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1、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
2、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
3、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
4、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 Medical Trilogy DR+/DAO Model 2360L/2364L Integrity AFx DR Model 5346 M
5、edtronic AT 500 Kappa 900 Vitatron Vita 900E ,9000,AF Suppression,Algorithm Overview 运算方式,Sinus rate Dynamic 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
6、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 Pacing 1200 ms (50 ppm),Ove
7、rdrive Pacing 1016 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
8、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,
9、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
10、, 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=1
11、58,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-
12、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 hospi
13、talization (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,Classifi
14、cation,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
15、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: 106 Female: 149 Age: 70.1 18.2 years,方 法,85 patients Right Atrial Appendage Pacing + AF 85 patients Low Atrial Septum Pacing + AF 85 patients Control group Pacing without AF,
