房颤消融终点
Endoints of AF Abaltion
董建增
Jianzeng Dong, MD
首都医科大学附属北京安贞医院
Beijing Anzhen Hospital, Capital Medical University
消融终点取决于……
• 房颤类型
proxysmal
persistent
permanent
• 消融策略
CFAE
Step-wised
Fixed
2
阵发性房颤？
• PVI
•
•
•
•
•
•
•
CTI
LA roof line
MI
SVC isolation
Indcue and the protocol
Induced tachcardia
Indecement negatively
3
持续性房颤？
• By different approach applied
• Linear abaltion
• SVC isolation
• Termination by ablation or CV
• Induce
• Induced tachycardia
4
• Ablation strategies which target the PVs and/or PV antrum are the
cornerstone for most AF ablation procedures.
• If the PVs are targeted, complete electrical isolation should be the goal.
• Careful identification of the PV ostia is mandatory to avoid ablation within
the PVs.
• If a focal trigger is identified outside a PV at the time of an AF ablation
procedure, it should be targeted, if possible.
• If additional linear lesions are applied, line completeness should be
demonstrated by mapping or pacing maneuvers.
• Ablation of the cavotricuspid isthmus is recommended only in patients
with a history of typical atrial flutter or inducible cavotricuspid isthmus
dependent atrial flutter.
• If patients with longstanding persistent AF are approached, ostial PV
isolation alone may not be sufficient.
Calkins H, Europace ; 2007: 9, 335–379 5
阵发性房颤……
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阵发性房颤
89 pts
1/1000 ISO+ Burst
9 Pts
Afib 4 pts
AT 2 pts
SVC 2 pts
RA 1 pts
NAC 1 pts
AFL 3 pts
CTI 2 pts
MI 1 pt
持续性房颤消融终点……
• 是否需要肺静脉外消融？
• 肺静脉外消融：CFAE, 线性, 局灶，或全部?
• CFAE 消融在 PVI + 线性消融之后？
• 还是CFAE消融在 PVI + 线性阻滞之后？
• 术中房速需要逐个标测么？
• 消融终止房颤或规则？
• 窦律恢复后（abl. or CV）是否需要诱发及EP检查？
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Results of Long-lasting AF Abl
“most cited JCE paper”
Methods
PVI + SVCI + CS + Defrag + CTI,ROOF,MI（60pts.）
Results
Afib. Termi 87%(52/60)
Afib.-Sinus 11.7%(7/60)
Foci : 38
CAF : 95%
Through Flut. 75%(45/60)
Macro （ROOF, CTI,MI）: 49
MICHEL HAISSAGUERRE, et al. J CE. 2005;16: 1125-1137
AT During CAF ablation
• CAF 86
• Turned to SNR via 179 ATs in 80% (69/86) pts.
• Mechanisms of AT
-- Macroreentry:81%(145/179)
perimitral 65, CTI 48, roof 32
-- Localized reentry:12%(21/179)
-- Focal:7%(13/179)
Ning M, et al. CMJ 2010 (accepted)
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Mechanisms of Post Abalation AT
Basic Data
N
ATs
Average Ats
Type of AF
PAF
Persistent
initial approach
Mechanism of AT
reentrant
macro
localized
focal
Jais
Chae
128
246
1.92
78
155
1.99
20%
80%
segmental+
73%
27%
Circ.+
83%
44%
39%
14%
88%
75%
13%
12%
Jais P, et al. JCE 2009; 20: 480-91
Chae S, et al. JACC 2007;50:1781–7
Mechanism of Reentrant Circuits
MI+CTI+ROOF
= 78% （91/116）
Chae S, et al. JACC 2007;50:1781–7
Possible Reentrant Circles After PVI
Cycle length: 240ms
Septal PPI: 240ms
Lateral PPI: 275ms
Pseudo localized reentry
20
P
QRS
A
V
LA
Multiple ATs after 1st ABL
固定消融策略--- 2“0”3L
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CASE CAF 58M
Abl：CPVA, roof-line, MAI, CTI, Cs
DC-CV
RSPV
RIPV
LSPV
LIPV
顶部线阻滞
二尖瓣环峡部阻滞(1)
CS近端起搏:S-ABLd 130ms
二尖瓣环峡部阻滞(2)
CS远端起搏:S-ABLd 145ms
二尖瓣环峡部阻滞(3)
大头远端起搏:S-CSd 150ms CSp>>CSd
三尖瓣环峡部阻滞
CS近端起搏:S-LRA 144ms
诱发阴性
Burst with the shortest 1:1 capture
2“0”3L的优点
2“0”3L的优点
• 策略相对固定
• 可重复性强
• 省时
• 有效
• 再次消融相对简单
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CAF诱发的必要性？
57
Trigers Outside PVs
60M CAF, Undergone 2 cather ablation, 1 open heart MAZE
RAA Cutted
LA Scar
4 PVs Isolated
V2
I
aVF
PV12
PV23
PV34
PV45
PV56
PV67
PV78
PV90
CS34
CS23
CS12
ABL34
ABL12
RSPV
RIPV
LSPV
LIPV
Two ATs Induced
I
V2
aVF
CS12
CS23
CS34
ABL12
ABL34
STM
S1S1=100ms
SVC AT（F）（CL=220ms）
S1S1=180ms
AVNRT（CL=340ms）
I
aVF
V2
CS12
CS23
CS34
ABL12
ABL34
STM
AVN Abl.
V2
I
aVF
PV12
PV23
PV34
PV45
PV56
PV67
PV78
PV90
CS34
CS23
CS12
ABL12
ABL34
STM
SVC
Isolation
BURST （－）
V2
I
aVF
PV12
PV23
PV34
PV45
PV56
PV67
PV78
PV90
CS34
CS23
CS12
ABL12
ABL34
STM
A-Stim.
SVC-Stim.
持续性房颤消融终点……
• 是否需要肺静脉外消融？ （Y)
• 肺静脉外消融：CFAE, 线性, 局灶，或全部? （N)
• CFAE 消融在 PVI + 线性消融之后？（N)
• CFAE消融在 PVI + 线性阻滞之后？（Not necessary)
• 术中房速需要逐个标测么？（N)
• 消融终止房颤或规则？（Not necessary)
• 窦律恢复后（abl. or CV）是否需要诱发？（Y)
65
谢谢
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