起搏防治房颤：果真形同鸡肋吗？.ppt

福建医科大学附属协和医院心内科福建省冠心病研究所陈良龙 MD PhD,起搏防治房颤：果真形同鸡肋吗？,传统治疗复律并维持窦律:AD/DC控制心室率:抗栓治疗:包括抗凝及抗血小板聚集 AD治疗并不理想，特别是AD的致心律失常作用，因此,非药物治疗受到了重视.非传统治疗外科迷宫手术导管消融术心脏起搏治疗,房颤的治疗,起搏抑制房颤的理论基础,房性早搏是房颤发生最常见的触发因素与房颤发生有关的因素还包括:显著心动过缓,如窦缓、SSS房内及房间传导阻滞短长周期现象心房复极离散度增加理论上，心房起搏可以阻止心脏停搏或心动过缓导致的心房不应期及复极离散度改变、减少房内及房间传导时间、抑制心房异位兴奋点，从而预防折返、颤动样传导及触发引起的房颤。临床上，许多学者观察到植入生理性起搏器的房颤患者术后房颤发作频度减少或持续时间缩短。故而，起搏作为治疗和预防房颤的一种手段被提出来。,起搏抑制房颤的措施,起搏部位常规RA起搏双心房起搏右心房多部位起搏特殊部位起搏：Bechmen束多部位起搏使心房激动通过多个方向，减轻局部传导延迟，预防功能性传导阻滞的发生，使双心房再同步，减少复极的离散度，减轻心房的各向异性。起搏程序预防房颤的心房超速起搏程序（ODP）抗心动过速起搏程序（ATP）,心房超速起搏对房颤的预防作用,心房超速起搏预防房颤发生的机制主要是消除房颤的诱发因素，如抑制房性早搏消除早搏后的长间期现象此外，通过保持和控制心率及心律从而降低心房复极的离散度目前临床应用的有二类持续性起速起搏(sustained atrial overdriving,SAO)动态心房超速起搏(dynamic atrial overdriving,DAO),设置的心房频率比患者自身频率一般10%以上，通常在80-90bpm。设置心房起搏频率越快，则患者自主心率出现的机率越少，早搏的发生率则越低，从而预防房颤的效果越好。缺点:起搏频率快，导致耗氧量增加，尤其不利于心绞痛的病人。心率几乎全由起搏器控制，失去了心率变异性。,持续性心房超速起搏（SAO）,动态心房超速起搏的特点是起搏器能持续检测自身窦性P波，并与房性早搏相鉴别。当检测到16个窦性心搏有2次房性早搏出现，起搏器就会自动提高心房起搏频率，并逐渐增加起搏频率直到稍超过房性早搏频率，从而达到超速起搏的目的。这种起搏频率逐渐增加的方式，比固定频率超速起搏(SAO)要优越些，不但省电而且病人更适应，新近临床实验显示DAO使房颤发生率显著降低，圣犹达公司lntegrityTM AFxDR就是一种DAO起搏器。,动态心房超速起搏(DAO),主要产品,St.Jude MedicalTrilogy DR+/DAO Model 2360L/2364LIntegrity AFx DR Model 5346MedtronicAT 500Kappa 900VitatronVita 900E,9000,AF Suppression,Algorithm Overview运算方式,Sinus rateDynamic atrial overdrive,Maximum tracking rateBasic lower rate,Algorithm Overview,AF Suppression Algorithm Overview,保证心房起搏占90%以上比例起搏频率根据病人的自身心房活动而动态变化在连续16个心动周期中感知到2个P波，AF Suppression的起搏频率将自动提高起搏的次数可由程控决定 经一段时间起搏后，频率会逐渐下降，同时检测自身心房活动,AF Suppression Algorithm Overview,AF Suppression Algorithm Overview,2 P-waves were seen therefore,Overdrive occurs,AF Suppression Algorithm Overview,AF Suppression Algorithm Overview,低频超速抑制(LRO)150ppm:每步增加 5 ppm,1200,1,2,Base Rate Pacing1200 ms(50 ppm),Overdrive Pacing1016 ms(59 ppm),While base rate pacing at 50 ppm(1200 ms),2 P-waves occur in the 16-cycle window,the atrial pacing rate increases to 59 ppm(1016 ms),AF Suppression Algorithm Overview,AF Suppression Algorithm Overview,While base rate pacing at 50 ppm(1200 ms),2 P-waves within 16 cycles occur,the atrial pacing rate increases to 59 ppm(1016 ms),AF Suppression Algorithm Overview,频率的恢复:12/8 法则 100 ppm 每步增加12 ms 100 ppm 每步增加8 ms,ECG continued on next slide.,AF Suppression Algorithm Overview,2 P-waves within 16 cycles results in an atrial rate increase,12 mm/sec printer speed,Rate Increase,AF Suppression Algorithm Overview,Rate Recovery occurs when the interval increases from 1016 ms to 1022 ms,25 mm/sec printer speed,ECG demonstrates Rate Recovery continuing until Base Rate of 1200 ms is reached(25 mm/sec),AF Suppression Algorithm Overview,2 P-waves were seen therefore,Overdrive occurs followed by Rate Recovery,AF Suppression Algorithm Overview,起搏防治房颤临床试验,Integrity AFx DR Model 5346,St.Jude Medical pulse generators Used for the trial:,Atrial Dynamic Overdrive Pacing Trial-A(ADOPT-A),Trilogy DR+/DAO Model 2360L/2364L,ADOPT-A Clinical Trial,N=203,N=195,N=130,N=158,ADOPT-A Clinical Trial,ADOPT-A Clinical Trial,ADOPT-A Clinical Trial,ADOPT-A Clinical Trial,AFs OFF,AFs ON,Total Patients,158,130,Patients with AF Days,81,73,Total AF Days,682,421,Total Follow-up,Duration(Days),27,359,22,526,AF Burden,2.493%,1.869%,AF Burden Reduction 25.03%，P 0.05,AF负荷减少,ADOPT-A Clinical Trial,0,1,2,3,4,5,6,7,8,9,10,6 Months Prior to Implant,Implant to 6 Months,Mean AF Episodes,p 0.0001,8.1 4.2,8.3 4.1,4.3 11.5,3.2 8.5,AFs OFF,AFs ON,AF 事件的减少,ADOPT-A Clinical Trial,88,90,92,94,96,98,100,0,30,60,90,120,150,180,Duration(Days),(%)w/o Hospitalization*,Freedom to first hospitalization(n=288),6%Reduction in Hospitalizations,AFs OFF,AFs ON,p=NS,住院时间的减少,ADOPT-A Clinical Trial,Freedom from First Cardioversion(n=288),降低了63%转复,90,92,94,96,98,100,0,30,60,90,120,150,180,(Duration)Days,(%)w/o Cardioversion,AFs OFF,AFs ON,p=0.0925,ADOPT-A Clinical Trial,Event,Classification,AFs OFF,AFs ON,Lead Dislodgment,8,7,Pneumothorax,2,1,Myocardial Perforation,0,2,Cardiac Tamponade,0,1,System Infection,0,1,System Replacement,0,1,Total,10,13,并发症,ADOPT-A Clinical Trial,死亡率 心衰时主要的死亡原因(3 AFs ON,3 AFs OFF)没有与AF相关的死亡原因,ADOPT-A Clinical Trial,结论AF Suppression 是安全的，并可以降低病窦且伴有阵发性或持续性AF的发病率。AF Suppression 增加了DDDR起搏器对房颤的抑制作用。,Prevention of Atrial Fibrillation by Overdrive Atrial Septum Stimulation,OASES study,OASES Study,326 patients enrolled.71 patients excluded.9 patients with atrial flutter.7 patients on permanent AF.55 protocol violations.255 patients in the study.Male:106Female:149Age:70.1 18.2 years,方 法,85 patients Right Atrial Appendage Pacing+AF85 patients Low Atrial Septum Pacing+AF85 patients Control group Pacing without AF,结 果,结 果,结 论,低位右心房间隔部位+DAO ON的起搏模式是最有效的降低阵发性房颤病人AF负荷的起搏治疗方式。提高了病人的生活质量。,AF Suppression,是圣犹达公司为起搏器病人设计的优越的动态心房超速抑制功能，以预防阵发性和持续性房颤（AF)，降低病人AF的发生；减少有症状的AF病人的住院时间；减少持续性AF病人转复的痛苦；减少房性心律失常或固定较高心房频率起波引起的心悸，使病人感觉更舒服。,The Atrial Therapy Efficacy and Safety Trial,ATTEST study,ATTEST研究,a prospective,randomized studyto evaluate preventive pacing and anti-tachycardia pacing(ATP)in patients with symptomatic AF or AT.DDDRP(AT500,Medtronic)with three atrial preventive pacing algorithms and two ATP algorithms368 pts were randomized one-month post-implant to all prevention and ATP therapies ON or OFF and followed for three months.The AT/AF burden and frequency were determined from daily device counters in 324 patients.,Values shown are the median plus the 25th to 75th percentiles;patients did not receive an activator to log symptomatic episodes until the one-month visit;all atrial therapies were OFF during the run-in period.AF atrial fibrillation;AT atrial tachycardia.,Lee et al.The Effect of Atrial Pacing Therapies on Atrial Tachyarrhythmia Burden and Frequency JACC Vol.41,No.11,2003 June 4,2003:192632,Figure 3.Histogram of atrial tachycardia/atrial fibrillation episode duration.The median episode frequency in each duration band was compared between the ON and OFF groups,and no significant differences were observed(p 0.17).,Lee et al.The Effect of Atrial Pacing Therapies on Atrial Tachyarrhythmia Burden and Frequency JACC Vol.41,No.11,2003 June 4,2003:192632,ATTEST研究结论,This DDDRP pacemaker is safe,has accurate AT/AF detection,and provides ATP with 54%efficacy as defined by the device.The atrial prevention and termination therapies combined did not reduce AT/AF burden or frequency in this patient population.,DAPPAF研究,To compare the safety,tolerance and effectiveness of overdrive high right atrial(RA),dual-site RA and support(DDI or VDI)pacing(SP)in patients with symptomatic atrial fibrillation(AF)and bradycardia,and to determine optimal pacing methods for AF prevention.118 pts were randomized to each of three pacing modes in a crossover trial.,Figure 1.(A)Freedom from crossover within 4.5 months of entering randomized treatment phase for each pacing mode.Dual right atrial(RA)pacing shows a higher Proportion of pts able to remain in the randomized treatment mode as compared with other modes.Figure 1.(B)Freedom from all symptomatic AF in each randomized pacing mode in the entire study population.Dual RA pacing but not high RA pacing shows a trend to prolongation of time interval to AF recurrence.,Saksena et al.Improved Suppression of Recurrent Atrial Fibrillation With Dual-Site Right Atrial Pacing and Antiarrhythmic Drug Therapy JACC Vol.40,No.6,2002 September 18,2002:114050,Figure 2.Freedom from all symptomatic atrial fibrillation(AF)in each randomized pacing mode in study population receiving concomitant class 1 or 3 antiarrhythmic drugs(AAD on the left)or without concomitant drug therapy(AAD on the right).Dual right atrial(RA)pacing but not high RA pacing shows prolongation of time interval to AF recurrence as compared with support pacing and a trend to prolongation as compared with high RA pacing in drug-treated patients.There is no difference in outcome in patients on any randomized pacing mode without concomitant drug therapy.,Saksena et al.Improved Suppression of Recurrent Atrial Fibrillation With Dual-Site Right Atrial Pacing and Antiarrhythmic Drug Therapy JACC Vol.40,No.6,2002 September 18,2002:114050,Figure 3.Freedom from all symptomatic atrial fibrillation(AF)in each randomized pacing mode in study population receiving concomitant class 1 or 3 antiarrhythmic drugs with frequent(weekly events to two events in three months)AF at baseline.Dual right atrial(RA)pacing shows prolongation of time interval to AF recurrence as compared with high RA or support pacing in these patients.,Saksena et al.Improved Suppression of Recurrent Atrial Fibrillation With Dual-Site Right Atrial Pacing and Antiarrhythmic Drug Therapy JACC Vol.40,No.6,2002 September 18,2002:114050,Figure 4.Quality-of-life in the study population at baseline and in each randomized treatment mode for individual measures.Atrial fibrillation symptom checklist(paired analysis)in each randomized mode shows the benefits of both overdrive pacing modes as compared with support pacing.,Saksena et al.Improved Suppression of Recurrent Atrial Fibrillation With Dual-Site Right Atrial Pacing and Antiarrhythmic Drug Therapy JACC Vol.40,No.6,2002 September 18,2002:114050,Figure 5.Comparison of symptomatic or asymptomatic atrial fibrillation(AF)events meeting high rate atrial(HRA)event detection criteria in thedual-site right atrial(RA)pacing or high RA pacing arms of the study.Data are presented as mean values per-day.A significant reduction in mean event frequency is observed for both AF end points in dual-site RA pacing arm as compared with the high RA pacing arm,suggesting benefit with respect to both symptomatic and symptomatic AF.,Saksena et al.Improved Suppression of Recurrent Atrial Fibrillation With Dual-Site Right Atrial Pacing and Antiarrhythmic Drug Therapy JACC Vol.40,No.6,2002 September 18,2002:114050,DAPPAF研究结论,Dual-site RA is safe and better tolerated than high RA and SP.In patients on antiarrhythmics,dual-site RA prolonged and high RA trended to prolong time-to-recurrent AF compared with SP.Dual-site RA provides superior symptomatic and asymptomatic AF prevention compared with high RA in patients with symptomatic AF frequency of 1/week.,总 结,DDDR-DAO是安全并可以耐受的。多数较大规模随机实验证实、但部分试验未能证实：起搏（DAO）能够降低病窦伴阵发性或持续性AF患者日后AF的发病率（没有获得一致性数据）。很少资料支持对无症状心动过缓患者使用心房起搏来防治房颤的发生。因此,2006年ACC/AHA/ESC房颤治疗新指南指出:永久性起搏防治房颤还没有确切推荐指征;对无心动过缓、不需植入起搏器的患者,不应考虑用起搏的方法来预防房颤。,谢 谢!,