006;10:1162-1163发生率：60例(0.05-1%)死亡率：75%,左房食管瘘的识别：临床表现,目前最大病例数报道CummingsJE.etal.AnnInternMed.2006;144:572-574,CummingsJE.etal.AnnInternMed.2006;144:572-574,CummingsJE.etal.AnnInternMed.2006;144:572-574,CummingsJE.etal.AnnInternMed.2006;144:572-574,PreisO.JThoracImaging2007;22:283-285,左房食管瘘的识别：影像特征,PreisO.JThoracImaging2007;22:283-285,PreisO.JThoracImaging2007;22:283-285,PreisO.JThoracImaging2007;22:283-285,MalamisAP.JThoracImaging2007;22:188-191,MalamisAP.JThoracImaging2007;22:188-191,SchleyP.Europace2006;8189-190,SchleyP.Europace2006;8189-190,SchleyP.Europace2006;8189-190,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。,肺静脉、左房和食管的解剖关系,AnatomicRelationshipoftheEsophagusandLeftAtrium,TsaoHMChest.2005;128:2581-2587,AlthoughtheanatomicrelationshipbetweentheesophagusandLAposteriorwallvariedwidely,twomajorpatternsofesophagealroutescouldbedepicted,Sanchez-QuintanaD,etal.Circulation.,2005;112:1400-5,AnatomicRelationshipoftheEsophagusandLeftAtrium,Sanchez-QuintanaD,etal.Circulation.,2005;112:1400-5,AnatomicRelationshipoftheEsophagusandLeftAtrium,Sanchez-QuintanaD,etal.Circulation.,2005;112:1400-5,AnatomicRelationshipoftheEsophagusandLeftAtrium,Sanchez-QuintanaD,etal.Circulation.,2005;112:1400-5,AnatomicRelationshipoftheEsophagusandLeftAtrium,Sanchez-QuintanaD,etal.Circulation.,2005;112:1400-5,AnatomicRelationshipoftheEsophagusandLeftAtrium,左房食管瘘的预防,-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,预防与对策,术前影像检查了解食管走形,食管造影,GoodE.JACC2005;46:2107-2110,GoodE.JACC2005;46:2107-2110,2cm67%4cm4%,GoodE.JACC2005;46:2107-2110,实时检测食道的位置更为重要,GoodE.JACC2005;46:2107-2110,CARTO-Merge,Navix,改变消融策略,Pappone:左房后壁温度低于55C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55C射频功率应在30-50W1030S：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45C射频能量应低于30W左房顶部消融线前移,食管内温度监测,PerzanowskiC,etal.JCE,2006;17:166-170,食管内温度监测,PerzanowskiC,etal.JCE,2006;17:166-170,CummingsJE,etal.Circulation.,2005;112:459-64,食管内温度监测,CummingsJE,etal.Circulation.,2005;112:459-64,温度探测电极,食管内温度监测,CummingsJE,etal.Circulation.,2005;112:459-64,食管内温度监测,CummingsJE,etal.Circulation.,2005;112:459-64,食管内温度监测,CummingsJE,etal.Circulation.,2005;112:459-64,食管内温度监测,CummingsJE,etal.Circulation.,2005;112:459-64,食管内温度监测,CummingsJE,etal.Circulation.,2005;112:459-64,食管内温度监测,不同能源：冷凝,溃疡发生率：冷凝：0/44（0%）射频：9/44（22%）,心内超声（ICE）,心内超声（ICE）,食管内冷盐水灌注球囊,食管内冷盐水灌注球囊,IB:intraesophagealballoon食管内球囊LET:luminalesophagealtemperature食管腔内温度,Tsuchiya.Atrialfibrillationablationwithesophagealcoolingwithacooledwater-irrigatedintraesophagealballoon:apilotstudy.JCardiovascElectrophysiol.2007Feb;18(2):145-50.,食管内冷盐水灌注球囊,Tsuchiya.Atrialfibrillationablationwithesophagealcoolingwithacooledwater-irrigatedintraesophagealballoon:apilotstudy.JCardiovascE