心房碎裂电位在房颤消融中的应用

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,心房碎裂电位在房颤消融中的应用,中山大学附一院心血管医学部,何建桂,一、,What are CFAEs?,1心房波的碎裂电图由2个或2个以上的曲折组成和/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冲动波；,2与心房其它部位相比，心房冲动周期非常短，连续10秒心房冲动平均周长120ms。,3)CFAE电位振幅0.05mv0.15mv,Nademanee K,et al Heart Rhythm,2006;3(8):981-984,Examples of complex fractionated atrial electrograms,Nademanee K et al.JACC 2004;43:2044 53,左房后间隔部,CFAEs,Examples of complex fractionated atrial electrograms,Nademanee K et al.JACC 2004;43:2044 53,左房顶部,CFAEs,二、碎裂电位的产生机制,碎裂电位形成机制 ,不同子波叠加进入同一区域,碎裂电位形成机制 ,标测区出现功能性传导阻滞,碎裂电位形成机制 ,轴点,碎裂电位形成机制 ,标测区出现缓慢传导,三、碎裂电位的时间与空间分布稳定性,CFAE：,稳定而持续的？,或不稳定和暂时的？,Hassaguerre et al:,Circulation,.2005;112:789-797,碎裂电位的时间分布稳定性,RIPV,RSPV,LSPV,RA,在15分钟的时间内每5秒重复检测,，,各位点的最高频率无明显变化,19例阵发性,AF,和13例持续性,AF,Hassaguerre et al:,Circulation,.2005;112:789-797,碎裂电位的时间分布稳定性,596个局部高频位点，持续记录2个5秒，比照发现两次记录的最高频率无明显变化，说明房颤时主导频率在时间上的稳定性,Nademanee K et al.JACC 2004;43:2044 53,不同患者的,CFAEs,均常见于相同的解剖结构中，如肺静脉、房间隔、冠状窦口、二尖瓣环等心房组织连接处,碎裂电位的空间分布稳定性,CFAE,相对固定于某一部位,并不是毫无规律的漫游,四、消融碎裂电位的临床报道,AF,消融,消除触发灶,破坏,AF,维持基质,Pulmonary Vein Isolation,Segmental Approach,Hassaguerre,M.et al.,Circulation.2000;102:24632465.,Going,Going,Gone!,Nathan,Circ Res,1969?,肺静脉节段电隔离,消除触发灶,环肺静脉电隔离,消除触发灶,局部破坏AF维持基质,成功率,Nathan,Circ Res,1969?,AF,仍,AF,环肺静脉隔离,CFE,分布区域在,AF,维持中的作用,？,+,CFE,消融,AF,终止,A New Approach for Catheter Ablation of Atrial Fibrillation:Mapping of the Electrophysiologic Substrate,Nademanee K et al.JACC 2004;43:2044 53,单纯消融,CFE,-,病例：,121例,AF,(阵发性,57,例，持续性,64,例)，,方法：,AF,时标测,CFE,并标记在,CARTO,三维模型上，,消融,CFE，,不观察,PV,电位,消融终点,：,CFE,消失或转为,SR，,且,AF,不再被诱发,Nademanee K et al.JACC 2004;43:2044 53,Target Sites for AF Ablation,Nademanee K et al.JACC 2004;43:2044 53,Target Sites for Atrial Fibrillation Ablation,Nademanee K et al.JACC 2004;43:2044 53,Regional distribution of CFAEs,Nademanee K et al.JACC 2004;43:2044 53,RESULTS,115例(95%)在消融过程中,AF,终止，随访1年,110例(91%)无复发，92例1次手术，18例经2次手术。,CEF,主要分布于房间隔、肺静脉、左房顶部、二尖瓣环后间隔部及冠状窦口,Nademanee K et al.JACC 2004;43:2044 53,CONCLUSIONS,碎裂电位分布区域是房颤维持的电生理基质，是终止房颤和维持窦律的理想靶点,Nademanee K et al.JACC 2004;43:2044 53,CFE,标测图示,Organized E-gram,More Complex E-gram,CFE Mean Map,FRACTIONATED ELECTROGRAMS(CFEs)IDENTIFIED BY A NOVEL REAL-TIME AUTOMATED MAPPING ALGORITHM ON ATRIAL FIBRILLATION(AF)CYCLE LENGTH,TERMINATION,AND INDUCIBILITY,A Verma,L Macle,P Novak,B Whaley,M Beardsall,Z Wulffhart,Y KhaykinNewmarket,Ontario,方 法:,12 例,AF(,阵发性8例，持续性 4例),EnSite NavX,构建心房三维模型，自动标测并显示碎裂电位区域，指导消融。,-碎裂电位自动标测和消融,Baseline vs.Final CFE Map,Baseline CFE Map,Pre Termination CFE Map,结 果,CFAE,主要分布于房间隔(11)、上肺静脉(9)、顶部(6)及左心耳基底部(5),12例,AF,房颤变慢，周长延长(19427,ms to 31641ms),9/12(75%)AF,终止,2/12,左房房扑,1/12,右房房扑,电复律,消 融,12,例均不能诱发,AF，,但4/12可诱发房扑,-碎裂电位自动标测和消融,Randomized comparison of encircling and nonencircling left atrial ablation for chronic atrial fibrillation.,Oral H,et al.Heart rhythm,2005;2:11651172,消融CFE与CPVA术式比较-,病例：,80例慢性,AF,，随机,A、B,两组,各40例,方法：,A,组,：,LACA+post-line+MI,B,组,：3-5,lines in CFE Area:,Roof,Anterior,Septal,MI,Post-Annualus,结果：,A,组,：成功率68%，,LAFL,发生率15%,B,组,：成功率60%，,LAFL,发生率18%,Oral H,et al.Heart rhythm,2005;2:11651172,Circumferential pulmonary vein ablation(CPVA),Oral H,et al.Heart rhythm,2005;2:11651172,Electrogram-guided ablation(EGA),Oral H,et al.Heart rhythm,2005;2:11651172,CONCLUSIONS,消融CFE与CPVA，治疗AF同样有效,消融CFE减少了左房后壁消融，因而可防止左房食管瘘,Nademanee K et al.JACC 2004;43:2044 53,A Tailored Approach to Catheter Ablation of Paroxysmal AF,病例：153例阵发性AF,方法：对致心律失常的肺静脉行局灶消融或环肺静脉隔离，如房颤仍存在或仍可诱发，那么以CFE为靶点消融,Oral,H，et al:,Circulation,.2006;113:1824-1831,CPVA+,消融,CFE-,Examples of presence and absence of pulmonary vein tachycardia,Oral,H，et al:,Circulation,.2006;113:1824-1831,Examples of complex electrograms targeted for ablation,Oral,H，et al:,Circulation,.2006;113:1824-1831,An example of tailored ablation,右侧环肺静脉隔离+碎裂电位消融,Oral,H，et al:,Circulation,.2006;113:1824-1831,An example of tailored ablation,LSPV,隔离+碎裂电位消融,Oral,H，et al:,Circulation,.2006;113:1824-1831,Ablation strategy,Conclusions,对阵发性,AF，,采用肺静脉隔离与碎裂电位消融相结合，可以提高成功率并减少不必要的消融。,Oral,H，et al:,Circulation,.2006;113:1824-1831,Complex fractionated atrial electrograms represent“local complex activation or reentry.,Complex fractionated atrial electrograms are targets for AF ablation.,SUMMARY,Are complex fractionated atrial electrograms the Rosetta Stone that unlocks the door to sinus rhythm,or are they unimportant?,SUMMARY,Thank you,谢谢,AF Pre ablation CFE Mean Map,27 July,2006 CFE Map,Before,Ablation AP,C Pappone,et al,HSR,Milan,Italy,shortest cycle-length(highest frequency)on ridge between LAA and LSPV,228,52,lateral-to-medial frequency gradient,27 July,2006 CFE Map,After,Ablation AP,C Pappone,et al,HSR,Milan,Italy,228,52,significant increase in cycle-length(reduced frequency)within isolation line,no significant change in frequency gradient in LA body,AF After ablation CFE Mean Map,