房颤培训.ppt

房颤总论 潘凤超1培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department心房颤动的定义 心房纤颤是一个日益受到重视的疾病，因为其发病率随年龄而明显增高；其栓塞性疾病(尤其是脑卒中)是致死、致残的主要原因之一；房颤又导致患者生活质量下降及心功能受损。房颤是指规则有序的心房电活动丧失，代之以快速无序的颤动波，是最严重的心房电活动紊乱 心房无序的颤动失去了有效的收缩与舒张，心房泵血功能恶化或丧失，加之房室结对快速心房激动的递减传导，引起心室极不规则的反应 2培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department3房颤12导联心电图表现ECG中P波消失，代之以颤动波f，R-R间期不规则培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department流行病学4最常见的快速性心律失常估算：美国250万，欧盟450万，中国超过800万累积发生率男性为2.2%、女性为 1.7%发病率随年龄增大而增加：40岁 0.1%，80岁 8.8%心衰和瓣膜病者发病率高，70左右的房颤发生在器质性心脏病患者“孤立性”房颤发生率：1230%病死的最主要原因是缺血性脑卒中，其发生率随年龄增加明显升高1/6的中风患者为有房颤的患者培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department预后风湿性房颤年卒中的发生率是无房颤者的17倍，是非风湿性房颤的5倍非风湿性房颤的年卒中发生率为5%，是无房颤者的27倍卒中的发生率随年龄而增加 5059岁：1.5%，80岁：23.5%房颤的死亡率是窦律者的2倍，但与基础心脏病的严重程度有关房颤与心力衰竭房颤能使心功能恶化 房颤与心肌缺血 房颤使冠心病患者缺血程度加重 房颤与心动过速性心肌病正因为如此高的发病率及其危害巨大，房颤成为电生理 行业最大的市场。5房颤培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department房颤的危害6中国电生理行业奠基人之一-孙瑞龙教授因房颤引起脑栓塞及并发症去世。中国起搏电生理奠基者陈新教授因房颤引起脑栓塞导致下肢瘫痪抗SARS首席功臣钟南山受困于房颤带来的不适培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department心房颤动的病因与一些心血管疾病有关：风心病、高血压、心肌病、冠心病、肺心病、先心病、心脏外科手术等与一些急性原因有关：如饮酒过量、急性心肌梗死、急性心肌炎、急性心包炎、肺部疾患、胸腔手术以及甲状腺功能亢进等与一些心律失常伴存：包括房室折返、房室交界区折返性心动过速或房性心动过速上述原因消失或被治愈，房颤可能不再发作7培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department房颤的分类名称名称临床特点临床特点初发房颤初发房颤有症状的（首次发作）有症状的（首次发作）无症状的（首次发现）无症状的（首次发现）发生时间不明（首次发现）发生时间不明（首次发现）阵发性房颤阵发性房颤持续时间持续时间 7 7d d（常常 48 7 7d d非自限性非自限性永久性房颤永久性房颤不能终止的不能终止的终止后又复发的终止后又复发的没有转复愿望的没有转复愿望的8培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department房颤的电生理机制1947，Scherf等，完整的房颤局灶机制假说，即起源于心房的局灶发放高频电激动即可导致房颤。1959，Moe等，多子波折返激动学说，即房颤的维持有赖于心房内一定数量折返子波的同时存在，这些折返子波在空间上随机运行和分布，其折返环由心房局部有效不应期和可兴奋性所决定。1992年，Schuessler 等，局灶驱动伴颤动传导假说。肺静脉波假说与房颤的维持机制其他：自主神经系统，炎症，组织与电学基质等9培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentMichel Hassaguerre最先发现肺静脉的电活动触发房颤（1998 NEJM）10房颤的电生理机制培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentPVLALighter(trigger)Wood(substrate)房颤的电生理机制11培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department12房颤导致房颤作用F.Gramley et al.,Int.J.Cardiol.2009房早，房速等阵发性房颤持续性房颤永久性房颤培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department房颤导致房颤作用心房越大，易发生房颤。哺类动物中：体积大者，心房大，房颤发生率高。13培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department心房颤动的临床表现临床症状取决于心室率、心功能、伴随的疾病以及患者的敏感性多数患者有心悸、头晕、疲乏、气短和黑朦等 少数患者无症状左心室功能不全症状，可能继发于房颤时持续快速的心室率14培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department房颤的治疗策略心律控制（最佳）转为窦性心律心率控制 保持房颤心率，给与抗凝药物控制心室率在理想水平抗凝治疗，预防血栓栓塞15培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department房颤的治疗方法一、药物治疗 优势：简便易行，一次性费用少，患者易 接受，无创伤 劣势：长期服药，致心律失常作用，有副作用，生活质量低 成功率：控制成功率较低(约为20%-30%)二、非药物治疗 外科治疗:外科消融术 内科治疗：电复律，起搏治疗，导管射频消融术16培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department2006 ACC/AHA/ESC 房颤指南导管消融治疗 在2001年的指南中导管消融治疗的资料是有限的，而房颤的消融治疗也没有在当时的指南中得到推荐。2006指南第一次将导管消融治疗作为房颤患者的标准治疗手段。房颤消融治疗作为继药物治疗后的二线治疗手段，并指出无论是阵发性房颤还是持续性房颤，只要一种抗心律失常药物治疗失败，就可以进行导管消融治疗。对于不伴心脏疾病的房颤以及房颤伴有高血压或者冠状动脉疾病的患者，导管消融和胺碘酮治疗具有同等的地位17培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department2011 ACCF/AHA/HRS 房颤指南导管消融治疗18对于症状明显、应用抗心律失常药物无效、左房正常或轻度扩大、LVEF正常或轻度降低且无严重肺病的阵发性房颤患者，经导管消融术在维持窦性心律上是有用的（由a，C改为，A）对于症状性持续性房颤患者，消融术治疗合理（a，A）在左房明显扩大或LVEF显著降低的症状性阵发性房颤患者，消融术治疗可能合理（b，A）培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department 消融策略的演变（无论何种术式都需要三维导航）CPVICPVAPVAI+CFESequential ablation approachCFAE肺静脉口节段消融19培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department为什么要大力推广房颤消融手术1.必须使用三维标测系统：房颤手术耗时长，导管操作要求高，需要在直径大约4公分的心房内完成两个连续，立体的环形消融线，至少需要上百个消融点，没有三维的指导难以完成隔离，同时并发症的几率也会增加。2.必须使用冷盐水消融导管：房颤需要达成透壁的消融，心房壁薄厚不均，前壁、嵴部、二尖瓣峡部组织厚，普通导管能量无法形成透壁。3.肺静脉隔离是各种房产消融术式的基础，验证肺静脉电隔离的最有效方法是使用环肺电极。4.房颤手术穿间隔操作一般需要两根长鞘、一根穿间隔针。5.正因为以上4个理由，房颤消融术使用的耗材覆盖面最大，导管也是同质耗材内价格最高的产品，其整体费用至少是普通电生理手术的两倍以上。20培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department使用SJM产品治疗房颤带来的好处1.SJM是唯一可以从设备、耗材及疗法为临床提供全面解决方案的公司2.难点1-是穿间隔、SJM的长鞘及BRK针一直是行业无可争议的金标准3.难点2-术者对左房解剖的认识：NavX可以使用环肺快速建模，相较于Carto，速度快，安全、模型细节还原度高21NavX CT Carto 培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department使用SJM产品治疗房颤带来的好处1.难点3-肺静脉隔离，房颤手术中需要用环肺电极指导消融电极治疗，Carto无法显示普通环肺电极，意味着更多的射线量。2.难点4-房颤开展过程当中无法回避的问题是复发率，对于肺静脉触发的房颤，单次消融成功率是接近90%，而慢性房颤两次成功率大致为70%，这是成熟中心的数据，处于房颤学习曲线中的术者成功率更低，复发患者的投诉是许多术者最终放弃开展房颤手术的最主要原因。3.Carto的专用Navi Star导管是手术耗材中价格最高又无法复用，造成二次手术费用患者无法承受。NavX贴片可以共享，对于耗材没有特殊要求，给临床开展手术留有很大的余地。22培培训训部部Training DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining DepartmentTraining Department使用SJM产品治疗房颤的好处1.难点5-房颤术后房速占房颤复发的50%以上，由于机制复杂（多为大折返），标测困难、消融成功率低让很多临床医生望而却步。2.根据经典文献报道，对于非典型房扑，在心房采点300以上才能精确定位消融位点，Carto逐点采样的方式至少需要一小时以上，对医生的体力及操作都是巨大挑战3.Velo