房顫消融專題知識講座培訓課件

房顫消融專題知識講座TheFutureofCardiacIntervention

(NationalHealthCouncil)Stentandintravascularinterventionexpectedtodoubleovernext3yearsCABGvolumetodeclineabout10%withcardiacsurgeryprimarilyexpandinginEPSandCHFsuchasablativesurgery,biventricularpacing,LVremodeling,andcardiacmuscleaugmentation.Valvularvolumetoincreaseabout20%by20052房顫消融專題知識講座ChronicAtrialFibrillationAffects2millionpeopleintheUSalonewitha9%5yearmorbidityfromanticoagulationanda5%/yearriskofstrokeAshighasan80%riskofstrokeat8yearsintheJapanesestudygroup(Kitamura)Availabletreatmentmodalitiesincludesurgical“Maze”,cryotherapy,radiofrequency,irrigatingradiofrequency,microwave,andlaserSurgicalMazesuccessbestoverallbutMicrowavehastheleastcomplicationsandthebesteaseofuse3房顫消融專題知識講座MicrowaveAblation:~3000patientsOpenHeart2300patients75%success-0to4yearfollowupBeatingHeart–Off-Pump700patients80%success-0to2yearfollowupNo

adverse

eventsMIS–Off-PumpMiniThoracotomy 3casesRobotic 2casesThoracoscopy 2cases4房顫消融專題知識講座2cm-FLEX2TM4cm-FLEX4TM7cm-FLEX75房顫消融專題知識講座“...specimenswerecharacterizedbymyocellulardamageinvolvingthefullthicknessoftheatrialwall,wherethicknessrangedfrom4-5mmto1cm.”

ClinicalHistopathologyandUltrastructuralAnalysisofMyocardiumfollowingMicrowaveEnergyAblationEricManasseMD,PiergiuseppeColomboMD,PaolaBraidottiPhD,MassimoRoncalliMD-PhD,RobertoGallottiMD(submittedtotheAnnalsofTh.Surg.)6房顫消融專題知識講座from:InVitroandInVivoEvaluationoftheThermalPatternsandLesionsofCatheterAblationwithaMicrowaveMonopoleAntennaDavidKeaneMD,Ph.D.,JeremyRuskinMD,NancyNorris,Pierre-AntoineChapelon,DanyBerube,Ph.D.7房顫消融專題知識講座Beating-HeartSurgeryEpicardialablationEndocardialview8房顫消融專題知識講座TransmuralLesionViableTissueBeating-HeartSurgery9房顫消融專題知識講座Dr.Maessen-Maastricht,Netherlands(Off-pump)40patients(32cAF,8pAF)acute discharge FU40/40 26/39 32/39(82%) 10patients8-11months 10patients6-8months 19patients0-6monthsPresentedatISMICS-200210房顫消融專題知識講座n=31(mitralvalve)

26/31(84%)insinusrhythm

Dr.Zembala-

Zabrze,Poland(ArrestedHeart)PresentedatCTT-200211房顫消融專題知識講座29patients(concomitantsurgeries)14MV-15CABG92%inNSRFollow-up:8patientsmorethan6months21patientsbetween1and5months

submittedtotheAnnalsofTh.Surg.-2002Prof.Schutz-Munich,Germany(ArrestedHeart)12房顫消融專題知識講座14patients(beating-heartandarrested-heart)79%inNSR(11/14)64%withoutAAdrugFollow-up:mean131days(63-331days)

Prof.Gallotti/Dr.Manasse-Milan,Italy(ArrestedHeart)PresentedatCTT-200213房顫消融專題知識講座12patients(on-pump,concomitantsurgeries)75%inNSRFollow-up:upto3months

Dr.Gillinov-ClevelandClinic(ArrestedHeart)14房顫消融專題知識講座DresdenExperience211consecutivepatientswithdocumentedatrialfibrillationforaverageof6.8yearsconcomitantMVR,CABG,AVR,andTVRSurvival98%,noMWcomplications70%NSRat6months68%NSRat1yearwithnormalatrialtransportfunction23%hadapostopPPMimplant15房顫消融專題知識講座TheInternationalMedicalGroupConference“HowtoTreatAtrialFibrillationDuringMitralValveSurgery”,AnnoDiegeler,21July2001TheDresdenexperience-Dr.MichaelKnaut(ArrestedHeart)PatientPopulation: n=120

Atleast6monthsofdocumentedchronicAF Refractorytoatleast2AAdrugs1YearResults:

70-75%insinusrhythm(n=60)Sub-Populations

Bypass: 60%insinusrhythm Mitralreplacement: 70%insinusrhythm Mitralrepair: 71%insinusrhythm Tricuspid: 75%insinusrhythm Aortic: 85%insinusrhythm

16房顫消融專題知識講座ComparativestudyonConcomitantAtrialFibrillationGroupA-62patientswithnoablation duringsurgerysurvival94.2%NSRin6%ofMVD;9%withCAD;and5%withAVDdiseaseprocessesGroupB-88patientsreceivingMWablationwiththeirsurgerysurvival98%NSRin62%ofMVD;70%withCAD;and82%withAVDdiseaseprocessesKnaut,M;etalDresden,Germany17房顫消融專題知識講座10-15patientspersubgroupMicrowave =91%(11/12NSR)

Radiofrequency =65%

Cryoablation =55%7to12monthfollow-upPresentedatEACTS-2001Dr.Graffigna-Trento,Italy(ArrestedHeart)18房顫消融專題知識講座Dr.Kshettry&Dr.SaltmanMinneapolis&StonyBrook(Off-pump)21cAFpatients(allMitralValve)SubmittedSTS-2003Acute

13(62%)NSR5(24%)pacedrhythm1(7%)JCTrhythm2(10%)AF Follow-up(1-3months)(n=20)

17(85%)NSR3(15%)AF 19房顫消融專題知識講座Dr.TomMolloy

Portland,OR19patients(9off-pump,10on-pump)100%leftORinsinusorpacedrhythm62%freeofAFatdischarge89%ofptsfreeofAFatlastfollow-up(17/19)Only37%(7/19)arestillonanti-arrhymthicdrugPresentedatNewEra,January200321房顫消融專題知識講座Dr.DonaldThomas

Chicago,IL22patients(11off-pump,11on-pump)100%leftORinsinusorpacedrhythm86%ofpts(19/22)freeofAFatlastfollow-upSubmittedtoISMICS,200322房顫消融專題知識講座CardiologyEPExperiencePrimaryfociappeartobeatendovascularmuscularsheathsatvascularinsertionpointsinitialattemptsatprimaryablationwithinpulmonaryveinsledtopulmonaryveinstenosisPresentEPtechniqueinvolvesencirclingpulmonaryveinorificesablatingonendocardialsurfaceofatriumbutpresentlytakesanaverageof5-6hoursinexperthandsusingcatheterbasedapproach.23房顫消融專題知識講座

RSPVRIPVLAAMVLSPVLIPVEndocardialLeftAtrialAblation24房顫消融專題知識講座

RAATVEndocardialRightAtrialAblationCSIVCSVCSeptotomy25房顫消融專題知識講座26房顫消融專題知識講座27房顫消融專題知識講座28房顫消融專題知識講座InitialcardiomyoplastytrialsfromSingaporeandFrenchgroupsnowhave15-23%10yearsurvivalrateslargerpopulationnowconsideredinreopenedtrialsgiventhatatrialfibrillationwasaninitialcontraindicationinthefirstgroupswithconcurrentatrialablativesurgerysynchronyisachievableCardiomyopathySupport29房顫消融專題知識講座EnloeExperienceConcomitantcardiacsurgeryinpatientwithchronic(3months)atrialfibrillationorrecurrentparoxysmalatrialfibrillationFailureofAAdrugpreopIsthmusablationwhenRatrialapproach37leftatrialablations21epicardial, 16endocardial6rightsidedablationsSuccessrates87%successinendocardial85%successinepicardial30房顫消融專題知識講座PreAblationIssuesEnsureatriumisfreeofclotespeciallywhencontemplatingepicardialablationIfperformingconcomitant“off-pump”CABG,recommendperforminglateralwalldistalanastomosespriortoablationEnsurecomplete,detailedidentificationofpulmonaryveinanatomylookingforallpossibleaberrancies31房顫消融專題知識講座TechnicalConsiderationsEnsureadequacyofablation,takethetimetomakecrossinglesionsTrytokeepablationsurfacesrelativelydryEndocardialablation:Ensure1)bloodflowthroughcoronariesand2)TEEprobepulledback.Epicardialablation:Ensureavoidanceofcoronaryarteries,coronarysinus,andpulmonaryarteryRememberthatAtrialNatriureticPeptideproductionoccursintheatrialappenda