房颤如何选择器械治疗

单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,XUGENG 2011-04-17,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,内 容,1、,房颤：抗心动过缓起搏器治疗选择,2、CRT,及注意事项,3、ICD,及相关注意事项,1、,房颤：,抗心动过缓起搏器治疗选择,植入性心脏起搏器治疗,2010,修订版,清醒状态下无症状的房颤和心动过缓者，有一次或更多,5s,以上长间歇（,I,，,C,）；,清醒状态下无症状的房颤和心动过缓者，有多次,3s,以上长间歇（,IIb,，,C,）；,无其他永久性起搏器植入适应证，仅为预防房颤而植入起搏器（,III,，,B,）。,2012HRS/ACCF,起搏器类型选择建议,For sinus node dysfunction (SND),In patients with SND and intact AV conduction, programming dual-chamber pacemakers to minimize ventricular pacing can be useful for prevention of atrial fibrillation (AF) (IIa,B).,13,对于,SND,合并完整,AV,传导者，植入并程控双腔起搏器最小化右室起搏，对于预防房颤有帮助,-IIa,类适应证,Dual-chamber pacing or single-chamber atrial pacing should not be used in patients in permanent or longstanding persistent AF where efforts to restore or maintain sinus rhythm are not planned (III,C).,1,5,10,17,18,单纯为预防房颤而植入起搏器,-III,类适应证,Gillis et al. 2012 HRS/ACCF Pacemaker Mode Selection,2012HRS/ACCF,起搏器类型选择建议,For A-V Block,VVI pacing can be useful in patients following AV junction ablation, or in whom AV junction ablation is planned, for rate control of AF due to the high rate of progression to permanent AF (IIa, B).,8689,对于永久性房颤合并高心室率无法控制，行或计划行房室结消融术者，植入,VVI,起搏器,IIa,类适应证,Dual-chamber pacing should not be used in patients with AV block in permanent or longstanding persistent AF in whom efforts to restore or maintain sinus rhythm are not planned (III, C).,1,为预防房颤而植入双腔起搏器,III,类,Gillis et al. 2012 HRS/ACCF Pacemaker Mode Selection,房颤：抗心动过缓起搏器治疗选择,常规起搏器对房性心律失常的管理,提醒注意一些,心率、律,的异常变化,澄清临床观察到的一些现象：,房性心律失常：,IEKG、Burden,等,如：,触发的超速抑制起搏,房早后反应（,Post-PAC Response,）,房早抑制（,PAC Suppression,）,运动后反应（,Post-Exercise Response,）,房颤后反应（,Post-AF Response,）,持续的超速抑制起搏,起搏调控（,Pace Conditioning,）,房颤：抗心动过缓起搏器治疗选择,针对阵发房颤：一些特殊算式,一些特殊算式：,对阵发房颤,的循证医学,近几年来起搏器房颤干预功能被证明有效的临床研究,VIP,Lewalter T. et al., Individualized Selection of Pacing Algorithms for the Prevention of Recurrent Atrial Fibrillation; Results from the VIP Registry, PACE 2006;29:124-134,SAFARI,Gold, M., Presentation of results during Late Breaking Sessions, Cardiostim 2006, Nice France,常规,起搏器,：,房颤,干预,疗法的发展,过往研究可能存在的瑕疵,：,心房感知障碍,起搏器心房感知功能正常是检出房颤的核心，也是,干预,房颤特殊功能发挥作用的关键。,随访时间短,一些循证研究的随访时间多为,3,6,个月，如此短的随访时间会影响对疗效及患者获益的评估。,未设立洗脱期,16%,45%,的患者随机入组后未复发房颤，减少了有效样本量，削弱了研究证明力度。,心室起搏较多,起搏参数设置不当引起较高比例心室起搏会部分抵消起搏预防房颤的益处。,缺乏个体化治疗,房颤是一种综合性疾病，受多因素影响。多种抗房颤特殊功能是针对不同房颤患者电生理特点而设计的，各自有最佳适应证、一般适应证和禁忌证。因此，房颤患者应用抗房颤功能时，选择最佳预防程序和接受个体化治疗非常重要，,抗心动过缓起搏与房颤,单纯的预防房颤未被指南建议，,III,类适应证；,对于欲,/,已植入起搏器的患者，选择能减少不必要的右室心尖部起搏功能的起搏器，进而减少房颤发生的风险；,对于阵发房颤欲行起搏治疗，选择具有房性心律失常管理功能的起搏器，利于术后的管理。,2、,房颤：,CRT,治疗及注意事项,房颤,VS,心衰：互为影响,HF,恶化引起或加重,AF,AF,出现或加重引起,HF,恶化,HF,好转是否减少,AF,负荷甚至复律？,房颤患者：,CRT,治疗,CRT,适应证；,CRT,治疗对阵发房颤负荷及新发房颤的影响；,CRT,治疗对持续或慢性房颤是否可能复律？,CRT,术中心房导线是否需常规植入？,2012ESC:,永久性房颤患者,变为：,IIb,类,（原为,IIa,类）,QRS 120 ms(,原为,130ms),原因：,AF,患者伴,EF,降低及传统起搏适应证患者伴,EF,降低行,CRT,治疗的强有力证据甚少,1,。,1,、,ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012,修改原因,原因：,AF,患者伴,EF,降低及传统起搏适应证患者伴,EF,降低行,CRT,治疗的强有力证据甚少,1,。,1,、,MUSTIC AF:,未能在一级终点（,6,分钟步行距离）得出显著性差异，且整个试验退出率达,42%;,2,、,RAFT,试验含,229,个永久性房颤或房扑患者，分布在心室率控制组或计划行房室结消融组，但并未显示出差异。在,AF,亚组的风险比中也未见,CRT,效果,;,3,、其它的一些数据也未表明,CRT,能使,AF,（未行房室结消融）伴心衰患者获益,2,1,、,ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012,2,、,Outcomes of cardiac resynchronization therapy in patients with versus those without atrial fibrillation: A systematic review and meta-analysis,Heart Rhythm, Vol 8, No 7, July 2011,Outcomes of cardiac resynchronization therapy in patients with versus those without atrial fibrillation: A systematic review and meta-analysis,Figure 2 Meta-analysis of the relative risk (RR) of clinical nonresponse to cardiac resynchronization therapy (CRT) over 6 to 12 months in patients with,atrial fibrillation (AF) versus sinus rhythm (SR).,P value for the pooled RR 0.001. Heterogeneity P values from the Cochran Q statistic. CI confidence,interval; I2 proportion of the variation in relative risk that is due to between-study heterogeneity. *Data published in abstract only.,Heart Rhythm, Vol 8, No 7, July 2011,Outcomes of cardiac resynchronization therapy in patients with versus those without atrial fibrillation: A systematic review and meta-analysis,Figure 3 Meta-analysis of the relative risk (RR) of all-cause death in patients with versus those without atrial fibrillation (AF) undergoing cardiac,resynchronization therapy.,P values for the pooled RR in the peer-reviewed articles, abstracts, and combined groups are .06, .006, and .003, respectively.,Heterogeneity calculated as in Figure 2. CI confidence interval; SR sinus rhythm. *Data published in abstract only.,Heart Rhythm, Vol 8, No 7, July 2011,2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities,2012器械治疗指南更新,评论,Class I,1. CRT应用于：LVEF,35%，窦性心律，LBBB，QRS,150ms，优化药物治疗NYHA II、III或急性IV,（,NYHA III/IV 证据水平：A；NYHA II 证据水平：B）,推荐修改（,强调,CRT患者LBBB，QRS,150ms；增加NYHA II,）。,Class IIa,1. CRT可能有效：LVEF,35%，窦性心律，LBBB，120ms,QRS,149ms，优化药物治疗NYHA II、III或急性IV,（证据水平：,B）,新推荐,2. CRT可能有效：LVEF,35%，窦性心律，nLBBB，QRS,150ms，优化药物治疗NYHA II、III或急性IV,（证据水平：,A）,新推荐,3. CRT可能有效：,房颤，,LVEF,35%，优化药物治疗，如果,a）患者需要心室起搏或者复合CRT指证；b）房室结消融或药物控制室率，CRT接近100%心室起搏。,（证据水平：B）,推荐修改（,措辞从患者受益基于,NYHA评级到LVEF值；证据水平从C到B,）。,4. CRT可能有效：优化药物治疗，LVEF,35%，新植入或更换，预计心室起搏比例很高（40%）的患者。,（证据水平：C）,新推荐,CRT,：,对新发房颤及阵发房颤负荷的影响,CARE-HF,研究后续分析,研究目的,CRT,对心衰患者新发房颤的作用,新发房颤对,CRT,功能的影响,随机分组,最佳药物治疗,(n=404);,最佳药物治疗,+ CRT (n=409);,入选患者,缺血性或非缺血性心肌病,NYHA,III IV,级,LVEF 35%; LVEDD 30mm/m,QRS 120ms,若,QRS,120,-149ms,，需具备两条心脏收缩不同步证据,Hoppe et al. Circulation 2006;114: 18-25,CRT,对新发房颤的影响,CRT,和最佳药物治疗组,新发房颤危险无差异,CRT,和最佳药物治疗组,因房颤首次入院危险无差异,Hoppe et al. Circulation 2006;114: 18-25,CRT,降低新发房颤患者总死亡危险,死亡率,%,无论患者是否有,AF, CRT,均显著降低总死亡危险,36%,P=0.002,Hay, et al. Circulation 2004;110: 3404-3410,84,例心衰患者,LVEF,247 %,QRS,174 25 ms,NYHA,II-IV,CRT,降低心衰患者房颤负荷,房颤,负荷,小时,/,天,房颤负荷,:,房颤发作时间,/,天,Hgl et al. JCE 2006;17: 813-817,CRT,降低房颤发作患者人数,Hgl et al. JCE 2006;17: 813-817,CRT,有反应与否,，均,不减少AF发病率;,但延缓新发房颤的发生,.,Am J Cardiol 2007;100:268 272,CRT：,是否减少房颤负荷,？,Daubert et al EHRA/HRS Statement on Cardiac Resynchronization Therapy. Heart Rhythm, Vol 9, No 9, September 2012,2012CRT,专家共识中指出，就目前临床证据而言，,CRT,并不能减少房颤负荷,.,CRT,：,对持续或慢性房颤是否可能复律？,研究背景,研究目的,CRT,对于房颤心衰患者左房左室结构重塑和,房颤转律,的作用,入选患者,74,例房颤患者,持续性房颤,(n=20),；永久性房颤,(n=54),NYHA,III IV,级,LVEF 35%; LVEDD 30mm/m,QRS 120ms,评估指标：治疗,6,个月后,NYHA,分级、生活质量、,6,分钟步行距离,LVEF,、,LV,直径、,LA,直径；,房颤复律,Kis et al.Heart 2006;92: 490-494,78,患者,CRT,治疗有效,CRT,改善慢性房颤患者心功能,Kis et al.Heart 2006;92: 490-494,CRT,逆转房颤患者,LV/LA,结构重塑,Kis et al.Heart 2006;92: 490-494,CRT,对持续性房颤维持窦律的作用,例数,CRT,治疗,6,个月后,7,患者电复律后保持窦性心律,Kis et al.Heart 2006;92: 490-494,CRT-P/CRT-D,术中,是否对房颤患者需植入右心房导线？,尚无相应的循证及指南；,对阵发房颤者，应予植入右心房导线；,对于持续房颤或慢性房颤者，应根据具体情况而定：如具,CRT,适应证、房颤病程不长、左房内径未严重扩大及总体状况尚可，估计有复律可能者，可考虑植入；否则无需植入。,3、,房颤：,ICD,及相关注意事项,DFT,测试中AF转复发生率？,Permanent AF was noted in 12% of our patients undergoing ICD implantation, and SR return following defibrillation to terminate VF during testing after ICD implantation was seen in,36%,of patients who underwent this test.,N=671,Kardiologia Polska. 2011; 69, 1: 1722,DFT,测试与,AF,转复预测因子,Kardiologia Polska. 2011; 69, 1: 1722,1.,双线圈除颤导线,2.,心功能,3.,左房尺寸,4.,胺碘酮,DFT,测试：存在,AF,转复的可能,注意事项：,对,AF,需植入,ICD,的患者是否需抗凝及能否耐受术前的一些检查；,术前抗凝治疗？（时间？,INR？）,术前检查？（,TEE？CT？,）,ICD,放电的常见原因,MADIT II.,J Am Coll Cardiol,. April 2008;51(14):1357-1365.,Poster: Poole JE, et al. Analysis of ICD Shock Electrograms in the SCD-HeFT Trial.,Heart,Rhythm Society Conference. 2004.,SVT,中房颤是重要的房性心律失常，是引起,ICD,不恰当放电的常见原因之一，对于基础心律为窦性或有阵发房颤者选择双腔或单导线,VDD,除颤器可能可减少不恰当放电的发生率。,双腔,ICD：,提高阵发房颤的诊断能力,单导线,VDD,除颤器：,提高房性心律失常的鉴别诊断能力,小 结,1、,对于房颤或阵发房颤患者：抗心动过缓起搏器治疗选择主要为适应证、起搏方式及术后房性心律失常的监测管理；,2、CRT,和,ICD：,有房颤患者适应证的选择及相应的注意事项。,谢 谢！,