心房颤动(房颤)是临床最常见的快速心律失常之一。在我国,房颤总患病率为0.77%;70岁以上和80岁以上人群房颤患病率分别达到3.1%和7.5%。房颤患者发生缺血性卒中的风险平均增加5倍,占全部卒中病因的15%。80岁以上患者卒中病因中30%为房颤[1-3]。较高的发病率和致残率,相对于较低的治疗率使得房颤患者的治疗策略和管理水平亟需提升。 一、房颤管理
二、“一站式”治疗策略
左心耳封堵器 对房颤导管消融疗效的影响
三、“一站式”内科介入治疗 单中心经验
小 结 综合以上研究以及我中心的经验,射频消融+左心耳封堵联合的内科介入治疗策略为房颤患者提供了最为全面的治疗方案,联合术式不增加严重并发症和死亡率,对卒中的预防优于单独消融治疗。从房颤症状控制及卒中预防的整体角度上来讲,开展联合术式对患者临床获益最大。因此,对于不适合抗凝和卒中风险较高的症状性房颤患者,可以考虑给予射频消融合并左心耳封堵术的治疗建议,两种术式可以分步进行也可以在同一次介入手术中“一站式”完成,具体根据患者临床特点进行决策。作为进一步的研究发现,长程持续性房颤患者在左心耳封堵联合肺静脉隔离的基础上再实施左心耳电隔离可能是一种更好的消融策略,从目前的研究发现看可以提高房颤消融的成功率,这可能与心耳参与房颤的维持机制相关。 [1] Camm AJ, et al. Guidelines for the management of atrialfibrillation: the Task Force for the Management of Atrial Fibrillation of theEuropean Society of Cardiology (ESC). Europace. 2010;12:1360–1420. [2] Go AS, Hylek EM, Phillips KA, et al .Prevalence of diagnosed atrial fibrillation in adults: national implications forrhythm management and stroke prevention: the AnTicoagulation and RiskFactors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001;285:2370–2375. [3] Stewart S, Hart CL, Hole DJ,et al. Population prevalence, incidence,and predictors of atrial fibrillation in the Renfrew/Paisley study. Heart.2001;86:516–521. [4] Eikelboom JW, Wallentin L, Connolly SJ,et al. Risk of bleeding with 2 doses of dabigatrancompared with warfarin in older and younger patients with atrial fibrillation:an analysis of the randomized evaluation of long-term anticoagulant therapy(RE-LY) trial. Circulation. 2011;123:2363–2372. [5] Blackshear JL, Odell JA,et al. Appendage obliteration to reduce stroke in cardiacsurgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755–759. [6] Goldman ME, Pearce LA, Hart RG,et al. Pathophysiologic correlates of thromboembolism in nonvalvularatrial fibrillation: I. Reduced flow velocity in the left atrial appendage (TheStroke Prevention in Atrial Fibrillation [SPAF-Ⅲ] study). J Am Soc Echocardiogr.1999;12:1080–1087. [7] 周勇, 蒋逸风. 经皮穿刺左心耳闭合装置的研制及临床应用[J]. 介入放射学杂志, 2013, 22: 698- 700. [8] Oral H, Pappone C, Chugh A. Morady F. et al. Circumferential pulmonary-vein ablation for chronic atrial fibrillation. N Engl JMed. 2006;354:934–941. [9] Pappone C, Augello G, Sala S. et al. A randomized trial of circumferential pulmonaryvein ablation versus antiarrhythmic drug therapy in paroxysmal atria lfibrillation: the APAF Study. J Am Coll Cardiol. 2006;48:2340–2347. [10] Stabile G, Bertaglia E, Senatore G,et al. Catheter ablation treatment in patients with drug-refractory atrial fibrillation: a prospective, multi-centre, randomized,controlled study (Catheter Ablation for the Cure of Atrial Fibrillation Study). EurHeart J. 2006;27:216–221. [11] Weerasooriya R, Khairy P, Litalien J. et al. Catheter ablation for atrial fibrillation: are results maintained at 5 years of follow-up? J Am Coll Cardiol. 2011;57:160–166. [12] Karen P. Phillips, MBBSn, Daniel T. Walker. et al. MBBS Combined catheter ablation for atrial fibrillation and WATCHMAN?sleft atrial appendage occlusion procedures: Five-year experience. Journal of Arrhythmia.2015:23-211-217. [13] Christian-Hendrik Heeger, Andreas Rillig, Tina Lin. et al. Feasibility and clinical efficacy of left atrial ablation for the treatment of atrial tachyarrhythmias in patients with left atrial appendage closure devices. Heart Rhythm 2015;12:1524–1531. [14] Alexander Romanov , Evgeny Pokushalov , Sergey Artemenko, et al. Does left atrial appendage closure improve the success of pulmonary vein isolation? Results of a randomized clinical trial. J Interv Card Electrophysiol (2015) 44:9–16. [15] Nitish Badhwar,et al. Adding LAA ligation to conventional ablation improves outcomes. J Cardiovasc Electrophysiol, Vol. 26, pp.135-139, June 2015 [16] Schwartz RS, Holmes DR, Van Tassel RA,et al. Left atrial appendage obliteration: mechanisms of healing and intracardiacintegration. JACC Cardiovasc Interv 2010;3:870-7. 医 师 简 介 储慧民 副主任医师、硕士生导师 现任宁波市第一医院心律失常诊疗中心主任,储慧民心律失常工作室负责人。“书心剑律”中国青年论坛创始人。国家卫计委心律失常介入治疗培训导师,中华医学会心电生理和起搏分会心房颤动工作组委员,中华医学会心电生理和起搏分会室性心律失常治疗工作组委员、左心耳封堵委员会委员,中国心律学会心房颤动工作委员会委员,欧洲心律学会会员,浙江省医学会心脏电生理与起搏分会心电生理治疗组副组长,浙江省医学会心脏电生理与起搏分会青年委员会副主任委员,宁波市医学会心脏电生理和起搏分会秘书,武汉亚洲心脏病医院房颤中心顾问专家。《中华心律失常学杂志》特邀编委,《医学参考报》心律频道编委。 本文内容为《门诊》杂志原创内容 出自《门诊》杂志2016年06月刊 转载须经授权并请注明出处。 《门诊》杂志官方微信 |
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