房颤消融术后房性心律失常的处理和二次消融选择医学课件

1、房颤消融术中的左房房扑Left Atrial Flutter During Stepwise Linear Ablation of AF中国医学科学院 阜外心血管病医院 心律失常中心Arrhythmia Center ，Fuwai Herat Hospital Chinese Academy of Medical Sciences姚 焰 Yan Yao房颤消融术中的左房房扑Left Atrial Flutte背景 Background与房颤消融相关的左房房扑（LAFL）发生率介于2.631% 1；The morbidity of AF ablation related left atrial

2、flutter (LAFL) are 2.631%;包括局灶、大折返或小折返等多种机制且多与房颤消融线的“缝隙”有关；Focal、micro- & macro- reentrant mechanisms were documented and the gap on the lesions line is the sticking point of the circuit;1, Gerstenfeld EP, Heart Rhythm 2019; 4: S65-72背景 Background与房颤消融相关的左房房扑（LAFL房颤消融术后房性心律失常的处理和二次消融选择医学课件个体化递进式线性消融

3、术Stepwise Linear Ablation Approach个体化递进式线性消融术Stepwise Linear Ab 病例数 Patients (n)80性别 Gender: 男性(M)/女性(F)60/20年龄 Age(岁，years)579房颤持续时间 Duration of AF (年,years)74阵发性 Paroxysmal/持续性房颤 Persistent AF62/18左房内径 LA diameter (mm)388左室射血分数 LVEF (%)526器质性心脏病 Structral Heart Disease16 (20%)既往抗心律失常药物 AADs（n)21LA

4、FL患者基本特点 Basic Characteristics of LAFL Patients 病例数 Patients (n)80性别 Gender: 结果 ResultsLAFL可在消融中由AF转化而成，或房颤消融成功之后快速刺激诱发；LAFLs were either converted from AF by ablation or induced by CIS；34例有2(26)种的LAFL，共有146种，其中4种为局灶性，142种为大折返机制；There were 34 pts. with 2(26) LAFLs，of total 146 LAFLs， 142 were reentr

5、ant & 4 were focal；142种LAFL均与房颤消融线的缝隙有关，且均位于7字消融线上；The reentrant circuits were all related with the gaps on the Figure “7” lesions line.结果 ResultsCase 1： 绕MVA的折返 Reentrant around the MVA消融嵴部时AF转为LA AFL Case 1： 绕MVA的折返 Reentrant aro V1CS7.85678910111213141516180msLead IISOCHRONES绕二尖瓣环的折返(Isochronal m

6、ap of the MVA circuit)1.等时图显示为绕MVA的顺钟向折返；2.沿MVA激动时间占心动过速周长的100；3.折返环路上全程虚拟单极电图呈rS型且首尾相接； V1CS7.856789101112131415经MVALIPV峡部的“缝隙”The gap on MVA-LIPV isthmus经MVALIPV峡部的“缝隙”The gap on MV在峡部缝隙处消融转为窦律 Termination of the LAFL在峡部缝隙处消融转为窦律 Termination of tCase2：7字型消融终止房颤后CS S1S1 320bpm诱发LAFLLAFL induced aft

7、er termination of AF with figure “7” lesionsCase2：7字型消融终止房颤后CS S1S1 320bpmCase2：经LAA-LSPV间嵴部缝隙的折返 Reentrant through the gap at LAA-LSPV ridge左房房扑的动态等电位图Case2：经LAA-LSPV间嵴部缝隙的折返 Reent等时图 Isochronal map等时图 Isochronal map在嵴部消融终止了LAFLLAFL terminated during ablation at the LAA-LSPV ridge在嵴部消融终止了LAFLLAFL t

8、erminated dCase 3: 经左房顶部缝隙折返的LAFL Reentrant though the gap on the LA roof左房房扑的动态等电位图Case 3: 经左房顶部缝隙折返的LAFL Reentr等时图 Isochronal Map等时图 Isochronal Map在顶部缝隙处消融终止了LAFLLAFL termination during ablation on the gap在顶部缝隙处消融终止了LAFLLAFL terminati与左房房扑折返环相关的缝隙分布The distribution of the LAFL related gaps LAA-LSP

9、V 嵴部 （LAA-LSPV rigde） 68 (47%)二尖瓣环峡部 （MVA isthmus） 24 (17%)左房顶部（LA roof） 50 (36%)与左房房扑折返环相关的缝隙分布The distributi7字消融线的多个缝隙Multiple Gaps on the Figure “7” lesion line7字消融线的多个缝隙Multiple Gaps on t顶部的缝隙 Gap on LA Roof顶部的缝隙 Gap on LA Roof嵴部的缝隙 Gap at LAA-LSPV Ridge嵴部的缝隙 Gap at LAA-LSPV RidgeMVA的缝隙 Gap at L

10、IPV-MVA Isthmus MVA的缝隙 Gap at LIPV-MVA Isthmus最终消融成功部位 Final Target最终消融成功部位 Final Target消融效果 Ablation Results能量:功率60W，温度58，每次60-90s；平均放电 4 2.1 次；即时成功率(消融终止+不再诱发):LSPV-LAA间嵴部：60/68 (88.2%)；左房顶部：44/50 (88%)；LIPV-MVA峡部：22/24 (92%)；消融效果 Ablation Results能量:功率60W，随访 Follow up平均( 11 6.7) 月： 维持窦律 (sinus rhy

11、thm): 62/80(77.5%)； 短阵房速 (focal AT): 12/80(15%)； 左房房扑 (LAFL): 6/80 (7.5)；随访 Follow up平均( 11 6.7) 月：新发现 New Findings缝隙的分布：既往研究中经二尖瓣环峡部缝隙的折返多见，本研究中经LAALSPV间嵴部及左房顶部缝隙的折返更多见；Gaps on LAA-LSPV ridge & roof were more common in this study；折返环类型：既往报告经嵴部的折返环多为小折返，本研究中为经嵴部及RIPV-MVA间峡部的大折返。Most of the reentrant

12、 were macro circuits across ridge；新发现 New Findings缝隙的分布：既往研究中经二尖AF的机制 Mechanism of AF 快速的异位节律 （focal）;单个折返环伴颤动性传导（single randomized wave front with fibrillatory activation；3) 多个折返环? （multiple wavelets？）姚焰 中华心律失常学杂志, 2019; 8;356AF的机制 Mechanism of AF 消融线上缝隙的成因The formation of the gaps on the lesions l

13、ineLSPV-LAA间嵴部解剖特殊性1：（Anatomic features）局部肌带厚、狭窄；肌纤维走行复杂；邻近神经节及Marshall韧带；LSPV-LAA间嵴部消融导管贴靠困难2,3；顶部正中有毗邻组织结构和心包折叠；现有消融能量的局限性；1.Cabrera JA, Eur Heart J.2019;29:356-62.2. Deisenhofer I, Europace 2019;8:573-82. 3. Mesas CE, JACC 2019;44:1071-9.消融线上缝隙的成因The formation of theCabrera JA, et al. Eur Heart J

14、.2019;29:356-62.DCabrera JA, et al. Eur Heart J并发症 或 消融成功的过渡阶段？Complication or Transform to the Success of AF ablation？步进式线性消融的可行性已得到证实1,2；The feasibility of stepwise linear ablation approach were confirmed.当前消融能量无法安全地形成透壁损伤；Complete transmurality is not guaranteed with current ablation energy;LAFL可能是当前阶段房颤消融难以避免的过渡阶段但有望在组织和电重构后消失；LAFL may possibly be the transform during the successful ablation process of AF; 1, Yao Y, Heart Rhythm 20192, Bortone A, JCE 2019 19: 338-341并发症 或 消融成功的过渡阶段？Complication 总 结 Conclusions步进式线性消融术中大折返机制的左房房扑多见且均与7字型消融线上（尤其嵴部和顶部）的缝隙有关；Macro reentrant LAFLs are common