持续性房颤的消融策略进展.pptxVIP

持续性房颤导管消融进展王新华上海交通大学医学院附属仁济医院心内科2014 AHA/ACC/HRS GuildelineClass IIa AF catheter ablation is reasonable for selected patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication (388, 392-394). (Level of Evidence: A)Class IIb1. AF catheter ablation may be considered for symptomatic long-standing (12 months) persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication, when a rhythm control strategy is desired (356, 398). (Level of Evidence: B)2. AF catheter ablation may be considered prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication for symptomatic persistent AF, when a rhythm control strategy is desired. (Level of Evidence: C)持续性房颤消融——各领风骚32项LPAF消融荟萃分析（累计成功率） 消融术式繁杂同一术式结果差异性大无法评价孰优孰劣Brook AG et al. Heart Rhythm. 2010;7:835-846 欧洲心律学会持续性房颤消融技术最新调查主要结论：持续性房颤倾向于PVI作为首次消融术式。附加消融步骤和消融终点不统一反映了最优消融术式的不确定性激进消融术式的代表——stepwise ablationMark D. O’Neill, J Interv Card Electrophysiol (2006) 16:153–167Stepwise ablation不是终极术式消融术式：序贯消融单次消融3年随访结果：房颤房速复发率71.6％CHADS2积分≥3或者左房内径≥44 mm1年内复发率100％三次消融后总成功率51％Chen SA, et al. Circ Arrhythm Electrophysiol. 2012;5:514-520. 激进消融伴随的风险不可轻视Takahashi. J Cardiovasc Electropysiol, 2005,16: 1104 Takahashi Y, et al. J Am Coll Cardiol,2007,49:1306–1314Weerasooriva R. JACC 2011;57:160Less is more？近期几项研究显示肺静脉隔离基础上附加消融并不能增加成功率Dixit, S. et al. Randomized ablation strategies for the treatment of persistent atrial fibrillation: RASTA study. Circ Arrhythm Electrophysiol 2012;5: 287–294Verma A, et al. Approaches to catheter ablation for persistent atrial fibrillation.N Engl J Med 2015;372:1812-22……STAR AF II Trial (The Substrate and Trigger Ablation Reduction of Atrial Fibrillation Trial Part II)N=589R1:4:4Verma A, et al. N Engl J Med 2015;372:1812-22各组基线资料主要结果术中参数PVI隔离成功率三组类似（97%）PVI+CFAE组：80%病例CFAE完全消除率PVI+线性消融组：74%消融线径阻滞率随访18个月，首次消融无房颤复发率PVI组59%PVI+CFAE组49%PVI+线性消融组46% （P=0.15）二次消融无房性心律失常复发率PVI组61%PVI+CFAE组50%PVI+Li