房顫消融后誘發(fā)試驗(yàn)：方法及意義-王祖祿

房顫消融后誘發(fā)試驗(yàn)：方法及意義

王祖祿沈陽軍區(qū)總醫(yī)院全軍心血管病研究所心內(nèi)科PVs和LA!現(xiàn)階段房顫經(jīng)導(dǎo)管消融策略以PV電隔離為核心的策略

·節(jié)段性消融·PV電隔離＋左房線性消融以環(huán)PV左房消融為核心的策略

·CARTO/NavX引導(dǎo)消融電隔離

·ICE＋Lasso引導(dǎo)LA-PV消融電隔離

·CARTO/NavX引導(dǎo)LA-PV消融局灶性消融策略

·肺靜脈外局灶·心內(nèi)電圖指導(dǎo)(CAFE)·去迷走神經(jīng)輔助手段

·左房內(nèi)線性消融·針對(duì)右房基質(zhì)的消融

·隔離SVC·TA-IVC峽部消融HeartRhythm,Vol4,No6,June2007PV或PV前庭電隔離的局限性單次消融成功率低－PV電隔離30％～50％，多次70%－PV前庭消融60%～80%，多次≥90%～95%PV電隔離與否與成功率關(guān)系仍有爭論長期保持PV電隔離困難－消融徑線長，易出現(xiàn)漏點(diǎn)（gap）－消融能量受限（左房－食道瘺、心包填塞等）不同類型房顫消融效果不同－陣發(fā)性vs持續(xù)性vs長期持續(xù)性？基于PV-LA消融基礎(chǔ)上

可能提高單次房顫消融成功率的措施PV前庭電隔離vs節(jié)段性PV電隔離左房內(nèi)環(huán)PV消融vs左房內(nèi)環(huán)肺靜脈電隔離誘發(fā)及消融非肺靜脈觸發(fā)灶左房內(nèi)線性消融：頂部線、左側(cè)峽部線、CS內(nèi)/外右房內(nèi)線性消融：右側(cè)峽部線、SVC隔離心房碎裂電位（CAFE)消融去迷走神經(jīng)消融

房顫導(dǎo)管消融終點(diǎn)

完成主要消融靶點(diǎn)(肺靜脈電隔離、完整線性消融)消融中終止房顫消融后房顫不能誘發(fā)

不同房顫類型終點(diǎn)可能不同房顫不能誘發(fā)作為消融終點(diǎn)的爭議房顫不能誘發(fā)作為消融終點(diǎn)的爭議PV-LA傳導(dǎo)恢復(fù)為主要機(jī)制非PV機(jī)制--大折返房速/AFL--局灶性（SVC、CS、LA、RA、L/R-AA）#陣發(fā)性/持續(xù)性AF電重構(gòu)/解剖重構(gòu)，不同于陣發(fā)性AF?機(jī)制復(fù)雜、標(biāo)測和消融困難#慢性/長期持續(xù)性AF永久性房顫消融療效Earley,Heart200636%58%71%74%CARTO＋LASSO引導(dǎo)環(huán)肺靜脈電隔離OuyangF,etal.Circulation,2004,110LSPVMapCSHisLIPVRSPVMapRIPVCSHisRAOLAORecurrencesofatrialtachyarrhythmias47/174

(27%)ptsduringafollow-upof198

57days42ptswithreablation(2-193days):ATin35andAFin7pts36ptswithrecoveredPVconductiongaps

inleft-sidedPV′sin29ptsinright-sidedPV′sin23pts164/174ptsinSR(94.3%)after2ndpro.(F/U6months)Follow-up陣發(fā)性房顫患者導(dǎo)管消融結(jié)果

PVisolationwithCartoanddoubleLasso在大多數(shù)患者中誘發(fā)試驗(yàn)的意義？房顫不能誘發(fā)作為消融終點(diǎn)的爭議節(jié)段性PV電隔離－PV內(nèi)經(jīng)GAP傳出（局灶）－PV外局灶（常見左房頂部或右PV前部）左房內(nèi)環(huán)PV＋線性消融（左房后壁＋峽部）－大折返：

關(guān)鍵峽部分布在MA峽部、房間隔、左房頂部或CS）左房內(nèi)環(huán)PV消融電隔離－PV內(nèi)經(jīng)GAP傳出（局灶）－大折返（圍繞同側(cè)PV或MA折返）－左房－肺靜脈大折返房速階段性PV電隔離有經(jīng)驗(yàn)的中心隔離率可近100%臨床成功率20-93%(65%)復(fù)發(fā)原因

－PV內(nèi)經(jīng)GAP傳出（局灶）－PV外局灶（常見LA頂部或RPV前部）癥狀性PV狹窄/閉塞~1%不能誘發(fā)房顫對(duì)長期預(yù)后判定的價(jià)值？Ja?sP,etal.HeartRhythm.2006Feb;3(2):146-7.不能誘發(fā)房顫對(duì)長期預(yù)后判定的價(jià)值？

PVI+左房峽部線消融Haissaguerre,etal.Circulation.2004Non-inducibilitypost-pulmonaryveinisolationachievingexitblockpredictsfreedomfromAFPVIin102pt,paroxysmal59%,persistent32%,permanent9%Follow-upfor16+10mInductionofAFbyburstpacingon/offisoproterenolafterPVIRecurrence:70%at6mand62%at12mNon-inducibilityofAFpredictedfreedomfromAFat12mEssebagV,etal.EuropeanHeartJournal,2006,27:2553Conclusion:Non-inducibilityofAFafterPVIpredictsmaintenanceofsinusrhythm.ThisfindingsuggeststhatroutineextensiveleftatrialablationmaybeunnecessaryIsinducibilityofAFafterablation

reallyarelevantprognosticfactor?234pts,paroxysmal165,persistent69PVI83pts,CARTO-guidedleftatrialcircumferentialablation151pts67%ptswithparoxysmaland48%ptswithpersistentAFwereAF-freeInducibilityofAFwasasignificantpredictorofAFrecurrenceinbothparoxysmalandpersistentAFptsRichterB,etal.EuropeanHeartJournal,2006,27,2553Conclusion:InducibilityofAFafterablationisasignificantpredictorofrecurrentAF.However,owingtothelowdiagnosticaccuracyoftheAFinductiontest,non-inducibilitydoesnotqualifyasreliableproceduralendpointCARTO＋LASSO引導(dǎo)環(huán)肺靜脈電隔離OuyangF,etal.Circulation,2004,110LSPVMapCSHisLIPVRSPVMapRIPVCSHisRAOLAORecurrencesofatrialtachyarrhythmias47/174

(27%)ptsduringafollow-upof198

57days42ptswithreablation(2-193days):ATin35andAFin7pts36ptswithrecoveredPVconductiongaps

inleft-sidedPV′sin29ptsinright-sidedPV′sin23pts164/174ptsinSR(94.3%)after2ndpro.(F/U6months)Follow-up陣發(fā)性房顫患者導(dǎo)管消融結(jié)果

PVisolationwithCartoanddoubleLasso在大多數(shù)患者中誘發(fā)試驗(yàn)的意義？SustainedATs(>10min)17/60pts(28%)InducibilityofatrialtachyarrhythmiasaftercircumferentialpulmonaryveinisolationinpatientswithparoxysmalAF:clinicalpredictorandoutcomeduringfollow-upSatomiK,etal.Europace200810:949

Conclusion:InducibilityofatrialtachyarrhythmiasisassociatedwithproportionallysmallerisolatedareaanddoesnotpredicttheclinicalefficacyofCPVIinpatientswithPAF不能誘發(fā)房顫為LACA消融終點(diǎn)的價(jià)值？OralH,etal.Circulation.2004;110:2797-2801結(jié)論：與LACA相比，對(duì)心房內(nèi)碎裂電位區(qū)域消融可使房顫不被誘發(fā)，進(jìn)而增加中期竇律維持100例陣發(fā)性AF60例持續(xù)或可誘發(fā)AF40例未誘發(fā)＞1minAF30例停止消融30例消融碎裂電位成功率(67%)成功率(86%)成功率(85%)（LACA+左房后壁及峽部）（27例AF終止）小結(jié)房顫不能誘發(fā)作為消融終點(diǎn)的爭議誘發(fā)房顫的方法和定義OralH,etal.Circulation.2004;110:2797--CS起搏10mA,脈寬2ms,起搏15s至最短1:1心房奪獲5次--AF定義為持續(xù)>1minuteSatomiK,FOuyang,etal.Europace200810:949--CS起搏最大20mA,脈寬2ms,起搏10s至最短1:1心房奪獲5次--持續(xù)性AF定義為持續(xù)>10minute誘發(fā)房顫的方法和定義EssebagV,etal.EuropeanHeartJournal,2006,27:2553--RA和CS起搏200ms，5s各2次不用/應(yīng)用異丙腎上腺素--AF定義為持續(xù)>10sRichterB,etal.EuropeanHeartJournal,2006,27,2553--CS近端起搏最大20mA,脈寬2ms,至最短1:1心房奪獲或最短200ms共2次--AF定義為持續(xù)>1min，超過5min電復(fù)律--其它AFL、AT不認(rèn)為誘發(fā)目前尚無較統(tǒng)一的誘發(fā)房顫的方法和定義房顫不能誘發(fā)作為消融終點(diǎn)的爭議誘發(fā)房顫患者的經(jīng)導(dǎo)管消融策略？消融肺靜脈外局灶左房內(nèi)線性消融（頂部、MA峽部）右房內(nèi)線性消融（TA峽部、隔離SVC）CAFE電位消融（PV、LA、RA、CS）自主神經(jīng)節(jié)叢消融基于以PV電隔離為核心

·PV節(jié)段性電隔離·左房內(nèi)環(huán)PV電隔離目前尚無較統(tǒng)一的方法和步驟房顫不能誘發(fā)作為消融終點(diǎn)的爭議ClinicalSignificanceofInducibleAFL

DuringPVIinPatientsWithAFPVIin133AFpts,paroxysmal112,persistent21AclinicalepisodeofAFLwasdocumentedin40/133pts(30%)Duringtheablationprocedure,AFLoccurredin86pts(65%),eitherspo