心房颤动的研究现状江洪

江洪武汉大学人民医院心内科心房颤抖的研究现状AF发生机制的再认识：对消融治疗的指导AF发生机制的经典假说多发子波折返局灶驱动学说主折返环伴颤抖样传导局灶冲动－肺静脉SleeveHaissaguerreetal.NEnglJMed1998;339:659-66肺静脉异常电活动驱动AF局灶冲动－分布Haissaguerreetal.NEnglJMed1998;339:659-66局灶冲动的机制－1、自律性增加？Perez-LugonesAetal,JCardiovascElectrophysiol2003;14:803-809Cheung–JPhysiol314:445,1980

FromdistalPVofsuperfusedguineapigatrium-lungprep(7/17)Approximately30bpm,increasesinratewith10-7MnorepinephrineWangetal–IntJofCardiol89:187,2003SuperfusedcaninePVpreparationsNoexamplesofspontaneousactivityobserved(N=50)Chenetal–CardiovascRes48:265,2000Automaticitypresentin12of14superfusedcaninePVpreparationsfollowingrapidchronicatrialpacing(780bpm)and9of17controlPVpreparationsAroraetal–Circulation107:1816,200466%inperfusedcanineatrium+PVpreparations,55–180bpminthepresenceof10-6MisoproterenolCheung–JPhysiol314:445,1980Wangetal–IntJofCardiol89:187,2003Chenetal–CardiovascRes48:265,2000Aroraetal–Circulation107:1816,2004自律性曾加—组织电生理研究NoDiastolicDepolarizationPVFocalFiringPattersonEandSunnyPo,JACC.2006无舒张期除极：不支持自律性增加LSPVLIPVPAAOFiringPAView肺静脉口部消融终止Firing：不支持自律性增加PVRapidFiringMicro-reentryKalifa,Circulation.2003CD局灶冲动的机制－2、PV内微折返(Microreentry)?SunnyPo,JACC,20060ms32ms64ms128ms早搏刺激：支持微折返LAOProjectionLSPVLIPVHighDensity篮状电极标测PattersonE,SunnyPo,JCE,2007肺静脉篮状电极标测：支持微折返LSPVLIPVPAAOFiringPAView肺静脉口部消融终止Firing：不支持微折返ActionPotentialIntracellularCalcium(CalciumTransient)Basedon2Propertiesof

PVMyocardialCellsShortactionpotentialduration-Intracellularcalciumconcentration(calciumtransient)remainshighafterrepolarizationPattersonetal,HeartRhythm2005;2:624局灶冲动的机制－3、TriggeredActivitySinusRhythmRapidRhythmFollowedByPauseRapidRhythmCalciumLoadingPauseLargeCalciumReleaseFromSRActionPotentialCa++Ca++“Calcium-TransientTriggering”HypothesisEADNa+/Ca++Exchanger(3Na+In

1Ca++Out)NetInwardCurrent(+)EADTriggeredFiringEADActionPotentialTriggeredFiringIncreasedAutonomic(GP)ActivityAcetylcholineShortensActionPotentialNorepinephrineIncreasesCalciumLoadingEADsCa++Ca++SinusRhythmRapidRhythmFollowedByPause“Calcium-TransientTriggering”HypothesisAcetylcholine(10-7M)+Norepinephrine(10-8M)Pause-InducedTriggeredFiringCanineLSPVPreparation25-25-50-750200msSS1.5secEADEADLSPVMicro-ElectrodemVPatterson,Po,Scherlag,Lazzara,etalLSPVBipolarSSLast3Beatsof20BeatTrainCycleLength180ms(Rate333/min)TriggeredFiringCycleLength48ms(1240/min)AortaLALSPVLIPVIVCRVLVRIPV1ARGP5RASVCRPARSPVLassoCatheter234LOMPAViewInVivoStudyAutonomicMechanismforFocalFiringLuZ,JiangH,PoS.Unpublished.1=SLGP2=ILGP3=ARGP4=IRGP5=RPA-GPIIHBELSPVD2LSPV34LIPVD2LIPV34LAALARSPVD2RIPVD2RAARAAHAHAAHAAHA200msec2:1AVconductionblockbyHFS(1.5V)attheLSPVLuZ,JiangH,SunnyPo.Unpublished.S1-S2train(30ms)IIHBELSPVD2LSPV34LIPVD2LIPV34LAALARSPVD2RIPVD2RAARA200msecAVblockbyHFS(2.4V)justbeforeinitiationofAFLuZ,JiangH,SunnyPo.Unpublished.aVLHBERSPVD2RSPV34RSPV56RIPVD2RIPV34RIPV56RAAD2RAA34RAD2RA34300msecAFwasinitiatedbyHFS(1.5V)fromRSPVLuZ,JiangH,SunnyPo.Unpublished.aVLHBERSPVD2RSPV34RSPV56RIPVD2RIPV34RIPV56RAAD2RAA34RAD2RA34300msecNoAFbyHFS(12V)afterGPablationLuZ,JiangH,SunnyPo.Unpublished.MRAngiogram-PAProjectionPosteriorSurfaceAnteriorSurfaceSuperiorLeftGPInferiorLeftGPInferiorRightGPGPAxonsAnteriorRightGPGanglionatedPlexi(GP)多发子波折返主折返环伴颤抖样传导折返理论的根底－心房重构AFBegetsAFWijffelsetal.Circulation1995;92:1954–68DurationofAFAFBegetsAF的机制－心房重构Allessieetal.CardiovascularResearch2002心房电重构Natteletal.JICE.2005ChenPSetal.AJP.2002FocalActivityinChronicPacinginducedAFFocalActivityinChronicPacinginducedAFChenPSetal.AJP.2002RightThoracotomyLeftThoracotomyIVCRARIPVRAAAnteriorRightGPInferiorRightGPRSPVSVCLVLPALSPVLIPVRVLASuperiorLeftGPInferiorLeftGPLAAPacing1200/minfor6hrsLAALuZ,JiangHandSunnyPo.Circ.2021心房电重构的神经机制14dogsEPTesting:ERP,AFInductionEPTesting:ERP,AFInductionEPTesting:ERP,AFInductionEPTesting:ERP,AFInduction6hrLAApacing(1200/min)GPAblation(ARGP+IRGP+SLGP+ILGP+LOM)6hrLAApacing(1200/min)GPAblation(ARGP+IRGP+SLGP+ILGP+LOM)Group1Group2Group1:ChangeinERPDuringAtrialPacing2001601208040123456BaselineDurationofRapidAtrialPacing(Hours)ERP(ms)LSPVERP2xThresholdERP10xThresholdLuZ,JiangHandSunnyPo.Circ.20212001601208040123456BaselineERP(ms)LSPVERP2xThresholdERP10xThresholdPost-AblGPAblationGroup1:ChangeinERPafterGPAblationDurationofRapidAtrialPacing(Hours)LuZ,JiangHandSunnyPo.Circ.2021123456Baseline∑WoV(ms)GPAblation040080012001600Post-AblGroup1:ChangeinAFInducibilityDurationofRapidAtrialPacing(Hours)LuZ,JiangHandSunnyPo.Circ.20212001601208040123456Post-AblERP(ms)LSPVGPAblationAfterGPAblationGroup2:ChangeinERPDuringAtrialPacingERP2xThresholdERP10xThresholdDurationofRapidAtrialPacing(Hours)LuZ,JiangHandSunnyPo.Circ.2021123456Post-Abl040080012001600GPAblationGroup2:NoChangeinAFInducibilityAfterGPAblation∑WoV(ms)DurationofRapidAtrialPacing(Hours)LuZ,JiangHandSunnyPo.Circ.2021MotherRotorsandFibrillatoryConductionJalife,etal.Circulation.1998,2000,2001ElectrogramAcrosstheAtriaDuringAFSVCRAABarrierIVCRAMidRSPVRIPVARGPIRGPAchRAAARAGPLuZ,JiangHandSunnyPo.JCE.2021IIRAARSPVRIPVRAAAMidGP100msRotorFiringRAFract++++++ElectrogramAcrosstheAtriaDuringAFLuZ,JiangHandSunnyPo.JCE.2021NotFibrillatoryConductionIIRAARSPVRIPVBeforeGPAblationAfterGP