手术消融手术技术和临床试验结果及东西方比较(中英文）.ppt

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1、房颤是一常见的疾病,美国有280万房颤患者-人群发病率0.9%（总人口3亿）每年有160,000新发病例老年人和风湿性心脏病患者为房颤高发人群每年700000例中风其中140000(20%)例 中风由房颤所致,房颤在亚洲的现状,日本 新加坡 越南 泰国 印度尼西亚 马来西亚 中国总人数 128 4.7 87 63 230 27 1400(百万)房颤患者数 1.15 0.04 0.78 0.56 2 0.24 12.6(总人口数0.9%)中风数 82 2 39 28 100 12 630(千）风心病高发+,房颤的结局,非致命性疾病中风:致残并发症死亡率:正常人群的两倍医疗费用高，需要治愈目前没有

2、普遍认可的治疗方案,消融工具 祝福或诅咒?,Thomas,Cardiac EP 1999,房颤的消融术VS 切与缝:,动物狗实验中，双极射频消融产生线性、透壁消融线。(Prasad et al,2003)双极射频消融可替代 Cox 迷宫 III术(Damiano et al 2004)多中心临床试验中，双极射频消融可替代Cox 迷宫 III 术(Barns,Cleveland Clinic,Dallas)冠脉搭桥/体外循环患者，双极射频消融可替代 Cox 迷宫 III 术(Khargi et al 2004),“切与缝”技术优于消融术吗？,存在争议,AATS 2006 Mayo Clinic:

3、切与缝 冲洗式双极干式双极 St.Louis:无差异,“切与缝”与手术消融术孰优熟劣仍是一个值得商榷的问题。Melo等人2008年在胸心血管外科杂志（JTCS）上发表了全球房颤手术临床研究的结果。1733名纳入本研究 的房颤患者，仅44名接受“切与缝”手术。其他患者接受某一类型的能量消融术治疗。,在亚洲,射频消融器械占房颤手术消融器械市场的95.某些国家其比例可达100%!,射频消融器械的金标准是可以产生Cox 迷宫III手术透壁消融线（除外二尖瓣和三尖瓣峡部线性消融）的双极。由于其可能会损伤冠脉回旋支动脉、冠状静脉窦和右冠状动脉，峡部线性消融时应使用单极进行笔式射频消融或冷冻消融。,Copy

4、right 2008 The American Association for Thoracic Surgery,Castella M.et al.;J Thorac Cardiovasc Surg 2008;136:419-423,两例左冠脉优势型病例,Copyright 2008 The American Association for Thoracic Surgery,Castella M.et al.;J Thorac Cardiovasc Surg 2008;136:419-423,射频双极钳在左心耳切口至二尖瓣瓣环间形成消融线,Castella M.et al.;J Thorac

5、Cardiovasc Surg 2008;136:419-423,补体C9免疫组化染色显示，消融后8小时左房后壁 透壁性坏死(放大倍数：20倍),Copyright 2008 The American Association for Thoracic Surgery,Castella M.et al.;J Thorac Cardiovasc Surg 2008;136:419-423,双极射频钳顶端位于三尖瓣瓣环附近,发展中国家医疗费用问题,人均国民生产总值,在中国，使用可形成Cox 迷宫III手术消融线单极设备的费用与普通居民一年的收入相当.,由于医疗费用问题很重要，发展中国家患者仅能支付一

6、种设备的费用。,使用单极进行笔式射频消融时，如何保证其透壁性？,冲洗式单极射频消融,确保透壁性的技术,心内膜和心外膜联合消融,确保透壁性,在同一消融线上，对心内膜和心外膜消融。,g,左心房,Click on picture to start movie,Transmurality,从左肺静脉至二尖瓣瓣环消融线的透壁性,左心房,Click on picture to start movie,序贯心内膜和心外膜冲洗式单极消融以确保消融线的透壁性,我们希望得到什么结果 研究时限:2002年10月 2003年12月 44 例患者:30 例二尖瓣反流/修复术,10 例二尖瓣反流主动脉瓣反流,2 例冠脉搭

7、桥,2例房间隔缺损 死亡率:(2 例患者)1例二尖瓣反流,1例 二尖瓣反流+主动脉瓣反流 平均年龄:45 岁(范围：22 60 岁)平均左房直径:51mm(范围：45 62 mm)房颤类型:所有患者均为慢性房颤（大于 1 年）随诊时间:4 5 年 结果:34/42 恢复窦律(81%).心房收缩(M-超声):LA 70%,RA 90%无中风发生，无晚期死亡病例失败患者:6 例，其中有4名患者为累及左心房峡部的房扑,谢谢!,Dr James WongChief Surgeon,Heart,Lung&Vascular Centre Mt Elizabeth HospitalSingapore,AF

8、Is Common,2.8 Million AF in USA-0.9%population 300 million160,000 new cases annuallyPrevalence increased in elderly and RHD700000 strokes annually140000(20%)strokes from AF,Scope Of The Problem in Asia,Japan Singapore Vietnam Thailand Indonesia Malaysia ChinaPopulation 128 4.7 87 63 230 27 1400(mill

9、ion)No of patientwith AF 1.15 0.04 0.78 0.56 2 0.24 12.6(0.9%of popln)(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 nee

10、d for cureNo widely accepted treatment available,ABLATION TOOLS BLESSING OR CURSE?,Thomas,Cardiac EP 1999,AF 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

11、 surgical incisions in Cox Maze III in multicentre trials(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.L

12、ouis:No difference,Cut&Sew vs Surgical Ablation 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 ene

13、rgy ablation or another.,In Asia,RF devices occupy 95%of the market share for AF surgical ablation.In some countries it is 100%!,The Gold S,For 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

14、tricupid isthmus line.Because of the 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 Surgery,Castella M.et al.;J Thorac Cardiovasc Surg 2008;136:419-

15、423,Two examples of left dominant coronary circulation,Copyright 2008 The American Association for Thoracic Surgery,Castella M.et al.;J Thorac Cardiovasc Surg 2008;136:419-423,Radiofrequency bipolar clamp positioned to carry out the ablation line from the left auriculotomy to the mitral annulus,Cast

16、ella M.et al.;J Thorac Cardiovasc Surg 2008;136:419-423,Complement 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 Surgery,Castel

17、la M.et al.;J Thorac Cardiovasc Surg 2008;136:419-423,The radiofrequency clamp is positioned to reach the tricuspid annulus,COST ISSUES IN DEVELOPING COUNTRIES,GPD(nominal)per capital,In China the monopolar device which can create all the lines of the Cox Maze III can cost up to almost a year of per

18、sonal income.,Because of cost consideration can be important,only one device is affordablein developing countries,The issue then if the monopolar RF pen is to be used,how can one ensure transmurality with it,Unipolar Irrigated RF,Technique To Ensure Transmurality,Endocardial&Epicardial Combined Lesi

19、ons,Ensuring Transmurality,Apply ablation to both surfaces along the same line.,g,LEFT ATRIUM,Click on picture to start movie,Transmurality,Transmurality of line of block from LPV to MA,LEFT ATRIUM,Click on picture to start movie,Sequential Endocardial and Epicardial Irrigated Monopolar Ablation to

20、ensure transmurality,What type of results one expect to get Study interval:Oct 2002 Dec 2003 44 patients:30 MVR/Repair,10 MVR+AVR,2 CABG,2 ASD Mortality:(2 patients)1 MVR,1 MVR+AVR Average age:45 years(range 22 60 years)Average LA diameter:51mm(range 45 62 mm)AF type:All chronic and 1 year Follow up duration:4 5 years Result:34/42 in SR(81%).Atrial contraction(M-mode echo):LA 70%,RA 90%No stroke,no late mortality Restudy of failure:6 Patients 4/6 patient has left atrial flutter involving left atrial isthmus,