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 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 50W10 30S 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 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 JCardiovasc