手术消融手术技术和临床试验结果及东西方比较(中英文）

《手术消融手术技术和临床试验结果及东西方比较(中英文）》由会员分享，可在线阅读，更多相关《手术消融手术技术和临床试验结果及东西方比较(中英文）（92页珍藏版）》请在装配图网上搜索。

1、手术消融:手术技术和临床试验结果及东西方比较:Dr James WongChief Surgeon,Heart, Lung & Vascular Centre Mt Elizabeth HospitalSingapore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

2、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

3、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)“切与缝切与缝”技术优于消融术吗？技术优于消融术吗？存在争议存在争议 AATS 2006 Mayo Clinic: 切与缝 冲洗式双极干式双极 St. Louis: 无差异“切与缝切与缝”与手术消融术孰优熟劣与手术消融术孰优熟劣仍是一个值得商榷的问题。仍是一个值得商榷的问题。Melo等人等人2008年在胸心血管外科杂志年在胸心血管外科杂志（JTCS）上发表了全球房颤手术）上发表了全球房颤手术临床研究的结果。

4、临床研究的结果。1733名纳入本名纳入本研究研究 的房颤患者，仅的房颤患者，仅44名接受名接受“切与缝切与缝”手术。其他患者接受某手术。其他患者接受某一类型的能量消融术治疗。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。Copyright 2008 The American Association for Thoracic S

5、urgeryCastella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423两例左冠脉优势型病例两例左冠脉优势型病例Copyright 2008 The American Association for Thoracic SurgeryCastella 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 Cardiovasc Surg 2

6、008;136:419-423补体补体C9免疫组化染色显示，消融后免疫组化染色显示，消融后8小时左房后壁小时左房后壁 透壁性坏死透壁性坏死 (放大倍数：放大倍数：20倍倍)Copyright 2008 The American Association for Thoracic SurgeryCastella 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 0 5 10 15 20 25 30 35 40 中国 日本 新加坡 马来西亚 印度尼西亚 越南

7、泰国 USDollars34312351636948192581837372461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。fg左心房ClickonpicturetostartmovieTransmurality从左肺静脉至二尖瓣瓣环消融线的透壁性左心房Clickonpicturetostartmovi

8、ecd序贯心内膜和心外膜冲洗式单极消融以确保消融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线的透壁性q 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 (

9、 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谢谢!SurgicalAblation:TechniquesandTrialResults,ComparisonofEastandWest:Dr James WongChief Surgeon,Heart, Lung & Vascular Centre Mt Elizabeth HospitalSingaporeAF Is Common 2.8 Million AF in USA - 0.9% population 300 million

10、 160,000 new cases annually Prevalence increased in elderly and RHD 700000 strokes annually 140000(20%) strokes from AFScope Of The Problem in Asia Japan Singapore Vietnam Thailand Indonesia Malaysia ChinaPopulation 128 4.7 87 63 230 27 1400(million)No of patientwith AF 1.15 0.04 0.78 0.56 2 0.24 12

11、.6(0.9% of popln)(millions)Potential Stroke 82 2 39 28 100 12 630(thousands)Rheumatic + + + + +prevalence Consequences of AF Not life-threatening disease Stroke: devastating complications Mortality: 2x expected for general population Costly condition, strong need for cure No widely accepted treatmen

12、t available Irrigated BipolarABLATION TOOLS BLESSING OR CURSE?Thomas, Cardiac EP 1999AF 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 surgical inc

13、isions 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. Louis:

14、No differenceCut & 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 e

15、nergy 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 SFor 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

16、and 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 SurgeryCastella M. et al.; J Thorac Cardiovasc Surg 2008;1

17、36:419-423Two examples of left dominant coronary circulationCopyright 2008 The American Association for Thoracic SurgeryCastella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423Radiofrequency bipolar clamp positioned to carry out the ablation line from the left auriculotomy to the mitral annulus

18、Castella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423Complement 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 SurgeryCa

19、stella M. et al.; J Thorac Cardiovasc Surg 2008;136:419-423The radiofrequency clamp is positioned to reach the tricuspid annulusCOST ISSUES IN DEVELOPING COUNTRIES 0 5 10 15 20 25 30 35 40 Greater Japan Singapore Malaysia Indonesia Vietnam Thailand ChinaUSDollars34312351636948192581837372461GPD ( no

20、minal) per capitalIn China the monopolar device which can create all the lines of the Cox Maze III can cost up to almost a year of personal income. Because of cost consideration can be important, only one device is affordablein developing countriesThe issue then if the monopolar RF pen is to be used

21、, how can one ensure transmurality with itThermodynamnics of Surface HeatingUnipolar Irrigated RFTechnique To Ensure TransmuralityEndocardial & Epicardial Endocardial & Epicardial Combined LesionsCombined LesionsEnsuring TransmuralityApply ablation to both surfaces along the same line.fgLEFTATRIUMCl

22、ickonpicturetostartmovieTransmuralityTransmuralityoflineofblockfromLPVtoMALEFTATRIUMClickonpicturetostartmoviecdSequential Endocardial and Epicardial Irrigated Monopolar Ablation to ensure transmuralityq What type of results one expect to get Study interval: Oct 2002 Dec 2003 44 patients: 30 MVR/Rep

23、air, 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 isthmusThank You !