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1、厦门大学附属中山医院 厦门心脏中心心内科 黄卫斌,房颤及房颤射频消融术相关缓慢型心律失常,Summary,病窦综合征房颤与病窦关系消融术能否替代起搏器治疗消融术相关缓慢心律失常展望,病窦综合征,窦 性心动过缓窦房结变时性功能障碍快-慢综合征慢-快综合征,Sick sinus syndrome,PathologyMachanismSss中af 发生率？,Discovery of sinus node,1907年,structure of sinus node,Three-dimensional sinus node,Position of leading pacemaker site(ident
2、ified by arrows)in humans:,Sick sinus syndrome,平均发病年龄68岁,但可发生于任何年龄,新生儿中亦有发病,年龄大于65岁人群中患病率1/600,占美国植入起搏器病人中的50%病因推测可能为纤维化或缺血,但未能得到充分证实,病窦综合征对心房影响,房颤与病窦的关系,房颤对心房及窦房结电重构作用快-慢综合征房颤治疗可逆转电重构作用,病窦合并房颤发生率?,慢-快综合征以心率慢为主，合并房颤、房扑，用药存在矛盾是否可行消融治疗？,J Cardiovasc Electrophysiol.2004 Jul;15(7):784-9.,Pulmonary vein
3、isolation for atrial fibrillation in patients with symptomatic sinus bradycardia or pauses.Khaykin Y,Natale A.Center for Atrial Fibrillation,Department of Cardiovascular Medicine,The Cleveland Clinic Foundation,Cleveland,Ohio 44195,USA.INTRODUCTION:Sick sinus syndrome is commonly associated with tac
4、hyarrhythmias and bradyarrhythmias that often are symptomatic.The aim of this study was to assess the effect of pulmonary vein isolation in patients with sick sinus syndrome and atrial fibrillation(AF).METHODS AND RESULTS:Three hundred fourteen consecutive patients who underwent pulmonary vein isola
5、tion between December 2000 and January 2002 were included in the study.Thirty-one patients had sick sinus syndrome,which was defined as a preprocedural history of symptomatic sinus bradycardia or pauses.Endpoints included AF recurrence,change in the frequency of sinus pauses,and symptoms of presynco
6、pe or syncope,as well as mean heart rate and percentage of atrial pacing in patients with pacemakers implanted prior to the pulmonary vein isolation.Patients had AF for an average of 6+/-3 years.Patients were 58+/-8 years old and had ejection fractions of 55+/-4%.Sixty-one percent had implanted pace
7、makers.AF recurred within 6 months in 4 patients.Two had a successful second pulmonary vein isolation procedure.There were no recurrences of presyncopal events(P 0.05)or documented sinus pauses(P 0.05)after successful pulmonary vein isolation in the patients without permanent pacemakers.Patients wit
8、h pacemakers had a 13-fold reduction in the percentage of atrial pacing(P 0.05).Both groups showed a significant increase in average heart rates at 6-month follow-up.CONCLUSION:Cure of AF by pulmonary vein isolation helped resolve the clinical manifestations of sick sinus syndrome,suggesting that th
9、e occurrence of AF and/or the associated treatment could be partially responsible for sick sinus syndrome.,快-慢综合征,房颤终止后长间歇，消融是否有效？,房颤可导致窦房结功能障碍房扑房颤终止后,窦房结功能可恢复,Electrophysiological properties in chronic lone atrial fibrillation.K Kumagai,K Arakawa.Circulation 1991;84;1662-1668,Patients.The study gro
10、up consisted of 12 patients with chronic(more than 1 year)lone AF who were referred for external direct current cardioversion.Adiagnosis of chronic lone AF in the present study was made by excluding the following diseases:coronaryThe control group consisted of 12 patients with associated arrhythmias
11、 except for atrial flutter or fibrillation,sick sinus syndrome,and organic heart disease.,Sinus nodalfunction.Corrected sinus recovery time was over 525 msec in nine patients with AF and significantly longer(p0.01)than that in the control group.Sinoatrial conduction time was over 150 msec in 11 pati
12、ents and significantly longer(p0.01)thanthat in the control group.,Electrical Remodeling of the Atria Associated With Paroxysmal and Chronic Atrial Flutter.Paul B.Sparks,Jonathan M.Kalman.Circulation2000;102;1807-1813,ERPs at LRA,Septum,and CS and cSNRTs(600ms/450 ms)at 15 Minutes,30 Minutes,and 3 W
13、eeks AfterTermination of Chronic AFL,Reverse Remodeling of Sinus Node Function After CatheterAblation of Atrial Fibrillation in Patients With Prolonged Sinus Pauses(Circulation.2003;108:1172-1175.)Mlze Hocini,Michel Haissaguerre,20例,(14 men;age 56.012.1 years)阵发性房颤(房颤史10080month),并房颤转律后RR大于3秒(4.82.2
14、秒),晕厥6例,近似晕厥11例,2例术前有行起搏器术,5例器质性心脏病或高血压排除无房颤时有窦性停搏者.术式:环肺静脉隔离,左房附加线(左下肺静脉至二尖瓣瓣环,左房顶部线,左房前壁线),三尖瓣峡部线隔离,窦房结功能评估,CSNRT:大于基础心动周长+400-600ms,起搏60秒,术后6月评估平均心率与心率范围,Holter评估,术后1周1,3,6月最高心率:最大运动负荷心率,术后1周1,3,6月,消融情况,共进行33次消融,1次10人,2次7人,3次3人.暴光时间5428,手术时间 16511 minutes,临床结果,随访26.017.6 months,3例病人房颤复发,1例应用药物,房颤
15、不再发作;2例房颤发作减少,其中一例仍有房颤终止时窦性停搏,植入起搏器.17例病人(85%)没有房颤发作,也没有应用药物,均无心动过缓症状.,窦房结功能,No sinus pauses3 seconds were observed by ambulatory monitoring during the first week after ablation or at 1,3,and 6 months in 19 patients.,Mean heart rate.,conclusion,Although the mechanisms resulting in the association be
16、tween sinus node dysfunction and atrial arrhythmias remain unknown,the present study demonstrates that paroxysms of AF may produce depression of sinus node function resulting in prolonged sinus pauses.This phenomenon is reversible by curative ablation of AF,thus avoiding the need for pacemaker implantation.,Maximal heart rate.,Heart Rate Range,Corrected sinus node recovery time,慢性房颤并长RR,房颤消融相关心动过缓,消融术中迷走反射,Vagal reflexes were defined as sinus bradycardia(40 bpm),asystole,AV block,or hypotension that occurred within a few second of the onset of ablation.,
