房颤消融专题知识讲座培训课件.ppt

Click to edit Master title style,Click to edit Master text styles,Second Level,Third Level,Fourth Level,Fifth Level,*,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,The Future of Cardiac Intervention,(National Health Council),Stent and intravascular intervention expected to double over next 3 years,CABG volume to decline about 10%with cardiac surgery primarily expanding in EPS and CHF such as ablative surgery,biventricular pacing,LV remodeling,and cardiac muscle augmentation.,Valvular volume to increase about 20%by 2005,Chronic Atrial Fibrillation,Affects 2 million people in the US alone with a 9%5 year morbidity from anticoagulation and a 5%/year risk of stroke,As high as an 80%risk of stroke at 8 years in the Japanese study group,(Kitamura),Available treatment modalities include surgical“Maze”,cryotherapy,radiofrequency,irrigating radiofrequency,microwave,and laser,Surgical Maze success best overall but Microwave has the least complications and the best ease of use,Microwave Ablation:3000 patients,Open Heart,2300 patients,75%success-0 to 4 year follow up,Beating Heart Off-Pump,700 patients,80%success-0 to 2 year follow up,No,adverse,events,MIS Off-Pump,Mini Thoracotomy 3 cases,Robotic2 cases,Thoracoscopy 2 cases,2,cm-FLEX 2,TM,4,cm-FLEX 4,TM,7,cm-FLEX 7,“.,specimens were characterized by myocellular damage involving the,full thickness,of the atrial wall,where thickness ranged from 4-5 mm to 1 cm.”,Clinical Histopathology and Ultrastructural Analysis of Myocardium following Microwave Energy Ablation,Eric Manasse MD,Piergiuseppe Colombo MD,Paola Braidotti PhD,Massimo Roncalli MD-PhD,Roberto Gallotti MD,(,submitted to the Annals of Th.Surg.),from:,In Vitro,and,In Vivo,Evaluation of the Thermal Patterns and Lesions,of Catheter Ablation with a Microwave Monopole Antenna,David Keane MD,Ph.D.,Jeremy Ruskin MD,Nancy Norris,Pierre-Antoine Chapelon,Dany Berube,Ph.D.,Beating-Heart Surgery,Epicardial ablation,Endocardial view,Transmural Lesion,Viable Tissue,Beating-Heart Surgery,Dr.Maessen-Maastricht,Netherlands,(Off-pump),40,patients(32 cAF,8 pAF),acutedischargeFU,40/4026/3932/39(82%),10 patients 8-11 months,10 patients 6-8 months,19 patients 0-6 months,Presented at ISMICS-2002,n=31(mitral valve),26/31(84%)in sinus rhythm,Dr.Zembala-,Zabrze,Poland,(Arrested Heart),Presented at CTT-2002,29,patients(concomitant surgeries),14 MV-15 CABG,92%in NSR,Follow-up:,8 patients more than 6 months,21 patients between 1 and 5 months,submitted to the Annals of Th.Surg.-2002,Prof.Schutz-Munich,Germany,(Arrested Heart),14,patients(beating-heart and arrested-heart),79%in NSR(11/14),64%without AA drug,Follow-up:,mean 131 days(63-331 days),Prof.Gallotti/Dr.Manasse-Milan,Italy,(Arrested Heart),Presented at CTT-2002,12,patients(on-pump,concomitant surgeries),75%in NSR,Follow-up:,up to 3 months,Dr.Gillinov-Cleveland Clinic,(Arrested Heart),Dresden Experience,211,consecutive patients with documented atrial fibrillation for average of 6.8 years,concomitant MVR,CABG,AVR,and TVR,Survival 98%,no MW complications,70%NSR at 6 months,68%NSR at 1 year with normal atrial transport function,23%had a postop PPM implant,The International Medical Group Conference,“How to Treat Atrial Fibrillation During Mitral Valve Surgery”,Anno Diegeler,21 July 2001,The Dresden experience-Dr.Michael Knaut,(Arrested Heart),Patient Population:n=120,At least 6 months of documented chronic AF,Refractory to at least 2 AA drugs,1 Year Results:,70-75%in sinus rhythm(n=60),Sub-Populations,Bypass:60%in sinus rhythm,Mitral replacement:70%in sinus rhythm,Mitral repair:71%in sinus rhythm,Tricuspid:75%in sinus rhythm,Aortic:85%in sinus rhythm,Comparative study on Concomitant Atrial Fibrillation,Group A-62 patients with no ablationduring surgery,survival 94.2%,NSR in 6%of MVD;9%with CAD;and 5%with AVD disease processes,Group B-88 patients receiving MW ablation with their surgery,survival 98%,NSR in 62%of MVD;70%with CAD;and 82%with AVD disease processes,Knaut,M;et al,Dresden,Germany,10-15,patients per subgroup,Microwave=91%(11/12 NSR),Radiofrequency,=65%,Cryoablation,=55%,7 to 12 month follow-up,Presented at EACTS-2001,Dr.Graffigna-Trento,Italy,(Arrested Heart),Dr.Kshettry&Dr.Saltman,Minneapolis&Stony Brook,(Off-pump),21,cAF patients(all Mitral Valve),Submitted STS-2003,Acute,13(62%)NSR,5(24%)paced rhythm,1(7%)JCT rhythm,2(10%)AF,Follow-up(1-3 months)(n=20),17(85%)NSR,3(15%)AF,Dr.David Kress and Dr.Murali Dharan,20,patients(18 epicardial,2 endocardial),100%left OR in sinus or paced rhythm,75%free of AF at discharge,73%of chronic pts free of AF at 3 months(11/15),80%pf paroxysmal pts free of AF at 3 months(4/5),No perioperative complications,deaths,or collateral damage,Presented at NASPE,May 2002,Presented at NASPE,May 2002,Dr.Tom MolloyPortland,OR,19,patients(9 off-pump,10 on-pump),100%left OR in sinus or paced rhythm,62%free of AF at discharge,89%of pts free of AF at last follow-up(17/19),Only 37%(7/19)are still on anti-arrhymthic drug,Presented at New Era,January 2003,Dr.Donald ThomasChicago,IL,22,patients(11 off-pump,11 on-pump),100%left OR in sinus or paced rhythm,86%of pts(19/22)free of AF at last follow-up,Submitted to ISMICS,2003,Cardiology EP Experience,Primary foci appear to be at endovascular muscular sheaths at vascular insertion points,initial attempts at primary ablation within pulmonary veins led to pulmonary vein stenosis,Present EP technique involves encircling pulmonary vein orifices ablating on endocardial surface of atrium but presently takes an average of 5-6 hours in expert hands using catheter based approach.,RSPV,RIPV,LAA,MV,LSPV,LIPV,Endocardial Left Atrial Ablation,RAA,TV,Endocardial Right Atrial Ablation,CS,IVC,SVC,Septotomy,Initial cardiomyoplasty trials from Singapore and French groups now have 15-23%10 year survival rates,larger population now considered in reopened trials given that atrial fibrillation was an initial contraindication in the first groups with concurrent atrial ablative surgery synchrony is achievable,Cardiomyopathy Support,Enloe Experience,Concomitant cardiac surgery in patient with chronic(3 months)atrial fibrillation or recurrent paroxysmal atrial fibrillation,Failure of AA drug preop,Isthmus ablation when R atrial approach,37,left atrial ablations 21 epicardial,16 endocardial,6 right sided ablations,Success rates,87%success in endocardial,85%success in epicardial,PreAblation Issues,Ensure atrium is free of clot especially when contemplating epicardial ablation,If performing concomitant“off-pump”CABG,recommend performing lateral wall distal anastomoses prior to ablation,Ensure complete,detailed identification of pulmonary vein anatomy looking for all possible aberrancies,Technical Considerations,Ensure adequacy of ablation,take the time to make crossing lesions,Try to keep ablation surfaces relatively dry,Endocardial ablation:Ensure 1)blood flow through coronaries and 2)TEE probe pulled back.,Epicardial ablation:Ensure avoidance of coronary arteries,coronary sinus,and pulmonary artery,Remember that Atrial Natriuretic Peptide production occurs in the atrial appendages and full ligation/removal can cause transient renal insufficiency,Postoperative management,Continue patient on antiarrhythmic medication for 2-3 months,use aggressive cardioversion protocol for atrial fibrillation,Continue patient on anticoagulation therapy for 2-3 months,May need temporary cardiac stimulation for initial 48-72 hour period of atrial stunning so definitely have atrial pacing capability,Microwave Ablation Experience,3000,cases performed worldwide with no adverse effects,700 epicardial cases thus far and 7 by minimally invasive approaches,Success rates are approximately 100%upon leaving the OR with 1/3 going back into atrial fibrillation upon discharge but then range from 74-92%successful conversion and retention of NSR at 6 months postoperatively,