房颤的基质识别及价值

1、心房颤动的基质识别及价值,南京医科大学第一附属医院 心脏科 陈明龙,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”,PV,LA,Lighter (trigger),Wood (substrate),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”,复杂心房碎裂电位的定义(Complex Fractionated Atrial Electrograms,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1

2、0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120ms CFAE电位振幅0.05mv0.15mv !,Nademanee K, et al.Heart Rhythm 2006; 3: 981-4.,Collision,Slow conduction, functional conduction block, and pivot points are associated with CFEs （Konings, et al）,Am J Cardiology 1996; 77:10A-23A,复杂心房碎裂电位的定义(Complex Fractionated Atrial

3、 Electrograms,CFAEs),CFAE部位的电生理特点,CFAE部位电压低，围绕以高电压区,Park JH, ,et al.JCE. 2009 ;20(3):266-72.,CFAE部位的电生理特点,CFAE的传导速度延缓,Park JH, ,et al.J Cardiovasc Electrophysiol. 2009 ;20(3):266-72.,CFAE与自主神经过度兴奋有关,CFAE与GP,Lin JX,et al. CEl, 2007;18:1197-1205 Lin JX,et al. JCE, 2008;19:835-842,CFAE分布的影响-药物,Reddy et

4、 al.JCE,2010,碎裂电位分布区域的动态变化,Baseline,Post PVI,Post PVI+Roof,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,Roux JF, et al. Heart Rhythm 2009; 6:156,Lin YJ, et al. Circ EP 2009; 2:233,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,阵发性房颤碎裂电位消融的争议,阵发性房颤：CPVI+CFAECPVI,Deisenhofer I, et al.J Cardiovas

5、c Electrophysiol. 2008,19m,74%,83%,PVAI,PVAI+CFE,AF/AT Free Survival (%),Survival free of AF or atrial tachycardia without any antiarrhythmic agent (probability value for log-rank test) for intention-to-treat in PVAI and CFE ablation approach. Kaplan-Meier survival analysis of freedom from AF or atr

6、ial tachycardia without antiarrhythmic agent after 3 months “blanking period.” Solid line and dash line represents outcomes among those randomly assigned to PVAI ablation and CFE ablation approach, respectively.,3/24,6/35,5/58,13/58,40/58,2/35,12/24,9/24,27/35,AF/AT Free Survival (%),Survival free o

7、f AF or atrial tachycardia without any antiarrhythmic agent (probability value for log-rank test). Kaplan-Meier survival analysis freedom from AF or atrial tachycardia without an antiarrhythmic agent after 3 months “blanking period.” Blue line represents outcomes among patients randomly to PVAI grou

8、p (G2), green line represents outcomes among those randomly assigned to Cross-over group (G3), red line represents outcomes among those randomly assigned to CFE group (G1). The difference in the rate of free of recurrence among the three arms of the study was significant (P=0.0008).,381例持续性房颤; SNR:

9、76.4%,100 例慢性房颤；SNR 33%(1st); : 57% (2nd),持续性房颤消融的争议,持续性房颤碎裂电位消融的争议,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103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,Oral H, et al, JACC, 2009; 53:782-789.,长时间持续性房颤：CPVI+CFAECPVI,Conclusions: up to 2 h

10、 of additional ablation of CFAEs after APVI does not appear to improve clinical outcomes in patients with long-lasting persistent AF.,119例CAF，CPVI,100例AF,复律，50例,CFAE ABL，50例 9例SR,19例SR,15/19（79）,17/50（34）,18/50（36）,Oral H, et al. J Am Coll Cardiol, 2009;53(9):782-9,Natale, et al.Heart rhythm,2008,RA

11、STA Study,Randomized Controlled Trial 1 year Follow-up Evaluate the single procedure efficacy of Per-AF,Per-AF (n=156),Group2 (n=50),Group3 (n=51),Group1 (n=55),PVI PVI+Lines PVI+CFE,PVI PVI+Lines PVI+CFE,*P=0.04,*P=0.004,RASTA Study,Primary Study End Point: Freedom from AF/AT off AADs,29%?,碎裂电位的本质,

12、真正的“房颤巢”AF substrate 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,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,Comparison of Left Atrial Electrophysiologic Abnormalities during Sinus Rhythm in Patients with Paroxysmal, Persistent and Long-Standing Atrial Fibrillation,Par-AF: 30 pts Per-AF: 22 p

13、ts LS-AF: 28 pts Control: 20 pts with LAP,Mapping Methods,A-Focus high density mapping during sinus rhythm Mapping was done after CPVI, Per-AF and LS-AF need cardioversion NavX: interior and exterior projection, interpolaration were set at 5 mm LA voltage, activation time and complex electrograms we

14、re analyzed,Comparison of the LA activation time among different populations,The correlation of LA activation time with overall mean bipolar voltage, left atrium diameter，low voltage index and percentage of complex electrograms,Definition of Complex Electrocardiogram,Distinct deflections 3 Electroca

15、rdiogram duration 50 ms, 50ms,A: Comparison of the percentage of complex electrograms in LA. B: Comparison of the mean bipolar voltage of complex electrograms. C: Comparison of the duration of complex electrograms.,Study Findings,With AF progression there was a lower mean bipolar voltage, higher low

16、 voltage index and more prevalent and larger LVZ area in LA With AF progression there was also conduction abnormalities characterized by prolonged LA activation time and more proportion of complex electrogram The cutoff value to define low voltage zone (0.10.4mV) and the transitional zone (0.41.3mV)

17、 was defined,New ablation strategy,Novel ablation strategy for Per-AF,CPVI,Cavotricuspid isthmus ablation,LA high density electroanatomic mapping,Substrate modification,Check linear lesions to achieve bidirectional block,To double check PV being isolated,Cardioversion,CPVI+Substrate Modification,LA

18、Voltage Mapping (color 0.4mv-0.1mv),4mv,Case-1 Presentation (1 year history of Per-AF, 52y Male),Substrate Mapping (color 0.4mv-0.1mv),PP: 2.00mv,PP: 1.85mv,PP: 2.50mv,PP: 12.00mv,PP: 8.90mv,Ablation Strategy: No additional lesions besides CPVI and CTI,CTI,CTI,PP: 0.36mv,PP: 0.12mv,PP: 0.25mv,PP: 0.

19、17mv,Substrate Mapping (color 0.4mv-0.1mv),Case 2: 49y male 4-year history of per-AF,Substrate Mapping (color 1.3mv-0.4mv),Substrate Mapping,CTI,CTI,Ablation Strategy,ABL-d,ABL-p,ABL-d,ABL-p,Case-3 History,58 years old，Male 2 years history of palpitations Echo(2012-6-25): LA RA Enlarge, LAD 53mm, LVDd 46mm, LVEF 53.5% Holter(2012-6-30): Persistent AF Refractory to Beta-bloker,0.11mv,ABL-d,0.13mv,ABL-d,LA Substrate Mapping (color 0.4mv-0.1mv),0.56mv,ABL-d,1.18mv,ABL-d,0.54mv,ABL-d,0.42mv,ABL-d,0.80mv,ABL-d,LA Substrat