左房食管瘺的識別與處理

左房食管瘺的識別與處理李毅剛上海交通大學新華醫(yī)院SegmentalPVIsolationCircumferentialAblationCircumferentialIsolationCafes房顫介入治療方法LUPVLLPVRUPVRLPVSCVICVIRAAFSCVICVRUPVRLPVLUPVLLPVPappone環(huán)肺靜脈消融＋線性消融LUPVLLPVRUPVRLPVSCVICVHaissaguerre房顫消融治療主要的并發(fā)癥

--左房食管瘺

--

肺靜脈狹窄

--房性心律失常

--心包填塞

--腦卒中數(shù)天之后才發(fā)生不具有特異性胸痛發(fā)熱驚厥系統(tǒng)性栓塞敗血癥白細胞升高CRP升高左房食管瘺的識別：臨床表現(xiàn)CalkinsH.etal.HeartRhythm2006;10:1162-1163發(fā)生率：〉60例(0.05-1%)死亡率：〉75%左房食管瘺的識別：臨床表現(xiàn)目前最大病例數(shù)報道CummingsJE.etal.AnnInternMed.2006;144:572-574CummingsJE.etal.AnnInternMed.2006;144:572-574CummingsJE.etal.AnnInternMed.2006;144:572-574CummingsJE.etal.AnnInternMed.2006;144:572-574PreisO.JThoracImaging2007;22:283-285左房食管瘺的識別：影像特征PreisO.JThoracImaging2007;22:283-285PreisO.JThoracImaging2007;22:283-285PreisO.JThoracImaging2007;22:283-285MalamisAP.JThoracImaging2007;22:188-191MalamisAP.JThoracImaging2007;22:188-191SchleyP.Europace2006;8189-190SchleyP.Europace2006;8189-190SchleyP.Europace2006;8189-190左房食管瘺的診斷與處理肺靜脈、左房和食管的解剖關系AnatomicRelationshipoftheEsophagusandLeftAtriumTsaoHMChest.2005;128:2581-2587AlthoughtheanatomicrelationshipbetweentheesophagusandLAposteriorwallvariedwidely,twomajorpatternsofesophagealroutescouldbedepictedSanchez-QuintanaD,etal.Circulation.,2005;112:1400-5AnatomicRelationshipoftheEsophagusandLeftAtrium

Sanchez-QuintanaD,etal.Circulation.,2005;112:1400-5AnatomicRelationshipoftheEsophagusandLeftAtrium

Sanchez-QuintanaD,etal.Circulation.,2005;112:1400-5AnatomicRelationshipoftheEsophagusandLeftAtrium

Sanchez-QuintanaD,etal.Circulation.,2005;112:1400-5AnatomicRelationshipoftheEsophagusandLeftAtrium

Sanchez-QuintanaD,etal.Circulation.,2005;112:1400-5AnatomicRelationshipoftheEsophagusandLeftAtrium

左房食管瘺的預防 --了解食管走形 食管造影 CT,MRI，心內超聲（ICE） CARTO-Merge,Navix --放電前食管標測 --食管內溫度監(jiān)測 --低能量輸出 --不同能源：冷凝 --食管內冷鹽水灌注球囊預防與對策食管造影GoodE.JACC2005;46:2107-2110GoodE.JACC2005;46:2107-2110≥2cm 67%≥4cm 4%GoodE.JACC2005;46:2107-2110實時檢測食道的位置更為重要GoodE.JACC2005;46:2107-2110CARTO-MergeNavix改變消融策略Pappone:左房后壁溫度低于55°C

射頻能量應低于50W

左房消融線應移至左房頂壁Ren:臨近食管處溫度低于55°C

射頻功率應在30-50W10－30S：微泡形成/早期超聲可見的損傷形成

我們消融方案:左房后壁溫度低于45°C

射頻能量應低于30W

左房頂部消融線前移食管內溫度監(jiān)測PerzanowskiC,etal.JCE,2006;17:166-170食管內溫度監(jiān)測PerzanowskiC,etal.JCE,2006;17:166-170CummingsJE,etal.Circulation.,2005;112:459-64食管內溫度監(jiān)測CummingsJE,etal.Circulation.,2005;112:459-64溫度探測電極食管內溫度監(jiān)測CummingsJE,etal.Circulation.,2005;112:459-64食管內溫度監(jiān)測CummingsJE,etal.Circulation.,2005;112:459-64食管內溫度監(jiān)測CummingsJE,etal.Circulation.,2005;112:459-64食管內溫度監(jiān)測CummingsJE,etal.Circulation.,2005;112:459-64食管內溫度監(jiān)測CummingsJE,etal.Circulation.,2005;112:459-64食管內溫度監(jiān)測不同能源：冷凝潰瘍發(fā)生率：冷凝：0/44（0%） 射頻：9/44（22%）心內超聲（ICE）心內超聲（ICE）食管內冷鹽水灌注球囊食管內冷鹽水灌注球囊IB:intraesophagealballoon食管內球囊LET:luminalesophagealtemperature食管腔內溫度Tsuchiya.Atrialfibrillationablationwithesophagealcoolingwithacooledwater-irrigatedintraesophagealballoon:apilotstudy.JCardiovascElectrophysiol.2007Feb;18(2):145-50.食管內冷鹽水灌注球囊Tsuchiya.Atrialfibrilla