手術(shù)消融手術(shù)技術(shù)和臨床試驗結(jié)果及東西方比較中英文課件

1、手術(shù)消融: 手術(shù)技術(shù) 和臨床試驗結(jié)果及東西方比較:Dr James WongChief Surgeon,Heart, Lung & Vascular Centre Mt Elizabeth HospitalSingapore房顫是一常見的疾病美國有280萬房顫患者 - 人群發(fā)病率0.9% （總?cè)丝?億）每年有160,000新發(fā)病例老年人和風(fēng)濕性心臟病患者為房顫高發(fā)人群每年700000例中風(fēng)其中140000(20%)例 中風(fēng)由房顫所致房顫在亞洲的現(xiàn)狀 日本 新加坡 越南 泰國 印度尼西亞 馬來西亞 中國總?cè)藬?shù) 128 4.7 87 63 230 27 1400(百萬)房顫患者數(shù) 1.15 0.0

2、4 0.78 0.56 2 0.24 12.6(總?cè)丝跀?shù)0.9%)中風(fēng)數(shù) 82 2 39 28 100 12 630(千）風(fēng)心病高發(fā) + + + + + 房顫的結(jié)局 非致命性疾病中風(fēng): 致殘并發(fā)癥死亡率: 正常人群的兩倍醫(yī)療費用高，需要治愈目前沒有普遍認可的治療方案消融工具 祝?；蛟{咒?Thomas, Cardiac EP 1999“切與縫”與手術(shù)消融術(shù)孰優(yōu)熟劣仍是一個值得商榷的問題。Melo等人2008年在胸心血管外科雜志（JTCS）上發(fā)表了全球房顫手術(shù)臨床研究的結(jié)果。1733名納入本研究 的房顫患者，僅44名接受“切與縫”手術(shù)。其他患者接受某一類型的能量消融術(shù)治療。在亞洲, 射頻消融器械占

3、房顫手術(shù)消融器械市場的95.某些國家其比例可達100 %!射頻消融器械的金標準是可以產(chǎn)生Cox 迷宮III手術(shù)透壁消融線（除外二尖瓣和三尖瓣峽部線性消融）的雙極。由于其可能會損傷冠脈回旋支動脈、冠狀靜脈竇和右冠狀動脈，峽部線性消融時應(yīng)使用單極進行筆式射頻消融或冷凍消融。Copyright 2008 The American Association for Thoracic SurgeryCastella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423雙極射頻鉗頂端位于三尖瓣瓣環(huán)附近發(fā)展中國家醫(yī)療費用問題 0 5 10 15 20 25

4、30 35 40 中國 日本 新加坡 馬來西亞 印度尼西亞 越南 泰國 USDollars34312351636948192581837372461人均國民生產(chǎn)總值在中國，使用可形成Cox 迷宮III手術(shù)消融線單極設(shè)備的費用與普通居民一年的收入相當(dāng). 由于醫(yī)療費用問題很重要，發(fā)展中國家患者僅能支付一種設(shè)備的費用。沖洗式單極射頻消融確保透壁性的技術(shù)心內(nèi)膜和心外膜聯(lián)合消融確保透壁性在同一消融線上，對心內(nèi)膜和心外膜消融。fg左心房Click on picture to start movieTransmurality從左肺靜脈至二尖瓣瓣環(huán)消融線的透壁性左心房Click on picture to s

5、tart moviecd序貫心內(nèi)膜和心外膜沖洗式單極消融以確保消融線的透壁性 我們希望得到什么結(jié)果 研究時限: 2002年10月 2003年12月 44 例患者: 30 例二尖瓣反流/修復(fù)術(shù), 10 例二尖瓣反流主動脈瓣反流, 2 例冠脈搭橋, 2例房間隔缺損 死亡率: (2 例患者 ) 1例二尖瓣反流, 1例 二尖瓣反流 + 主動脈瓣反流 平均年齡: 45 歲 ( 范圍： 22 60 歲 ) 平均左房直徑: 51mm ( 范圍： 45 62 mm ) 房顫類型: 所有患者均為慢性房顫（大于 1 年） 隨診時間: 4 5 年 結(jié)果: 34/42 恢復(fù)竇律 ( 81%). 心房收縮 ( M-超聲

6、): LA 70%, RA 90% 無中風(fēng)發(fā)生，無晚期死亡病例失敗患者: 6 例，其中有4名患者為累及左心房峽部的房撲謝謝!Surgical Ablation: Techniques and Trial Results, Comparison of East and West:Dr James WongChief Surgeon,Heart, Lung & Vascular Centre Mt Elizabeth HospitalSingaporeAF Is Common2.8 Million AF in USA - 0.9% population 300 million160,000 new

7、 cases annuallyPrevalence increased in elderly and RHD700000 strokes annually140000(20%) strokes from AFScope Of The Problem in Asia Japan Singapore Vietnam Thailand Indonesia Malaysia ChinaPopulation 128 4.7 87 63 230 27 1400(million)No of patientwith AF 1.15 0.04 0.78 0.56 2 0.24 12.6(0.9% of popl

8、n)(millions)Potential Stroke 82 2 39 28 100 12 630(thousands)Rheumatic + + + + +prevalence Consequences of AF Not life-threatening diseaseStroke: devastating complicationsMortality: 2x expected for general populationCostly condition, strong need for cureNo widely accepted treatment available ABLATIO

9、N TOOLS BLESSING OR CURSE?Thomas, Cardiac EP 1999AF ABLATION VS CUT & SEW:Bioplar RF creates linear, transmural lesions in dogs (Prasad et al, 2003)Bipolar RF can replace surgical incisions in Cox Maze III (Damiano et al 2004)Bipolar RF can replace surgical incisions in Cox Maze III in multicentre t

10、rials ( Barns, Cleveland Clinic, Dallas)Bipolar RF can replace surgical incisions of Cox Maze III in CABG/CPB patients (Khargi et al 2004)Is the Cut and Sew better than the ablation device ?Controversy AATS 2006 Mayo Clinic: C&S BP irrigated BP Dry St. Louis: No differenceCut & Sew vs Surgical Ablat

11、ion may be a moote point. In the International Registry of Atrial Fibrillation Surgery in which the results were published in the JTCS 2008 by Melo et al, out of 1733 patients in the study, only 44 patients have the cut & sew. All the others have one form of energy ablation or another.In Asia , RF d

12、evices occupy 95% of the market share for AF surgical ablation . In some countries it is 100%!The Gold SFor the RF devices the gold standard is the Bipolar device which can create transmural all the lines of block of the Cox Maze III except for the the mitral and tricupid isthmus line. Because of th

13、e potential damage to the circumflex artery , coronary sinus and the right coronary artery the monopolar RFpen or cryo is used for the isthmus lines.Copyright 2008 The American Association for Thoracic SurgeryCastella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423Two examples of left dominant

14、coronary circulationCopyright 2008 The American Association for Thoracic SurgeryCastella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423Radiofrequency bipolar clamp positioned to carry out the ablation line from the left auriculotomy to the mitral annulusCastella M. et al.; J Thorac Cardiovasc

15、Surg 2008;136:419-423Complement C9 immunostaining of the posterior wall of the left atrium showing transmural necrosis approximately 8 hours after ablation was performed (original magnification x20)Copyright 2008 The American Association for Thoracic SurgeryCastella M. et al.; J Thorac Cardiovasc Su

16、rg 2008;136:419-423The radiofrequency clamp is positioned to reach the tricuspid annulusCOST ISSUES IN DEVELOPING COUNTRIES 0 5 10 15 20 25 30 35 40 Greater Japan Singapore Malaysia Indonesia Vietnam Thailand ChinaUSDollars34312351636948192581837372461GPD ( nominal) per capitalIn China the monopolar

17、 device which can create all the lines of the Cox Maze III can cost up to almost a year of personal income. Because of cost consideration can be important, only one device is affordablein developing countriesThe issue then if the monopolar RF pen is to be used, how can one ensure transmurality with

18、itUnipolar Irrigated RFTechnique To Ensure TransmuralityEndocardial & Epicardial Combined LesionsEnsuring TransmuralityApply ablation to both surfaces along the same line.fgLEFT ATRIUMClick on picture to start movieTransmuralityTransmurality of line of block from LPV to MALEFT ATRIUMClick on picture to start moviecdSequential Endocardial and