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1、1,孟 旭 首都医科大学附属安贞医院房颤诊疗中心 心脏外科9病区,心脏外科射频消融手术治疗心房颤动： - 术中心外膜电生理检测,2,研究背景,目前外科手术治疗房颤的疗效报道不一 双极射频消融系统对于消融透壁性的判定，与实际的消融质量有一定的差别 缺乏适合外科手术中的电生理标测系统 目前为止，肺静脉隔离的质量是可以控制的重要因素,3,研究内容,房颤射频消融手术中，肺静脉隔离质量的心外膜电生理检测 * 肺静脉前庭的感知（Sensing） * 肺静脉前庭的起搏（Pacing） 2. 房颤射频消融手术中，自主神经节的心外膜电生理检测,4,肺静脉隔离质量的心外膜电生理检测,射频消融手术中，肺静脉隔离质量
2、的心外膜电生理检测 1. 肺静脉前庭区域的感知（Sensing） 2. 肺静脉前庭区域的起搏（Pacing）,第一部分：,5,肺静脉隔离质量的心外膜电生理检测,原理：,* 肺静脉前庭的异位电活动灶触发机制 * 肺静脉-前庭微折返环路的维持机制,肺静脉异常 快速电位活动,肺静脉 前庭的微折返环路,触发,维持,6,肺静脉隔离质量的心外膜电生理检测,目的：,通过对肺静脉前庭的感知标测，了解异位电活动灶和微折返环路是否完全消失 通过对肺静脉前庭的起搏标测，了解潜在的异位电活动灶和微折返环路能否通过消融隔离环向外传布，导致可能的房颤复发,肺静脉隔离的理想效果： 1. 彻底隔离肺静脉前庭的异位电活动灶 2
3、. 彻底打断肺静脉-前庭微折返环路,心外膜电生理检测,7,肺静脉隔离质量的心外膜电生理检测,具体方法：,一、肺静脉前庭的感知标测（Sensing）,肺静脉前庭隔离前的感知标测：快速、细小，紊乱而不规律的电位活动,8,肺静脉前庭隔离后的感知标测：原有异常电位完全消失,肺静脉隔离质量的心外膜电生理检测,具体方法：,一、肺静脉前庭的感知标测（Sensing）,9,肺静脉隔离质量的心外膜电生理检测,具体方法：,二、肺静脉前庭的起搏标测（Pacing）,窦律时，以一定的刺激频率在肺静脉前庭区域进行起搏，观察心房电活动是否受到影响,1. 发生心房夺获，消融隔离环未能完全阻断肺静脉前庭的电活动，潜在的异位电
4、活动灶和微折返环路能够通过消融隔离环向外传布，导致可能的房颤复发,2. 不发生心房夺获，消融隔离环完全阻断肺静脉前庭的电活动，潜在的异位电活动灶和微折返环路不能通过消融隔离环向外传布，房颤复发几率低,10,肺静脉隔离质量的心外膜电生理检测,具体方法：,二、肺静脉前庭的起搏标测（Pacing）,刺激波,* 隔离前，肺静脉前庭起搏引发心房夺获,刺激波,* 隔离后，肺静脉前庭刺激无法引发心房夺获,11,肺静脉隔离质量的心外膜电生理检测,综上所述，肺静脉隔离消融的终点判定: 1.肺静脉前庭区域感知（sensing）为（） 2.肺静脉前庭区域起搏(pacing)无法发生心房夺获,12,最多12 道,右肺
5、静脉：(6.02.7)道 左肺静脉：(5.32.2)道,我们的经验（72例）：最终能达到消融终点的有68（94）例,肺静脉隔离质量的心外膜电生理检测,13,56例(78): PVI 2道仍未达消融终点；,47例(65): PVI 需5道以上达消融终点,肺静脉隔离质量的心外膜电生理检测,14,肺静脉隔离质量的心外膜电生理检测,第二部分：,射频消融手术中，自主神经节的心外膜电生理检测,15,肺静脉隔离质量的心外膜电生理检测,自主神经节（GPs）的标测原理：,* 利用高频刺激，对心外膜的GPs位点进行检测，凡是能够诱发出迷走神经反应，视为阳性GPs位点,窦性心动过缓（心率40次/分钟） 房室传导阻滞
6、 低血压,Pappone. Atrial fibrillation ablation. Ital Heart J 2005; 6 (3): 190-199.,16,L1,L2,L3,L5,L7,L4,L6,L8,L9,L10,心外膜GPs分布示意图,R1,R2,R3,R4,R5,R6,R7,R8,R9,R10,右侧,左侧,17,高频刺激诱发的迷走神经反应,18,我们的经验： 72例术中GPs检测,肺静脉隔离质量的心外膜电生理检测,19,R1: 62%,R2: 4%,R3: 78%,R4: 2%,R5: 64%,R6: 6%,R7: 67%,R8: 8%,R9: 57%,R10: 2%,右侧 G
7、Ps: 74%（165/222）,右侧心外膜GPs分布：,20,L1: 27%,L2: 54%,L3: 50%,L5: 45%,L7: 68%,L4: 0%,L6: 5%,L8: 9%,L9: 27%,L10: 0%,左 GPs: 26% (57/222),左侧心外膜GPs分布：,21,GPs部分消融（11例） - GPs完全消融（61例）,GPs消融效果的随访,22,术中心外膜电生理检测,23,安贞医院房颤诊疗中心、心脏外科9病房,1. 2006年12月开展微创射频消融手术 至2008年12月 共完成 147 例 2. 亚洲最早、最大的微创手术治疗组,我们的微创射频消融手术经验,24,73.
8、2 %,63.7 %,83.5 %,86.6 %,SR,SR,SR,SR,79.6 %,SR,SR,88.9 %,不同随访时间的总体心律恢复情况,EARLY RESULTS,25,术前不同房颤类型的窦律恢复情况,26,总 结,术中电生理检测对于肺静脉消融隔离的质量有着重要意义 外科医生需要掌握这项技术 未来的电生理标测手段将会对所有消融线的质量进行术中检测,27,谢谢,28,29,Xu Meng M.D. Atrial Fibrillation Center Beijing Anzhen Hospital, Capital Medical University Beijing,Radiofre
9、quency Ablation Operation for Atrial Fibrillation： - Intraoperative epicardial EP testing,30,Background,Current AF surgery: Different outcomes reports Bipoar RF ablation system: Impedence algorhythm dosent guarantee histological transmurality No EP mapping system for intraoperative epicardial mappin
10、g Quality of PV isolation can be enhanced with EP testing,31,Intraoperative epicardial EP testing,EP testing for PV-antrum isolation * PV-antrum Sensing * PV-antrum Pacing 2. EP testing for Ganglionated Plexi (GPs),32,EP testing for PV-antrum isolation * PV-antrum Sensing * PV-antrum Pacing,PART I：,
11、Intraoperative epicardial EP testing,33,EP testing for PV-antrum isolation,Mechanisms:,* PV-antrum Focal Triggers * PV-antrum Micro-reentry,Focal foci,Micro-reentry,trigger,maintenance,34,EP testing for PV-antrum isolation,Object：,PV-antrum sensing: disappearance of local foci and micro-reenty PV-an
12、trum pacing: if local foci and micro-reentry could be confined to PV isolation lesions,Transmural PVI： 1. Totally block PV-antrum foci 2. Totally block PV-antrum micro-reentry,Epicardial EP testing,35,Methods：,1、 PV-antrum sensing,PV-antrum sensing (pre-isolation)：Rapid, irregular and small potentia
13、ls,EP testing for PV-antrum isolation,36,Methods：,1、 PV-antrum sensing,PV-antrum sensing (post-isolation)：no potentials detected,EP testing for PV-antrum isolation,37,2、 PV-antrum pacing (in sinus rhythm),Epicardial pacing of PV-antrum to see if atrium is “captured”,1. Capture is obtained, potential
14、 PV-antrum conduction recovery,2. Capture is NOT obtained, totally conduction block of isolation,Methods：,EP testing for PV-antrum isolation,38,Pacing,* Pre-isolation: PV pacing with capture. Note inverted p-waves indicating right-ward conduction across atria,刺激波,* Post-isolation: PV pacing with no
15、capture. Note that paces produce no response.,EP testing for PV-antrum isolation,Methods：,2、 PV-antrum pacing (in sinus rhythm),39,Primary endpoint of PV-antrum isolation: 1. PV-antrum sensing:（） 2. PV-antrum pacing: Non-capture,EP testing for PV-antrum isolation,40,The most: 12 isolation lesions,RP
16、Vs：(6.02.7) lesions LPVs：(5.32.2) lesions,Our experience（72 cases）：endpoint achieved in 68（94）cases,EP testing for PV-antrum isolation,41,56 cases(78): endpoint was not obtained after 2 PV isolation lesions,47cases (65):endpoint was obtained after 5 or more PV isolation lesions,EP testing for PV-ant
17、rum isolation,42,PART II：,EP testing for Ganglionated Plexi (GPs),Intraoperative epicardial EP testing,43,EP testing for Ganglionated Plexi (GPs),Mechanism of GPs testing,* GPs positive: High frequency stimulus to induced vagal reaction,Bradycardia（HR 2 times AV block Hypotension,Pappone. Atrial fib
18、rillation ablation. Ital Heart J 2005; 6 (3): 190-199.,44,L1,L2,L3,L5,L7,L4,L6,L8,L9,L10,Epicardial GPs,R1,R2,R3,R4,R5,R6,R7,R8,R9,R10,Right-sided,Left-sided,45,HFS induced Vagal reaction,46,Intraoperative GPs detection: Our experience (72case),EP testing for Ganglionated Plexi (GPs),47,R1: 62%,R2:
19、4%,R3: 78%,R4: 2%,R5: 64%,R6: 6%,R7: 67%,R8: 8%,R9: 57%,R10: 2%,Right-sided GPs: 74%（165/222）,Right-sided GPs：,48,L1: 27%,L2: 54%,L3: 50%,L5: 45%,L7: 68%,L4: 0%,L6: 5%,L8: 9%,L9: 27%,L10: 0%,Left-sided GPs: 26% (57/222),Left-sided GPs：,49,GPs (Partial ablation)（11例） - GPs (Total ablation)（61例）,Our e
20、xperience: Follow-ups of GPs ablation,50,Intraoperative epicardial EP testing,51,Atrial Fibrillation Center at Beijing Anzhen Hospital,Minimally Invasive Surgery for AF: our experience,1. Dec.2006 Dec,2008 147 cases 2. Largest MIS group in Asia,52,73.2 %,63.7 %,83.5 %,86.6 %,SR,SR,SR,SR,79.6 %,SR,SR
21、,88.9 %,Overall Heart Rhythms at Different Time Points,EARLY RESULTS,53,Outcomes of different AF types at time points,54,Summary,Intraoperative EP testing enhances PV-antrum isolation quality Clinical application of this technique In future, epicardial EP MAPPING technique tests all ablation lesions,55,Thank you,