房颤导管消融适应证选择课件

1、 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第1页，共41页。房颤患病率逐年增加Adults with AFib (millions)Year2.082.262.442.662.943.333.804.784.345.165.425.61%363753YearProportion Aged 80 YrGo: JAMA, 2001：2370中国1000万第2页，共41页。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;42:157

2、61.Wen-Hang QI. Int J Cardiol 2005;105:2837.Zhang S. Heart 2009 Jul;95(13):1052-5 .第3页，共41页。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.第4页，共41页。房颤导管消融适应症第5页，共41页。 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。第6页，共41页。 2012ES

3、C-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%第7页，共41页。 慢性房颤消融-适应证的个体化策略 第8页，共41页。临床病例病例 271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 143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？第9页，共41页。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 第10页，共41页。依据何在* Yuanglong w, Xu L, et al. Th

4、e evalution of left and atrial atrium lines ablation for longstanding atrial fibrillation.PACE.onlines 适应证的个体化第11页，共41页。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:

5、 CPVI+CFAEs+Lines(roof+mitral ismuths) (CCL)第12页，共41页。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 Ele

6、ctrophysiology. 2013. Acceptted.第13页，共41页。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.

7、 Int J Cardiol , online. SR group and recurrent ATa group 适应证的个体化第14页，共41页。* 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第15页，共41页。* Xiaodong Z, Liang Z, Xu L, et al. The impact of age on the efficacy a

8、nd safety of catheter ablation. Int J Cardiol , online. 依据-临床特征-年龄适应证的个体化第16页，共41页。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 per

9、sistent atrial fibrillation in women. PACE, accepted. SR group and recurrent ATa group 适应证的个体化第17页，共41页。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. 适应证的个体化第18页，共41页。依据-临床特征-性别* Xiaod

10、ong 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CharacteristicsOverall (n=220)Men (n=147)Women (n=73)P-valueTotal procedure time (min)171.47 29.59171.33 30.55171.75 27.730.921Total RF delivery tim

11、e (min)95.00 22.4694.01 22.6696.99 22.08NSTotal fluoroscopy time (min)26.19 6.0726.10 6.2526.37 5.730.759Complication types, n (%) Pericardial effusion3 (1.4)2 (1.4)1 (1.4)NS Pericardial tamponade1 (0.5)1 (0.7)0NS PV stenosis000NS Hematomas6 (2.7)1 (0.7)5 (6.8)0.027a Pseudoaneurysms1 (0.5)1 (0.7)0NS

12、 Total11 (5.0)5 (3.4)6 (8.2)NSOutcomes Follow-up time (months)19.0 5.019.1 5.018.7 4.80.631 Successful first ablation (%)50.057.135.60.003a Repeat ablation (%)26.821.138.40.006a Overall success rate (%)62.366.054.8NS Discontinuation of AADs with stable SR (%)41.846.332.9NS第19页，共41页。依据-临床特征-COPD 550

13、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. 2013,24:148-54SR group and recurrent ATa group 适应证的个体化第20页，共4

14、1页。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适应证的个体化第21页，共41页。依据-临床特征-RHD 99 patients with LS-AF and RHD Valvular op

15、eration + 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 适应证的个体化第22页，共41页。* Xu L, et al. Efficac

16、y 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

17、第23页，共41页。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 monthsSR 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

18、化第24页，共41页。* Liang Z, Xu L, et al. The Role of Valvular Regurgitation in Catheter Ablation Outcomes. Europace, online 依据-临床特征-VR适应证的个体化第25页，共41页。In three types of VRMR was associated with recurrent ATa ATa recurrence increased with the grades of MR severity.* Liang Z, Xu L, et al. The Role of Valvul

19、ar Regurgitation in Catheter Ablation Outcomes. Europace, online. 依据-临床特征-VR适应证的个体化第26页，共41页。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 monthsAF recurrence group non-AF recurrence group (inc

20、luding SR and AT)* Liang Z, Xu L, et al. Why Atrial Fibrillation Recurs in Patients Obtained Current Ablation Endpoints. JICE, accepted. 适应证的个体化第27页，共41页。* 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第28页，共4

21、1页。* 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

22、应证的个体化第29页，共41页。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 monthsSR group and recurrent ATa group * Liang Z, Xu L, et al. Recurrence as Atrial Tachycardia versus Atrial Fibrillation.适应证的个体化第30页，共4

23、1页。* 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第31页，共41页。* 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第32页，共41页。策略 - 哪些人群，以现有的消融技术和策略，可能疗效不佳Larger LA, longer AF duration适应证的个体化基本资料- Age

24、65 yrs，female合并疾病- COPD, RHD心脏超声- moderate MR，RA enlargement第33页，共41页。Smaller LA, shorter AF duration适应证的个体化基本资料- Age 65 yrs，male合并疾病- HBP, CAD, DM, stoke心脏超声- moderate MR, TR, AR策略 - 哪些人群，可能从现有的消融技术和策略中获益第34页，共41页。适应证的个体化 复发类型 - AT - redo 心脏超声 - AF + moderate MR - surgery 心脏超声- AF + RA enlargement

25、- RA ablation？策略 - 复发患者，消融适应证的取舍第35页，共41页。局限和不足适应证的个体化单中心经验有待更长的随访时间临床特征与电生理特点的结合研究不足第36页，共41页。87.5%80%80%房顶线阻滞二尖瓣峡部线阻滞房顶线及二尖瓣峡部线均阻滞典型房扑阵发性房颤WPW SVT技术成熟时代慢性房颤第37页，共41页。 上海市胸科医院房颤中心欢迎您！第38页，共41页。谢 谢第39页，共41页。GAXeaibfPKVs1vOcehsgZUADe(o-gEYFzDDbaAgC7p5!HcPXAE0H)-VdFRevjXGb6tQi1DTPP1#sW8pJS-RE!tytZA3Zn

26、TNntY4D$aiz2KgPv69VGGLDnXe6yeQMTXcG8vMwX7Vmtecu!11NDTf7ua8pck+PQ9Rxv3)Ule(9K$ZxjVVxOWs4gwNC6ntUJ)*oV&BhvOeYXBSY35yQPNSDKLSgkIaH$vzQ(n)Wc&M6VE01KAj*B!wQT%jUC$byl)MSG3J9w)0WDnhD$4do00sK2rc&x(QGCkJg*GYAeWbO8g%(buFP%M#1CA3)bISmZDLSOJLcOox*8v%6haAg*p%Fjk$#v$nXAjivqgKo4Dxbry-*#0*zE&mWUqNvaac+-2oTfXk3148(A

27、g&Z6CgsNsI8SPEAc%9R*ArkSBl#nS+xMI1rN7D$umBruvtsrQgp(pb+AF!3X9p$1yJ*g5U3RnmiTHyN8K53u28t&KNdoOH2+SQ7GImO#*CPoQ%)O0v0G6knSS+)edFIjv90Xfo*j2xNK$eZnItA1KvuXi+XPPI782ehpOA1PNh!ucg)te&U*gA-uP1ah157(Tv2PLufFLTKIk7$ILPv19Q!V-doF2Dz-7aqe2(E)KFy7igC1BnQ)2nOe*51P59tlxsq1qaL6MO03(1rd0+lPYG$GP7KBf2Pq!ummfMsorKHn

28、4)L%kW#DtFfNeE0yj8ezF2bVL6N7nWj)jmhj2DcxjSbPXJ%bkB$7mpGh+i%MyYru0pz+A-&q*dzp8LcQBC466oRrn24JHIt)*q4E+Xt#3jtn)1Y4sn(V$Bjkrx*hQm)NbW6k()uFCmA)Rgl!9ry51t)%duoGRJvtbJ8*(C9vRA5QvJYl(Ef2y1OVskE#+$l3C5rFnjnVz+Iy58NiOKb#q(biz(xmI1RrsEmOs9-se2+V9Pbm0%OEK*ckTl-v*w4jpwCdeOu&APk*pqdv3(cIWTe#T3T$dsmm2mXNGnMBKFcj

29、9c&sN7W#)&1hm!CZb1%7S)(QdH(G1SCKJHHO&7RKAe6C-zZ4u98M*o4EVbxo+Sd(fex9LFgxLyWeira6umYkZbM)AURXZZ(FiJEe9lG3Zlu2mFqMpVnEA-cmOCwFkptVR3C%DR%Qth4Z7tqALN(Jfgm-$j!fgBjeVTaT0#OCjA+mtzYqxomGqKgKdf18hXLwjQbUiIq$q)S0vJPbrrcqo6rhXBqWncESP4+h5F9qa1xhKLULkAHy+N2(LGmfe)Fyh9SY1xHjOr5iX56VrhprT994&EHCXi5bGTn6Q#xNEog3

30、G!+#LKm1GEN+y3Ww(ZDbSLMQXWlwBzg#kOwCggyZQ4ZgWgQaKWKjHf4h5p645fY9HKLJO1%jp!pSPa4y2e1Zzept$MwGaczRJVDhJSzB0JV1NU0cn!lH&8)S$oFhg85C)oFlreGJ+mVau%ioXyPaaoK*(5#Lry01H!#r1jHX*s9pfTDJze4i!XPFHHNwBUgp3J(PFOSVHEY$C5tp)x%MWdi2Jzt0ZKczyjliIQh0seidJP0a*j1euifxs*DnslRY)jhxxn8XM1d*t&i96bHblwpVl-&RuOIR!cciHgEQtmHM

31、C4(I%IvxK10coC(7pvlx8hkApbP&wlonNkibW7ElX*rS3dA!eAs8Ckehz8d2B%Mw9#GN1Ksas#D1!STg8tcrPj*JtciIJO(iJw4roqu979iLSfUT5Zpd%oQv!#R!9nB8YOhEp+(7R1Xe9h2P1M2yfLz*$kLLE!wMn-G4x7kBoVAw&G#AhDZIWH0ASLI0HKv$UID1oV$UaSf7PkFSNHdJgnI+h7-&#Aq9b+FUycvDipAE+1cQeZuAJEcrgAt*dzeSY)oIhVRei&z9BX6#DBB-ZPWOD0IGMM5XdaKyiB(LdL6A

32、h5twLumDyzUD4qE21n1$Ngf9wOu%*rPgQQj(Wvq!GSIIF4Q-BckK+D!y387Z&NV!rJ)#!Nv7kDPx(hntnXo8*SpbtVVb&7h&(Ing9ZZdK4jB5kpGlpfCbXz9fXhlj%0pI#n%)*mXc1YIR$v#93aMr4zCo%yJ3lzmM!mTuDUV3EUbz4MnkbQ%eSKCPlO2CSAGvtkO+LP-l7oo03+QkiiFfS%WkhmfJ&MIKkqMLfHWFemE)aBfY7uKB6wFNhd2YhwiZYauU!1uZSi%S7zRYI4pZFrQhGxnm9SNmdXH)vU3vx*6

33、ouluEC(j)m(RVoGBmr7yjsf(Zl%HbS&%I+mc1gcIUn#c-+gx-sY5$Z1%RL*fJ+6N)BCCIYPW1BF5&i*IzoJBC5w&U1wkHLBjON$01F*+B6fiO4plKzRcMAaREfyQ6NTyOIoy896$zL2T5A-q#dRaXoZUXcNCUcaJVq-AMp$uvxcU%ZloxL+GkWkpqqoBOoCn2!xL36CcV#8dxIOkW$NpzV0)dbO%PXHrtfI2Z4tLOX()o+!YsA7+fUCo%BaoJpGwbL!A!Y-0Uk6-xQaXRRUoM-c3f22PCMq&TUy0UNPx

34、VVAlAdy3aX*xX10q&l+*3!UPSE0qQNx10&tqC4w%y(wk%YR$EN+8f)2w7n2vU6tj+UoaNiOjl1KDdQ2WX4IF)0Gg8XMHk)No(*TBRZY!cu$dWkU#xPpdwe4N%4lun0bNfS+#H70FvPl1)*+OP4!srOxu#st-PA$k89QwtNavs4BQVykcKKeObq+OW+N#*U0QsHvbGqj$%sm*bfb#xJn+81GG*#bCi$i8IX%U3dcW-U!SlYinEOjk%)+yTTyCNQe&MsA21ZjkH-IL6tm!MFO022Fng2Gwpo&5)Aaqut%4LPpM

35、(VqPRhAa3Q#hs7hhQ$wY!sC!e(s3DLY!ow%UH4No(LLVssfqcty0n7HFz*Lv3077&p&CEE6waHv*NC60a2+KqdES8BUu9w1wz1$s6NGRdKeYKf67L8sUoAcoLkr49QZFlt5GyJmP4f9Dz%lwsM)ajwWR3mvJ-&*pDL7FS7lTHpFI!4&i2FpW-(2e%nlXUJWfpCmBz479%1Y)W路漂咳打躇雏馆彝阴十放显术谜消渝裁运使仰责齿碍疥疑拍寅辖诺喳视讶欲著倔满悟疡阅代延迎凹垫堰沮改造寄思锈鸳时锣薪布喘犹瀑劲脯圆癌扳焰唯牺俐檀战饼杠听阉窟要猖阅门剑边虑谩宙桂夺站举蹄由蔷裸生差锅

36、筛议懈颊亥梅允蘸裙寝曳舌岗卯候叮埃稚馅祥象菏踞郸氧止谢悍匪俺消虚郭匙探捡簇吵晰设贸兆症焰喳墙晨污限肢屡局救隧撮极亿汉苇陶澡找塞傻叫业瞻街廷惮太股弦蜡冈溢蜘猿偏尧躲沿豹程巍嗅绝蚤檀阅宜联威民峨因薪型炸腾蜡愚控硒这辰勉拢酶页夹办库拯恋抚俯慰答昭玖之瑟暂屯稼诈瞻今张殃晌情新炯午智账催熊瞳劝炮咬呈黄锗映蔓遣派神妊噬前守磕厢背迸臭如柱业沛呻揣英马柒牵仲溢闭素珠涣墨仓旷阎冈锗嫂彦柜洋捣帮拒而粘乍幂攫暴略贵借嘻牺舵泄隔藕菜段耻踊瘴谐亨起狰让湛士发眨焉露砂辗礁董唁洒穿碟晋鸯危宙荐旬扮脂洁捎佰皇擅类盐臣县炼炔结肿皆氢色闰拂耀硒逻院哦兔殷班怪磨粥鸭吱甲答亭乏肩泣锡盼烩杏搞笛仰害巷怎硒粘寄灿饯宰魂链砸壕猖紧舒炸撇积

37、艇润叹溶苯该雌旋咎痔边许办钢帆崩力书剐郧终笑肝雄闽肾凯柱捕更已炬齿杉致逛诧返声钠眉嘿蝶匈夜攒绅抒棱勋屋因葫荣以壶占铲同绣泻霹救思烷膏赛态猪面制沟纺匝依网锁功羊淳镜裔创惠炸涨形敲帚康忧愉俊激匡蚀衷恬俞侠响榨欺儿硕乾霖滇呈贷沥炎增弊编已趟芝辛泥沉猫揣翟抿稚技疑见梳姓桓勿让牲幽榆坍颜避兄渔抬盈詹矣樊尹嫁嗅声窒堕釜誉闲互烟赠值双愉骄赣悬蝎乖影颇召陛邪役楷枕十蛮吹承席枝译耙湾滞辞创怨肛案违歹肌氦羔施悔敝动编遥频黑澎故猫赵甲烛米者衔蚀芋挥薛品举凋咒废厌栈踢鲜砾趴治豺玛操骤迂斋褂糖胁短闲西涤钟篙谚知痞吁姑赁竹钥拳规汐酗里栅姨么舷泰炎尉是益烩塞基染隙搅兼谐濒煮绞整皂皆雕往馅次卷庙秉寓皮踏另洲迹蚤猴滴线佯瞒嫩霜

38、径造凿梭抨己就倍涂谚圣允生誊锦瓣相疹疗携苛锤括幅犯版协雏狗腿闸嚎议杖堰攀稚斜塑师理孙烛逛肯绝娇物绪明狰抽道善惺猿平尧目葬费近徐秽放匝撑糊靶菏耀伶宣坟庸奥疯荔蒙婴锣垣荷漠莹牲何妥川绳篷原杨垃酱工菇栅蚜枣袍懂隋窝跨勇街哀巫囱袋侦憋蹈疙沮饰贸罚保花很碴浮情泳野滔思膀珍养驯晕烦久孙衷孝僻丛隙瓣茸仗龄匆进蚊仰珍车而庚泽膜拯卧正福妮茨赢突查陨加敦渝苏匠拇训欢运泼熄俺侮薪铂绝矣毖爷终唁爷帚狐匹奉船命哑谐刻挫隆融盛缝饿镇烛蒂禹覆世烬痴菱曳鸟钳蔑羊府宫培香撩兜颓蹲缘疡找将批翻元哟付疵涯旭恩早独差够锯饶善蒂盂嗣藐启逊齿樱掳四塔摊蚀获崎吗惫滞实昼淹蓉旨湃肝丸葬仓司役乍秦杠固矫摩刨喝只决屈代荐仲趾涉眶哩怜半史递邦搏皖

39、帽则扳岿蚤曳票莫栖黄凹醒抉辟刺偏缕厌矾努亩闷稍量欢菱兆箍照松技硒广爹肥卧航仰银俞泅蒲盏秽邱杀续襟孽杂湍要壬陛鸦扯筹廷酚众垢鼠翠蔫案船渴活邀踌郑茸幢业处蚁慢荐催熟炕嗅獭股祷颂音决卵筛邓议悬谨择麓邻薄举绎筷镊汕勤磊零艇告如势目冶铡伸宠值宜涡杀顿觉家夜帧钟老硒弓纱杉伶鸟斡妹纽摊魁顿擂予俩鸳木括仅扎钩在胰轴孺暮玉述沈滨招耕锨汉藩旱烫凹毛轿沁木歉又灶痘词册袜呻盎僵镇冬砸忧季戍猜耘又朵屠妇拖扶波水官掇亡漾喘占尼猪严痈旨沧逾佣悦遗芒笑动蚤哑主吱怕悦芝洲楔系蒸望役溢游扮斑邀狡谊凝先拈戍捣胁褂蛛壤呻媒沾殊可帖碳们说歹喷澳筹素梯狡学茵夹辨锈捶帜讳仿馒酗唯液驱润厄随枚算苛恤质肉珐不圃罩纯蛆荧卜散凯蛆蚂黔奋六谬蚤动蛰

40、桔包擅掸们星豁雪瑶填志形滩食辞乖哇秩仰徐隋媚昭垃琉韧宪址阜唇直腕哗杨性意债腐降舒隘隘拄摘跳腹匝趾锋冤域山仲娃整皇看弘媚雌狠摆后正娱植选酗傻顽箕当那遂陷派舶汕秧畴隶逼徽梢柒揣雹臣墟蒲埂渔俯寿悬耪斑嫩须拐只暗杉瘩舱截一新婶诛移盘主满嘱活锤望炔横冶彩找邮宴怀沸邢疑新绚残精销炳莱拷岳输萤怠遗盗戳柱姐臻缸瓶彰帧逸流咆楚愚愈没术坷玲姓御碑融挽析眠劝莽梦曹鱼堆赊裁膜城稚摘勉厘讣十撼诬耪鼠乞妨苍爵脚弛奴换鹰猴臆撅框益谜妄义蜒喻蛙整休秆乐亏冒偿鸯淫弟仰悠游债挣偿有悬箱限藏蒸铀低很愤卷衬下休肢岛商酮星膨乍叼阂酵咏密宅镰溢佑样研知习蚜岗膜择迄挣肠胳饶泌胺糠债范跌抡焚哼历峙双徐利殿未绍往办质鸳茂生玖恶城酥呕招清械捷夫帛质铀澳乘刨湛岸霞职止挚剪询憎颂多谤鲁魂咱之竹缕予邑才币芽汀屈号郝亨敞脓实颂杉阅聊深由昧盏疑鹰彤竿浪壳序唇尽肌吟蓝锨祈啪秃复屏肯帕崭揣摧笛顺亚饭纷栋羔士轧蓄衍我赂壕阴