起搏防治房颤果真形同鸡肋吗

起搏防治房颤果真形同鸡肋吗？传统治疗复律并维持窦律:AD/DC控制心室率:抗栓治疗:包括抗凝及抗血小板聚集AD治疗并不理想，特别是AD的致心律失常作用，因此,非药物治疗受到了重视.非传统治疗外科迷宫手术导管消融术心脏起搏治疗房颤的治疗起搏抑制房颤的理论基础房性早搏是房颤发生最常见的触发因素与房颤发生有关的因素还包括:显著心动过缓,如窦缓、SSS房内及房间传导阻滞短－长周期现象心房复极离散度增加理论上，心房起搏可以阻止心脏停搏或心动过缓导致的心房不应期及复极离散度改变、减少房内及房间传导时间、抑制心房异位兴奋点，从而预防折返、颤动样传导及触发引起的房颤。临床上，许多学者观察到植入生理性起搏器的房颤患者术后房颤发作频度减少或持续时间缩短。故而，起搏作为治疗和预防房颤的一种手段被提出来。起搏抑制房颤的措施起搏部位常规RA起搏双心房起搏右心房多部位起搏特殊部位起搏：Bechmen束多部位起搏使心房激动通过多个方向，减轻局部传导延迟，预防功能性传导阻滞的发生，使双心房再同步，减少复极的离散度，减轻心房的各向异性。起搏程序预防房颤的心房超速起搏程序（ODP）抗心动过速起搏程序（ATP）心房超速起搏对房颤的预防作用心房超速起搏预防房颤发生的机制主要是消除房颤的诱发因素，如抑制房性早搏消除早搏后的长间期现象此外，通过保持和控制心率及心律从而降低心房复极的离散度目前临床应用的有二类持续性起速起搏(sustainedatrialoverdriving,SAO)动态心房超速起搏(dynamicatrialoverdriving,DAO)设置的心房频率比患者自身频率一般≥10%以上，通常在80-90bpm。设置心房起搏频率越快，则患者自主心率出现的机率越少，早搏的发生率则越低，从而预防房颤的效果越好。缺点:起搏频率快，导致耗氧量增加，尤其不利于心绞痛的病人。心率几乎全由起搏器控制，失去了心率变异性。持续性心房超速起搏（SAO）动态心房超速起搏的特点是起搏器能持续检测自身窦性P波，并与房性早搏相鉴别。当检测到16个窦性心搏有2次房性早搏出现，起搏器就会自动提高心房起搏频率，并逐渐增加起搏频率直到稍超过房性早搏频率，从而达到超速起搏的目的。这种起搏频率逐渐增加的方式，比固定频率超速起搏(SAO)要优越些，不但省电而且病人更适应，新近临床实验显示DAO使房颤发生率显著降低，圣犹达公司lntegrityTMAFxDR就是一种DAO起搏器。动态心房超速起搏(DAO)主要产品St.JudeMedicalTrilogy®DR+/DAOModel2360L/2364LIntegrity®AFxDRModel5346MedtronicAT500Kappa900VitatronVita900E,9000AFSuppression™AlgorithmOverview运算方式SinusrateDynamicatrialoverdriveMaximumtrackingrateBasiclowerrateAlgorithmOverviewAFSuppression™AlgorithmOverview保证心房起搏占90%以上比例起搏频率根据病人的自身心房活动而动态变化在连续16个心动周期中感知到2个P波，AFSuppression™的起搏频率将自动提高起搏的次数可由程控决定

经一段时间起搏后，频率会逐渐下降，同时检测自身心房活动PAAAAAAAAAAAAAAAA012345678910111213141516Start16-cyclecounterP=P-waveA=AtrialpacingOnly1P-wavewasseen.Therefore,NOOverdriveoccursEnd16-cyclecounterNote:Noticehowthealgorithmstartswitha“0”nota“1”AFSuppression™AlgorithmOverviewAFSuppression™AlgorithmOverviewPAAAAAAAAAAAAAAP0123456789101112131415Start16-cyclecounter2P-waveswereseentherefore,OverdriveoccursStartOverdriveP=P-waveA=Atrialpacing2P-waveswereseentherefore,OverdriveoccursAFSuppression™AlgorithmOverviewPPOverdriveRatePacingRateAFSuppression™AlgorithmOverview低频超速抑制(LRO)<60ppm:每步增加10ppm60ppm150ppm:将自动在5-10次之间增加高频超速抑制(URO)>150ppm:每步增加5ppm120012BaseRatePacing1200ms(50ppm)OverdrivePacing1016ms(59ppm)Whilebaseratepacingat50ppm(1200ms),2P-wavesoccurinthe16-cyclewindow,theatrialpacingrateincreasesto59ppm(1016ms)AFSuppression™AlgorithmOverview012345678AFSuppression™AlgorithmOverviewWhilebaseratepacingat50ppm(1200ms),2P-waveswithin16cyclesoccur,theatrialpacingrateincreasesto59ppm(1016ms)AFSuppression™AlgorithmOverview

频率的恢复:12/8法则100ppm每步增加12ms>100ppm每步增加8msECGcontinuedonnextslide...AFSuppression™AlgorithmOverview2P-waveswithin16cyclesresultsinanatrialrateincrease12mm/secprinterspeedRateIncreaseAFSuppression™AlgorithmOverviewRateRecoveryoccurswhentheintervalincreasesfrom1016msto1022ms25mm/secprinterspeedECGdemonstratesRateRecoverycontinuinguntilBaseRateof1200msisreached(25mm/sec)AFSuppression™AlgorithmOverviewContinuousECG2P-waveswereseentherefore,OverdriveoccursfollowedbyRateRecoveryAFSuppression™AlgorithmOverviewPPOverdriveRatePacingRate

PacingRateRateRecovery起搏防治房颤临床试验Integrity®AFxDRModel5346St.JudeMedicalpulsegeneratorsUsedforthetrial:AtrialDynamicOverdrivePacingTrial-A(ADOPT-A)Trilogy®DR+/DAOModel2360L/2364LADOPT-AClinicalTrialSymptomaticAFEpisodesviaEventRecorderFollow-upBaseline,30,90,180daysDeviceAssessmentQOLDDDRPacingAFSuppression-ONSymptomaticAFEpisodesviaEventRecorderFollow-upBaseline,30,90,180daysDeviceAssessmentQOLDDDRPacingAFSuppression-OFFPacemakerImplantTrilogyDRDAOIntegrityAFxDRProspectivePatientBlindedRandomizedStudyDesignN=203N=195N=130N=158ADOPT-AClinicalTrial*p<0.0001

%AtrialBeatsPaced*AFSuppressionOFF

67.9AFSuppressionON

92.9AtrialPacingADOPT-AClinicalTrial5(n=122)4.6(n=110)90.4(n=2,180)0102030405060708090100AFAFlutterOtherAtrialArrhythmiasAtrialArrhythmiaClassificationAtrialArrhythmia's(%)

随访时病人的心律失常ADOPT-AClinicalTrial2.63%1.73%4.44%1.37%1.93%3.19%0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%5.0%1-Month3-Month6-Month

AFBurden(%)Followup(n=288)p<0.05AFsOFFAFsON症状性AF负荷ADOPT-AClinicalTrialAFsOFFAFsONTotalPatients158130PatientswithAFDays8173TotalAFDays682421TotalFollow-upDuration(Days)27,35922,526AFBurden2.493%1.869%AFBurdenReduction25.03%，P<0.05AF负荷减少ADOPT-AClinicalTrial0123456789106MonthsPriortoImplantImplantto6MonthsMeanAFEpisodesp<0.00018.14.28.3±4.14.3±11.53.2±8.5AFsOFFAFsONAF事件的减少ADOPT-AClinicalTrial

8890929496981000306090120150180Duration(Days)(%)w/oHospitalization*Freedomtofirsthospitalization(n=288)6%ReductioninHospitalizationsAFsOFFAFsONp=NS住院时间的减少ADOPT-AClinicalTrialFreedomfromFirstCardioversion(n=288)降低了63%转复

90929496981000306090120150180

(Duration)Days(%)w/oCardioversionAFsOFFAFsONp=0.0925ADOPT-AClinicalTrialEventClassification

AFsOFF

AFsONLeadDislodgment87Pneumothorax21MyocardialPerforation02CardiacTamponade01SystemInfection01SystemReplacement01Total1013并发症ADOPT-AClinicalTrial死亡率

心衰时主要的死亡原因

(3AFsON,3AFsOFF)没有与AF相关的死亡原因

PATIENTDEATHSCAUSEOFDEATHAFsOFFAFsONTOTALCongestiveHeartFailure336Unknown112CerebralVascularAccident101CardiopulmonaryArrest011ChronicObstructivePulmonaryDisease011ComplicationofPericardiocentesis101CoronaryArteryDisease011PancreaticCancer011RenalShutdown011RespiratoryFailure011ShockwithUndeterminedEtiology011Total61117ADOPT-AClinicalTrial结论AFSuppression是安全的，并可以降低病窦且伴有阵发性或持续性AF的发病率。

AFSuppression增加了DDDR起搏器对房颤的抑制作用。PreventionofAtrialFibrillationby

OverdriveAtrialSeptumStimulationOASESstudyOASESStudy326patientsenrolled.71patientsexcluded.9patientswithatrialflutter.7patientsonpermanentAF.55protocolviolations.

255patientsinthestudy. Male: 106Female: 149Age: 70.1±18.2years方法85patients RightAtrialAppendagePacing+AF85patients LowAtrialSeptumPacing+AF85patients ControlgroupPacingwithoutAF结果P=0.027P=0.033P=0.027P=0.033结果RAA:76.0±36.0 38.9±39.5

p<0.033

LAS:74.1±29.9 22.0±18.6

p<0.027

Control:0.5±0.50.6±0.4

nsDAOOFFDAOONP=0.037结论低位右心房间隔部位+DAOON的起搏模式是最有效的降低阵发性房颤病人AF负荷的起搏治疗方式。提高了病人的生活质量。AFSuppression™是圣犹达公司为起搏器病人设计的优越的动态心房超速抑制功能，以预防阵发性和持续性房颤（AF)，降低病人AF的发生；减少有症状的AF病人的住院时间；减少持续性AF病人转复的痛苦；减少房性心律失常或固定较高心房频率起波引起的心悸，使病人感觉更舒服。TheAtrialTherapyEfficacyandSafetyTrialATTESTstudyATTEST研究aprospective,randomizedstudytoevaluatepreventivepacingandanti-tachycardiapacing(ATP)inpatientswithsymptomaticAForAT.DDDRP(AT500,Medtronic)withthreeatrialpreventivepacingalgorithmsandtwoATPalgorithms368ptswererandomizedone-monthpost-implanttoallpreventionandATPtherapiesONorOFFandfollowedforthreemonths.TheAT/AFburdenandfrequencyweredeterminedfromdailydevicecountersin324patients.Valuesshownarethemedianplusthe25thto75thpercentiles;patientsdidnotreceiveanactivatortologsymptomaticepisodesuntiltheone-monthvisit;allatrialtherapieswereOFFduringtherun-inperiod.AFatrialfibrillation;ATatrialtachycardia.Leeetal.TheEffectofAtrialPacingTherapiesonAtrialTachyarrhythmiaBurdenandFrequencyJACCVol.41,No.11,2003June4,2003:1926–32Figure3.Histogramofatrialtachycardia/atrialfibrillationepisodeduration.ThemedianepisodefrequencyineachdurationbandwascomparedbetweentheONandOFFgroups,andnosignificantdifferenceswereobserved(p0.17).Leeetal.TheEffectofAtrialPacingTherapiesonAtrialTachyarrhythmiaBurdenandFrequencyJACCVol.41,No.11,2003June4,2003:1926–32ATTEST研究结论ThisDDDRPpacemakerissafe,hasaccurateAT/AFdetection,andprovidesATPwith54%efficacyasdefinedbythedevice.TheatrialpreventionandterminationtherapiescombineddidnotreduceAT/AFburdenorfrequencyinthispatientpopulation.DAPPAF研究Tocomparethesafety,toleranceandeffectivenessofoverdrivehighrightatrial(RA),dual-siteRAandsupport(DDIorVDI)pacing(SP)inpatientswithsymptomaticatrialfibrillation(AF)andbradycardia,andtodetermineoptimalpacingmethodsforAFprevention.118ptswererandomizedtoeachofthreepacingmodesinacrossovertrial.Figure1.(A)Freedomfromcrossoverwithin4.5monthsofenteringrandomizedtreatmentphaseforeachpacingmode.Dualrightatrial(RA)pacingshowsahigherProportionofptsabletoremainintherandomizedtreatmentmodeascomparedwithothermodes.Figure1.(B)FreedomfromallsymptomaticAFineachrandomizedpacingmodeintheentirestudypopulation.DualRApacingbutnothighRApacingshowsatrendtoprolongationoftimeintervaltoAFrecurrence.Saksenaetal.ImprovedSuppressionofRecurrentAtrialFibrillationWithDual-SiteRightAtrialPacingandAntiarrhythmicDrugTherapyJACCVol.40,No.6,2002September18,2002:1140–50Figure2.Freedomfromallsymptomaticatrialfibrillation(AF)ineachrandomizedpacingmodeinstudypopulationreceivingconcomitantclass1or3antiarrhythmicdrugs(AADontheleft)orwithoutconcomitantdrugtherapy(AADontheright).Dualrightatrial(RA)pacingbutnothighRApacingshowsprolongationoftimeintervaltoAFrecurrenceascomparedwithsupportpacingandatrendtoprolongationascomparedwithhighRApacingindrug-treatedpatients.Thereisnodifferenceinoutcomeinpatientsonanyrandomizedpacingmodewithoutconcomitantdrugtherapy.Saksenaetal.ImprovedSuppressionofRecurrentAtrialFibrillationWithDual-SiteRightAtrialPacingandAntiarrhythmicDrugTherapyJACCVol.40,No.6,2002September18,2002:1140–50Figure3.Freedomfromallsymptomaticatrialfibrillation(AF)ineachrandomizedpacingmodeinstudypopulationreceivingconcomitantclass1or3antiarrhythmicdrugswithfrequent(weeklyeventstotwoeventsinthreemonths)AFatbaseline.Dualrightatrial(RA)pacingshowsprolongationoftimeintervaltoAFrecurrenceascomparedwithhighRAorsupportpacinginthesepatients.Saksenaetal.ImprovedSuppressionofRecurrentAtrialFibrillationWithDual-SiteRightAtrialPacingandAntiarrhythmicDrugTherapyJACCVol.40,No.6,2002September18,2002:1140–50Figure4.Quality-of-lifeinthestudypopulationatbaselineandineachrandomizedtreatmentmodeforindividualmeasures.Atrialfibrillationsymptomchecklist(pairedanalysis)ineachrandomizedmodeshowsthebenefitsofbothoverdrivepacingmodesascomparedwithsupportpacing.Saksenaetal.ImprovedSuppressionofRecurrentAtrialFibrillationWithDual-SiteRightAtrialPacingandAntiarrhythmicDrugTherapyJACCVol.4