房颤的基质识别及价值

房颤的基质识别及价值演示文稿当前第1页\共有64页\编于星期三\5点心房颤动的维持基质肺静脉及其前庭－－天然基质非肺静脉区域主频区域ROTOR迷走神经节碎裂电位区域窦律下的“低电压区”和“复杂电位区”当前第2页\共有64页\编于星期三\5点PVLALighter(trigger)Wood(substrate)当前第3页\共有64页\编于星期三\5点持续性房颤的基质？除肺静脉及其前庭外，持续性房颤的基质碎裂电位区？多个rotor窦律下的“低电压区”和“复杂电位区”当前第4页\共有64页\编于星期三\5点复杂心房碎裂电位的定义

(ComplexFractionatedAtrialElectrograms,CFAEs)心房波的碎裂电图由2个或2个以上的波折组成和/或心房波连续10秒以上无恒定基线且伴有延长的连续心房激动波连续10秒心房激动平均周长≤120msCFAE电位振幅0.05mv~0.15mv!!NademaneeK,etal.HeartRhythm2006;3:981-4.当前第5页\共有64页\编于星期三\5点Collision,Slowconduction,functionalconductionblock,andpivotpointsareassociatedwithCFE’s

（Konings,etal）AmJCardiology1996;77:10A-23A复杂心房碎裂电位的定义

(ComplexFractionatedAtrialElectrograms,CFAEs)当前第6页\共有64页\编于星期三\5点CFAE部位的电生理特点CFAE部位电压低，围绕以高电压区ParkJH,,etal.JCE.2009;20(3):266-72.当前第7页\共有64页\编于星期三\5点CFAE部位的电生理特点CFAE的传导速度延缓ParkJH,,etal.JCardiovascElectrophysiol.2009;20(3):266-72.当前第8页\共有64页\编于星期三\5点CFAE与自主神经过度兴奋有关CFAE与GPLinJX,etal.CEl,2007;18:1197-1205LinJX,etal.JCE,2008;19:835-842当前第9页\共有64页\编于星期三\5点CFAE分布的影响-药物Reddyetal.JCE,2010当前第10页\共有64页\编于星期三\5点碎裂电位分布区域的动态变化BaselinePostPVIPostPVI+Roof当前第11页\共有64页\编于星期三\5点并不是所有的碎裂电位区域都代表房颤的触发或者维持部位，部分碎裂电位是被动激动RouxJF,etal.HeartRhythm2009;6:156LinYJ,etal.CircEP2009;2:233当前第12页\共有64页\编于星期三\5点碎裂电位的本质是什么？哪些碎裂电位需要消融？哪些病人需要做碎裂电位消融？怎样消融碎裂电位？碎裂电位消融的思考当前第13页\共有64页\编于星期三\5点房颤类型术式

例数年份总成功率NademaneeetalPAFCFE57200482.5%PorteretalPAFCFE42200888%VermaAPAF+CAFCFE34200829%KhaykinetalPAFPAVI30200957%PAVI+CFE3027%DeisenhoferetalPAFPVAI48200974%PVAI+CFE5083%DiBiaseLetalPAFPVAI35200989%PVAI+CFE3491%CFE3423%阵发性房颤碎裂电位消融的争议当前第14页\共有64页\编于星期三\5点阵发性房颤：CPVI+CFAE≯CPVIDeisenhoferI,etal.JCardiovascElectrophysiol.200819m74%83%PVAIPVAI+CFE当前第15页\共有64页\编于星期三\5点当前第16页\共有64页\编于星期三\5点当前第17页\共有64页\编于星期三\5点当前第18页\共有64页\编于星期三\5点当前第19页\共有64页\编于星期三\5点当前第20页\共有64页\编于星期三\5点当前第21页\共有64页\编于星期三\5点当前第22页\共有64页\编于星期三\5点当前第23页\共有64页\编于星期三\5点00255075100036912151821242730Time,monthsPVAICFEP=0.075AF/ATFreeSurvival(%)SurvivalfreeofAForatrialtachycardiawithoutanyantiarrhythmicagent(probabilityvalueforlog-ranktest)forintention-to-treatinPVAIandCFEablationapproach.Kaplan-MeiersurvivalanalysisoffreedomfromAForatrialtachycardiawithoutantiarrhythmicagentafter3months“blankingperiod.”SolidlineanddashlinerepresentsoutcomesamongthoserandomlyassignedtoPVAIablationandCFEablationapproach,respectively.当前第24页\共有64页\编于星期三\5点P=0.395P=0.002P=0.008P=0.218P=0.626P=0.590P=0.034P<0.001P=0.0143/246/355/5813/5840/582/3512/249/2427/35当前第25页\共有64页\编于星期三\5点AF/ATFreeSurvival(%)0255075100036912151821242730Time,monthsG2G3G1SurvivalfreeofAForatrialtachycardiawithoutanyantiarrhythmicagent(probabilityvalueforlog-ranktest).Kaplan-MeiersurvivalanalysisfreedomfromAForatrialtachycardiawithoutanantiarrhythmicagentafter3months“blankingperiod.”BluelinerepresentsoutcomesamongpatientsrandomlytoPVAIgroup(G2),greenlinerepresentsoutcomesamongthoserandomlyassignedtoCross-overgroup(G3),redlinerepresentsoutcomesamongthoserandomlyassignedtoCFEgroup(G1).Thedifferenceintherateoffreeofrecurrenceamongthethreearmsofthestudywassignificant(P=0.0008).当前第26页\共有64页\编于星期三\5点381例持续性房颤;SNR:76.4%100例慢性房颤；SNR33%(1st);:57%(2nd)持续性房颤消融的争议当前第27页\共有64页\编于星期三\5点房颤类型术式年份例数总成功率NademaneeetalCAFCFE20046470.3%OraletalCAFCFE200610033%EstneretalCAFCFE2008238.7%PVAI+CFE5440.7%OraletalCAFPVAI20095068%PVAI+CFE5060%持续性房颤碎裂电位消融的争议当前第28页\共有64页\编于星期三\5点PVAI基础上进行CFAE消融的价值100例长时程持续性房颤（PVAI）后房颤未终止的患者随机分为两组

复律后结束手术

再消融左房及冠状窦CFAE单次消融后平均随访10±3个月直接复律组成功率36%;联合成功率34%结论：长病程持续性房颤，PVAI基础上辅助CFAE消融无助于提高成功率

OralH,etal,JACC,2009;53:782-789.当前第29页\共有64页\编于星期三\5点长时间持续性房颤：CPVI+CFAE≯CPVIConclusions:upto2hofadditionalablationofCFAEsafterAPVIdoesnotappeartoimproveclinicaloutcomesinpatientswithlong-lastingpersistentAF.

119例CAF，CPVI100例AF复律，50例CFAEABL，50例9例SR19例SR15/19（79％）17/50（34％）18/50（36％）OralH,etal.JAmCollCardiol,2009;53(9):782-9当前第30页\共有64页\编于星期三\5点Natale,etal.Heartrhythm,2008当前第31页\共有64页\编于星期三\5点RASTAStudyRandomizedControlledTrial1yearFollow-upEvaluatethesingleprocedureefficacyofPer-AFPer-AF(n=156)Group2(n=50)Group3(n=51)Group1(n=55)PVIPVI+LinesPVI+CFE当前第32页\共有64页\编于星期三\5点

PVIPVI+LinesPVI+CFE*P=0.04*P=0.004RASTAStudyPrimaryStudyEndPoint:FreedomfromAF/AToffAADs29%???当前第33页\共有64页\编于星期三\5点当前第34页\共有64页\编于星期三\5点碎裂电位的本质真正的“房颤巢”－－AFsubstrate心肌纤维排列紊乱或纤维化区域的各向异性传导及缓慢传导－－肺静脉前庭、后壁心肌排列重叠区域－－间隔、冠状窦当前第35页\共有64页\编于星期三\5点代表房颤基质的碎裂电位低振幅的碎裂电位单极记录持续负向的碎裂电位比较固定的碎裂电位当前第36页\共有64页\编于星期三\5点ComparisonofLeftAtrialElectrophysiologicAbnormalitiesduringSinusRhythminPatientswithParoxysmal,PersistentandLong-StandingAtrialFibrillation

Par-AF:30ptsPer-AF:22ptsLS-AF:28ptsControl:20ptswithLAP当前第37页\共有64页\编于星期三\5点MappingMethodsA-FocushighdensitymappingduringsinusrhythmMappingwasdoneafterCPVI,Per-AFandLS-AFneedcardioversionNavX:interiorandexteriorprojection,interpolarationweresetat5mmLAvoltage,activationtimeandcomplexelectrogramswereanalyzed当前第38页\共有64页\编于星期三\5点当前第39页\共有64页\编于星期三\5点当前第40页\共有64页\编于星期三\5点当前第41页\共有64页\编于星期三\5点ComparisonoftheLAactivationtimeamongdifferentpopulations当前第42页\共有64页\编于星期三\5点ThecorrelationofLAactivationtimewithoverallmeanbipolarvoltage,leftatriumdiameter，lowvoltageindexandpercentageofcomplexelectrograms

当前第43页\共有64页\编于星期三\5点DefinitionofComplexElectrocardiogramDistinctdeflections

≥3Electrocardiogramduration≥50ms

>50ms当前第44页\共有64页\编于星期三\5点A:ComparisonofthepercentageofcomplexelectrogramsinLA.B:Comparisonofthemeanbipolarvoltageofcomplexelectrograms.C:Comparisonofthedurationofcomplexelectrograms.当前第45页\共有64页\编于星期三\5点当前第46页\共有64页\编于星期三\5点StudyFindingsWithAFprogressiontherewasalowermeanbipolarvoltage,higherlowvoltageindexandmoreprevalentandlargerLVZareainLAWithAFprogressiontherewasalsoconductionabnormalitiescharacterizedbyprolongedLAactivationtimeandmoreproportionofcomplexelectrogramThecutoffvaluetodefinelowvoltagezone(0.1~0.4mV)andthetransitionalzone(0.4~1.3mV)wasdefined当前第47页\共有64页\编于星期三\5点NewablationstrategyNovelablationstrategyforPer-AFCPVICavotricuspidisthmusablationLAhighdensityelectroanatomicmappingSubstratemodificationChecklinearlesionstoachievebidirectionalblockTodoublecheckPVbeingisolatedCardioversion当前第48页\共有64页\编于星期三\5点CPVI+SubstrateModification

当前第49页\共有64页\编于星期三\5点当前第50页\共有64页\编于星期三\5点LAVoltageMapping(color0.4mv-0.1mv)4mvCase-1Presentation(1yearhistoryofPer-AF,52yMale)

当前第51页\共有64页\编于星期三\5点SubstrateMapping(color0.4mv-0.1mv)PP:2.00mvPP:1.85mvPP:2.50mvPP:12.00mvPP:8.90mv当前第52页\共有64页\编于星期三\5点AblationStrategy:

NoadditionallesionsbesidesCPVIandCTICTICTI当前第53页\共有64页\编于星期三\5点PP:0.36mvPP:0.12mvPP:0.25mvPP:0.17mvSubstrateMapping(color0.4mv-0.1mv)Case2:49ymale4-yearhistoryofper-AF当前第54页\共有64页\编于星期三\5点SubstrateMapping(color1.3mv-0.4mv)当前第55页\共有64页\编于星期三\5点SubstrateMapping当前第56页\共有64页\编于星期三\5点CTICTIAblationStrategyABL-dABL-pABL-dABL-p当前第57页\共有64页\编于星期三\5点Case-3History58yearsold，Male2yearshistoryofpalpitationsEcho(2012-6-25):LARAEnlarge,LAD53mm,LVDd46mm,LVEF53.5%Holter(2012-6-30):PersistentAFRefractorytoBeta-bloker当前第58页\共有64页\编于星期三\5点0.11mvABL-d0