心力衰竭合并心房顫動,crt與射頻消融攜手應(yīng)對

1、心力衰竭合并心房顫動 ——CRT與射頻消融攜手應(yīng)對,長河醫(yī)院 吳培俊,心力衰竭（心衰）和心房顫動（房顫）是21世紀(jì)心血管疾病領(lǐng)域里兩種新的流行病。兩者關(guān)系密切，常常并存，其發(fā)病率和死亡率往往非常高，且有不斷增加的趨勢，已成為當(dāng)前社會中最主要的公共健康問題。,2,,,心衰與房顫之間的關(guān)系,相同的人口學(xué)特征：發(fā)病率隨年齡的增長而增加共同的危險因子：高血壓，糖尿病，心肌梗死，瓣膜性心肌病等互為因果：,3,心衰,

2、房顫,促進(jìn)/維持,引發(fā),,左房壓力升高，交感神經(jīng)激活，心房擴(kuò)大，心房肌功能喪失，心臟傳導(dǎo)系統(tǒng)損傷,,心房心肌和電重構(gòu),,影響冠狀動脈血供，血流動力學(xué)障礙，射血分?jǐn)?shù)降低,,左房收縮功能喪失，房室失同步，RR間期不規(guī)則,4,最新指南建議,關(guān)于心室再同步化的臨床試驗(yàn)所涵蓋的大多是竇律患者；對患永久性房顫合并左室收縮功能降低的患者，若其QRS≥120ms，大部分證據(jù)顯示房室結(jié)消融后能夠從雙室起搏獲益；CRT對于射血分?jǐn)?shù)低的

3、房顫患者療效尤為顯著。,心衰合并房顫患者的心臟再同步化治療,5,Heart Rhythm, 2012 ， 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelinesfor Device-Based Therapy of Cardiac Rhythm Abnormalities,2012年AHA/ACC/HRS對器械治療指南進(jìn)行了更新，其中對于心衰合并房顫的患者，給出了如下總結(jié)：,

4、心衰合并房顫患者的心臟再同步化治療,6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,B,,最佳藥物治療基礎(chǔ)上，房顫心律的患者，如果滿足：1）需要心室起搏或符合CRT標(biāo)準(zhǔn)；2）房室結(jié)消融或藥物治療控制心率達(dá)到接近100%心 室起搏可考慮植入CRT。,Heart Rhythm, 2012 ， 2012 ACCF/AHA/HRS Focused U

5、pdate of the 2008 Guidelinesfor Device-Based Therapy of Cardiac Rhythm Abnormalities,心衰合并房顫患者的心臟再同步化治療—ESC指南更新,European Heart Journal 2012 ， ESC Guidelines for the diagnosis and treatmentof acute and chronic heart f

6、ailure 2012,7,心衰合并房顫患者的心臟再同步化治療—ESC指南更新,European Heart Journal 2012 ， ESC Guidelines for the diagnosis and treatmentof acute and chronic heart failure 2012,8,ESC認(rèn)為CRT對AF患者的療效還不是十分明確，有待進(jìn)一步驗(yàn)證理論依據(jù)：MUSTIC：一個小規(guī)模，單盲的臨床研究

7、 59例患永久性房顫的心衰患者，低心室率，QRS≥200ms， 心室起搏依賴，交叉設(shè)計(jì)3個月的傳統(tǒng)起搏，3個月的CRT治 療，主要終點(diǎn)——6分鐘步行結(jié)果沒有區(qū)別RAFT：一隨機(jī)對照試驗(yàn) 229例患永久性房顫或房撲患者，或藥物控制心室率在休息 時≤60bpm，6分鐘步行測試時≤90bpm，或行房室結(jié)消融術(shù)， 遠(yuǎn)期分析治

8、療效果和基線節(jié)律對比沒有顯示出有深遠(yuǎn)意義的 作用。,CRT的循證醫(yī)學(xué),9,大量大規(guī)模臨床試驗(yàn)已證實(shí)CRT不僅可以顯著改善心功能，緩解臨床癥狀，提高患者生活質(zhì)量，還能逆轉(zhuǎn)心臟重構(gòu)，可從根本上阻止心衰發(fā)生、發(fā)展的病理生理進(jìn)程。 BUT 為達(dá)到治療目的，需要最大程度地起搏雙室，同時為保證房室順序，需要病人必須是竇率，以提高CRT的療效。,對于房顫患者問題隨之而來

9、……,房顫是否會影響CRT的療效？CRT能否減少心衰患者房顫的發(fā)生？CRT對治療心衰合并房顫是否可行有效？對心衰伴慢性房顫患者，如何才能達(dá)到最佳治療？……,10,房顫是否會影響CRT的療效？,11,CARE-HF,813位心衰患者隨機(jī)分組為CRT組及藥物治療組（入選時排出患有持續(xù)性房顫的患者）房顫的發(fā)生作為不良事件而被記錄最終隨訪了29.4個月比較兩組患者新房顫發(fā)生率，以及新房顫發(fā)生對CRT結(jié)果及療效的影響,12,Circ

10、ulation July 4, 2006 Effect of Cardiac Resynchronization on the Incidence of Atrial Fibrillation in Patients With Severe Heart Failure。,CARE-HF——死亡率,13,Circulation July 4, 2006 Effect of Cardiac Resynchronization on t

11、he Incidence of Atrial Fibrillation in Patients With Severe Heart Failure。,CRT能夠降低死亡率，且CRT的療效不會因?yàn)榘l(fā)生新房顫而改變！,18個月的隨訪，無論有無房顫，CRT組的患者的左室射血分?jǐn)?shù)，左室收縮末期容積，左室充盈時間等均優(yōu)于藥物治療組,CARE-HF——血液動力學(xué)等方面的影響,14,,,,,Circulation July 4, 2006 Eff

12、ect of Cardiac Resynchronization on the Incidence of Atrial Fibrillation in Patients With Severe Heart Failure。,CARE-HF,15,Circulation July 4, 2006 Effect of Cardiac Resynchronization on the Incidence of Atrial Fibril

13、lation in Patients With Severe Heart Failure。,新房顫的發(fā)生：CRT合并藥物組：66（409）藥物治療組：58（404） 結(jié)論： 雖然CRT沒有降低房顫的發(fā)生率，但無論病人是否患有房顫，CRT都能明顯改善患者預(yù)后。,沒有區(qū)別,CRT能否減少心衰患者房顫的發(fā)生？,16,歐洲一項(xiàng)小規(guī)模的臨床試驗(yàn),入選84例難治性心衰患者，NYHA心功能分級Ⅱ～Ⅳ級進(jìn)行CRT治療，隨訪3個月植入時

14、AF患者32人，竇律患者52人觀察CRT治療后房顫發(fā)作次數(shù)及房顫負(fù)荷。,17,Journal of Cardiovascular Electrophysiology Vol. 17, No. 8, August 2006 Atrial Fibrillation Burden During the Post-Implant Period After CRT Using Device-Based Diagnostics,比較三個月的隨訪

15、，隨著CRT的治療，發(fā)生AF的病人數(shù)明顯減少,歐洲一項(xiàng)小規(guī)模的臨床試驗(yàn),18,Journal of Cardiovascular Electrophysiology Vol. 17, No. 8, August 2006 Atrial Fibrillation Burden During the Post-Implant Period After CRT Using Device-Based Diagnostics,歐洲一項(xiàng)小規(guī)模的臨

16、床試驗(yàn),19,Journal of Cardiovascular Electrophysiology Vol. 17, No. 8, August 2006 Atrial Fibrillation Burden During the Post-Implant Period After CRT Using Device-Based Diagnostics,隨著CRT治療，患者的房顫負(fù)荷以及發(fā)生房顫的病人數(shù)量均逐漸減少,美國一項(xiàng)臨床試驗(yàn),

17、回顧性研究，96例已植入CRT的患者，NYHA心功能III–IV 級的慢性心衰患者，LVEF≤ 35%, QRS ≥ 130 ms,其中91例患者植入時為竇律，5例患者為房顫經(jīng)藥物轉(zhuǎn)換為竇律隨訪6個月，其中CRT應(yīng)答者54例，無應(yīng)答者42例觀察房顫發(fā)作率及房顫負(fù)荷。,20,PACE 2007 Cardiac Resynchronization Therapy Response is Associated with Shorter

18、 Duration of Atrial Fibrillation,美國一項(xiàng)臨床試驗(yàn),21,PACE 2007 Cardiac Resynchronization Therapy Response is Associated with Shorter Duration of Atrial Fibrillation,對比CRT有應(yīng)答及無應(yīng)答兩組患者入選時的特性基本一致,美國一項(xiàng)臨床試驗(yàn),22,PACE 2007 Cardiac Res

19、ynchronization Therapy Response is Associated with Shorter Duration of Atrial Fibrillation,,,美國一項(xiàng)臨床試驗(yàn),23,PACE 2007 Cardiac Resynchronization Therapy Response is Associated with Shorter Duration of Atrial Fibrillation,

20、,對比CRT有應(yīng)答及無應(yīng)答兩組患者入選時的特性基本一致,結(jié)論: CRT應(yīng)答能夠縮短房顫負(fù)荷。,,CRT對治療心衰合并房顫是否可行有效？,24,一項(xiàng)前瞻性臨床研究,入選263例心衰患者，QRS ≥ 120 ms,心功能分級III–IV 級, LVEF≤35%，其中慢性房顫96例，竇律167例隨訪3個月和12個月評價兩組患者超聲心動及臨床指標(biāo)，包括左室重構(gòu)逆轉(zhuǎn)，NYHA心功能分級，6min步行距離，生活質(zhì)量評分，LVEF，二尖瓣返流

21、，1年住院率等同時比較兩組患者遠(yuǎn)期死亡率,25,The American Journal of Cardiology 2007 Comparison of Usefulness of Cardiac Resynchronization Therapy in Patients With Atrial Fibrillation and Heart Failure Versus Patients With Sinus Rhythm an

22、d Heart Failure,一項(xiàng)前瞻性臨床研究,26,The American Journal of Cardiology 2007 Comparison of Usefulness of Cardiac Resynchronization Therapy in Patients With Atrial Fibrillation and Heart Failure Versus Patients With Sinus Rhyth

23、m and Heart Failure,一項(xiàng)前瞻性臨床研究,27,The American Journal of Cardiology 2007 Comparison of Usefulness of Cardiac Resynchronization Therapy in Patients With Atrial Fibrillation and Heart Failure Versus Patients With Sinus R

24、hythm and Heart Failure,CRT治療能使心衰合并房顫的患者同樣受益！,一項(xiàng)前瞻性臨床研究,28,The American Journal of Cardiology 2007 Comparison of Usefulness of Cardiac Resynchronization Therapy in Patients With Atrial Fibrillation and Heart Failure Ve

25、rsus Patients With Sinus Rhythm and Heart Failure,慢性房顫組與竇律組1年因心衰住院率均明顯下降，分別為84%和90%，兩組長期死亡率幾乎相等。心衰合并房顫的患者應(yīng)該進(jìn)行CRT治療！,對心衰伴慢性房顫患者, 如何才能達(dá)到最佳治療？,29,治療方案,通過優(yōu)化程控參數(shù)提高房顫患者的CRT療效CRT結(jié)合房室結(jié)消融術(shù)PAVE研究MILOS研究環(huán)肺靜脈電隔離

26、結(jié)合CRT,30,優(yōu)化程控參數(shù),對于心衰伴房顫患者，如果心率控制穩(wěn)定，常規(guī)程控即可保證雙室起搏比例如果心室率控制不佳，則起搏器有如下功能可以幫助提高雙室起搏比例： AMS 自動模式轉(zhuǎn)換 DDT 觸發(fā),31,優(yōu)化程控參數(shù)---- AMS自動模式轉(zhuǎn)換,發(fā)生房性心動過速時，起搏模式由DDD/R自動轉(zhuǎn)換為DDI/RAMS基本頻率：當(dāng)起搏器發(fā)生模式轉(zhuǎn)換時，有一個可分開程控的起搏頻率 AMS基本頻率臨床目的:用一個增加的心室起搏頻率以補(bǔ)

27、償心房貢獻(xiàn)喪失使AT/AF期間增加的心室起搏頻率能最大程度減少快的、不規(guī)則的心室傳導(dǎo)，促進(jìn)雙室起搏,32,優(yōu)化程控參數(shù)---- AMS自動模式轉(zhuǎn)換,AMS的臨床意義 R-R間期的變化更小，從而減輕患者癥狀 更高的頻率增加心臟輸出，更大程度確保了雙室起搏，使患者有更好的血液動力學(xué),33,優(yōu)化程控參數(shù)---- DDT觸發(fā),DDT/R模式提供了存在自身R波或PVC時的觸發(fā)起搏，以促進(jìn)雙室起搏DDT 和 VVT 模式T = 觸發(fā)如

28、果脈沖發(fā)生器看見一個自身事件，那么將啟動一個輸出脈沖對感知事件的處理，與VVI相反在觸發(fā)起搏中，兩個心室的脈沖都會被發(fā)放在觸發(fā)起搏中，無論程控值，室間延遲是“同步的”(LV先10ms),34,優(yōu)化程控參數(shù)---- DDT觸發(fā),DDT的臨床意義：可確保接近100%的雙室起搏在房顫伴不穩(wěn)定的傳導(dǎo)期間（心率變化范圍很大）能確保雙室起搏（BV）,35,治療方案,通過優(yōu)化程控參數(shù)提高房顫患者的CRT療效CRT結(jié)合房室結(jié)消融術(shù)PAV

29、E研究MILOS研究環(huán)肺靜脈電隔離結(jié)合CRT,36,CRT結(jié)合房室結(jié)消融術(shù)——PAVE研究,37,J Cardiovasc Electrophysiol 2005 Left Ventricular-Based Cardiac Stimulation Post AV NodalAblation Evaluation (The PAVE Study),植入前患者評估,隨機(jī)分組（n=184）,消融+右室起搏(n=81)（S

30、JM單腔起搏器）,消融+雙室起搏(n=103)（SJM三腔起搏器）,入選標(biāo)準(zhǔn)：慢性房顫>30天，房室結(jié)消融后需起博治療，LVEF 0.46±0.16，83%NYHA Class II or III。,術(shù)后4周內(nèi)程控,基本頻率80ppm，以降低多形性室速的風(fēng)險,4周后隨訪,恢復(fù)正常起搏頻率，打開頻率應(yīng)答傳感器,6周后隨訪,3個月隨訪,6個月隨訪,此后每6個月隨訪,終點(diǎn)：評價6min步行時間，生活質(zhì)量，LVEF

31、,兩組病人的6-minute步行距離均有顯著提高，但是6個月時右室起搏組的步行距離減少，雙室起搏組仍然穩(wěn)定,PAVE研究,38,J Cardiovasc Electrophysiol 2005 Left Ventricular-Based Cardiac Stimulation Post AV NodalAblation Evaluation (The PAVE Study),6-minute hallway walk te

32、st,BV,RV,PAVE研究,39,J Cardiovasc Electrophysiol 2005 Left Ventricular-Based Cardiac Stimulation Post AV NodalAblation Evaluation (The PAVE Study),LVEF,基線時兩組LVEF相同，雙室起搏組一致穩(wěn)定右室起搏組在6周時降低3.1%，6個月時降低3.7%6個月時雙室起搏組明顯優(yōu)于右室起搏

33、組,PAVE研究,40,J Cardiovasc Electrophysiol 2005 Left Ventricular-Based Cardiac Stimulation Post AV NodalAblation Evaluation (The PAVE Study),EF ≤45%,EF >45%,p=0.02,LVEF低的患者，雙室起搏明顯優(yōu)于右室起搏,PAVE研究,41,J Cardiovasc Electro

34、physiol 2005 Left Ventricular-Based Cardiac Stimulation Post AV NodalAblation Evaluation (The PAVE Study),NYHA I,NYHA II, III,p<0.01, RV vs. BV,NYHA心功能分級 II, III 級的患者 雙室起搏明顯優(yōu)于右室起搏,PAVE研究,42,J Cardiovasc Electrophy

35、siol 2005 Left Ventricular-Based Cardiac Stimulation Post AV NodalAblation Evaluation (The PAVE Study),結(jié)論:PAVE試驗(yàn)證實(shí)了房顫患者進(jìn)行房室結(jié)射頻消融后，雙心室再同步化起搏較單純的右室起搏治療能夠顯著性提高6min步行時間和LVEF，尤其在收縮功能受損和心衰患者中獲益更加明顯。,PAVE研究,43,1，Pacing

36、 Clin Electrophysiol. 1997 Feb;20(2 Pt 1):343-8Ventricular fibrillation and sudden death after radiofrequency catheter ablation of the atrioventricular junction,房室結(jié)消融的風(fēng)險/并發(fā)癥:心室起搏依賴房室結(jié)消融的不可逆性使得患者必須要永久起搏房室結(jié)消融后起搏頻率設(shè)置不當(dāng)有

37、可能引發(fā)惡性室性心律失常房室結(jié)消融認(rèn)為阻斷了房室的正常傳導(dǎo)功能，設(shè)置慢的心室起搏頻率或是較慢的心室逸搏節(jié)律有可能導(dǎo)致惡性室性心律失常甚至猝死，這是房室結(jié)消融可能產(chǎn)生的并發(fā)癥（發(fā)生率約6%1）惡性室性心律失常的發(fā)生可以通過消融后即刻程控一個臨時的較快的起搏頻率來預(yù)防,MILOS研究,入選1285例患者，其中1042例竇律，243例房顫（19%），房顫組中125例采用藥物控制心室率，118例房室結(jié)消融隨訪34個月對比心衰患者的全因死

38、亡率和心源性死亡率，評價房室結(jié)射頻消融對心衰合并房顫患者CRT治療長期生存率的影響,44,European Heart Journal (2008) Long-term survival in patients undergoing cardiac resynchronization therapy: the importance of performing atrio-ventricular junction ablation i

39、n patients with permanent atrial fibrillation,MILOS研究,45,European Heart Journal (2008) Long-term survival in patients undergoing cardiac resynchronization therapy: the importance of performing atrio-ventricular junctio

40、n ablation in patients with permanent atrial fibrillation,房顫組與竇律組患者全因死亡率和心源性死亡率非常接近,MILOS研究,46,European Heart Journal (2008) Long-term survival in patients undergoing cardiac resynchronization therapy: the importance o

41、f performing atrio-ventricular junction ablation in patients with permanent atrial fibrillation,房顫兩個亞組中，與抗心律失常藥物相比，房室結(jié)消融能夠顯著提高CRT心衰患者的生存率。,MILOS研究,47,European Heart Journal (2008) Long-term survival in patients undergo

42、ing cardiac resynchronization therapy: the importance of performing atrio-ventricular junction ablation in patients with permanent atrial fibrillation,MILOS研究,48,European Heart Journal (2008) Long-term survival in pati

43、ents undergoing cardiac resynchronization therapy: the importance of performing atrio-ventricular junction ablation in patients with permanent atrial fibrillation,CRT治療有效的患者比例,將LVESV（左室收縮末容積）降低> 10%定義為CRT治療有效,結(jié)論：心衰

44、合并房顫的患者進(jìn)行CRT治療時，同時輔以房室結(jié)射頻消融是一種非常重要的手段。與抗心律失常藥物控制心室率相比，能夠降低心衰的死亡率。,CRT合并房室結(jié)消融療法總結(jié),CRT對于HF患者的療效是確切的，但合并AF的患者從CRT獲益仍存在一定的障礙：首先對于快心室率的患者無法保證合適的雙室起搏比例，經(jīng)常出現(xiàn)的融合或假性融合波會影響到CRT的療效；其次，AF還有可能增加不恰當(dāng)電擊的風(fēng)險，增加心衰住院率乃至死亡率。房室結(jié)消融術(shù)則使得房顫患者能夠

45、確保其雙室起搏近100%，有效提高了CRT的反應(yīng)，降低誤放電的風(fēng)險。但同時，房室結(jié)消融的不可逆性使得患者必須要心室永久起搏，對于HF的患者雙室起搏則是優(yōu)于單純右室起搏的。因此,我們可以得出這樣的結(jié)論：CRT與房室結(jié)射頻消融術(shù)的聯(lián)合治療是目前對于HF伴AF的患者有效的治療方法.,49,Heart failure2013 Recent advances in management of atrial ibrillation in

46、patients with heart failure,治療方案,通過優(yōu)化程控參數(shù)提高房顫患者的CRT療效CRT結(jié)合房室結(jié)消融術(shù)PAVE研究MILOS研究環(huán)肺靜脈電隔離結(jié)合CRT,50,環(huán)肺靜脈電隔離----A Meta-analysis,51,Circ Arrhythm Electrophysiol 2009 Pulmonary Vein Isolation for the Maintenance of Sinus

47、Rhythm in Patients With Atrial Fibrillation : A Meta-Analysis of Randomized, Controlled Trials,這是一個薈萃分析：分析了5個關(guān)于對比環(huán)肺靜脈消融和最佳藥物治療房顫的試驗(yàn)，肺靜脈消融術(shù)后12個月維持陣發(fā)性房顫不再發(fā)生的累積優(yōu)勢比是藥物治療的16倍,環(huán)肺靜脈電隔離----A Meta-analysis,52,Circ Arrhythm Elec

48、trophysiol 2009 Pulmonary Vein Isolation for the Maintenance of Sinus Rhythm in Patients With Atrial Fibrillation : A Meta-Analysis of Randomized, Controlled Trials,肺靜脈消融能夠降低因心源性原因?qū)е碌淖≡郝?環(huán)肺靜脈電隔離----A Meta-analysis,53

49、,Circ Arrhythm Electrophysiol 2009 Pulmonary Vein Isolation for the Maintenance of Sinus Rhythm in Patients With Atrial Fibrillation : A Meta-Analysis of Randomized, Controlled Trials,在12個月的隨訪中，有17%的患者接受了一次重復(fù)肺靜脈消融術(shù)5

50、1%的非消融治療組的患者接受了消融治療（這種交叉治療是被允許的）,環(huán)肺靜脈電隔離療法總結(jié),54,薈萃分析證明了PVI對于陣發(fā)性房顫的療效PVI的療效：1年維持竇律的患者為75%，是抗心律失常藥物療效的2倍。PVI可以降低2/3的心源性住院率 。并發(fā)癥：PVI也存在一定的術(shù)后并發(fā)癥的風(fēng)險：包括中風(fēng)，穿孔，肺靜脈狹窄等，但這些事件的發(fā)生概率極低。復(fù)發(fā)率：以上5個試驗(yàn)，1年之內(nèi)重復(fù)進(jìn)行一次PVI手術(shù)的患者達(dá)17%。,Circ

51、Arrhythm Electrophysiol 2009 Pulmonary Vein Isolation for the Maintenance of Sinus Rhythm in Patients With Atrial Fibrillation : A Meta-Analysis of Randomized, Controlled Trials,Pulmonary Vein Antrum Isolation vs A

52、V Node Ablation with Bi-Ventricular Pacing,55,PABA-CHF,Heart Rhythm, Vol 9, No 8S, August Supplement 2012 Managing atrial fibrillation in the CRT patient: Controversy or consensus?,56,PABA-CHF,隨機(jī)，雙盲 入選：81例心衰伴房顫患者， NY

53、HA心功能分級為Ⅱ～Ⅲ級，沒有室間傳導(dǎo)延遲（即QRS寬度在90ms左右），其中55%患者患陣發(fā)性房顫，45%為持續(xù)性房顫 隨訪6個月 主要終點(diǎn)：6min步行，LVEF，生活質(zhì)量,European Journal of Heart Failure 9 (2007) 92–97 Clinical trials update from the American Heart Association 2006: OAT, SALT 1 a

54、nd 2, MAGIC, ABCD, PABA-CHF, IMPROVE-CHF, and percutaneous mitral annuloplasty,57,PABA-CHF,結(jié)論：PVI組6個月隨訪內(nèi)維持竇律的患者占72%，聯(lián)合抗心律失常藥物治療可增加至90%，患者LVEF及6min步行顯著改善,尤其是陣發(fā)性房顫的患者。試驗(yàn)結(jié)果偏向于PVI組，但還有待繼續(xù)探索的是PVI對于左室功能紊亂及室間傳導(dǎo)延遲的患者（典型CRT適應(yīng)癥患

55、者）的療效,European Journal of Heart Failure 9 (2007) 92–97 Clinical trials update from the American Heart Association 2006: OAT, SALT 1 and 2, MAGIC, ABCD, PABA-CHF, IMPROVE-CHF, and percutaneous mitral annuloplasty,58,小結(jié),

56、以上臨床試驗(yàn)對肺靜脈電隔離治療陣發(fā)性房顫的療效得出了肯定的結(jié)論但仍缺乏大量臨床依據(jù)，需進(jìn)一步探討,Heart Rhythm, Vol 9, No 8S, August Supplement 2012 Managing atrial fibrillation in the CRT patient: Controversy or consensus?,59,綜上所述,對于心衰合并房顫的患者治療策略：個體化心衰合并房顫患者的CRT

57、療效明確，但選擇哪種控制心室率的方法存在差異不同心室率控制策略：藥物治療，房室結(jié)消融，環(huán)肺靜脈電隔離等治療原則：盡可能確保CRT的療效確保最大化的雙室起搏減少以及盡量最小化不恰當(dāng)?shù)目焖傩穆墒С５闹委?Heart Rhythm, Vol 9, No 8S, August Supplement 2012 Managing atrial fibrillation in the CRT patient: Controversy o

58、r consensus?,60,綜上所述,Heart Rhythm, Vol 9, No 8S, August Supplement 2012 Managing atrial fibrillation in the CRT patient: Controversy or consensus?,,確定雙室起搏比例,通過機(jī)器的診斷功能以及Hoter等,,,,持續(xù)性房顫,陣發(fā)性房顫,房室結(jié)消融AV Node Ablation,肺靜脈

59、電隔離Pulmonary Vein Antrum Isolation,心衰伴慢性房顫患者的推薦治療方案,THANKS!,References,Heart Rhythm, 2012 ， 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelinesfor Device-Based Therapy of Cardiac Rhythm AbnormalitiesEuropean Heart

60、 Journal 2012 ， ESC Guidelines for the diagnosis and treatmentof acute and chronic heart failure 2012Circulation July 4, 2006 Effect of Cardiac Resynchronization on the Incidence of Atrial Fibrillation in Patients W

61、ith Severe Heart Failure。Journal of Cardiovascular Electrophysiology Vol. 17, No. 8, August 2006 Atrial Fibrillation Burden During the Post-Implant Period After CRT Using Device-Based DiagnosticsPACE 2007 Cardiac Resy

62、nchronization Therapy Response is Associated with Shorter Duration of Atrial FibrillationThe American Journal of Cardiology 2007 Comparison of Usefulness of Cardiac Resynchronization Therapy in Patients With Atrial Fib

63、rillation and Heart Failure Versus Patients With Sinus Rhythm and Heart FailureJ Cardiovasc Electrophysiol 2005 Left Ventricular-Based Cardiac Stimulation Post AV Nodal Ablation Evaluation (The PAVE Study)Pacing Cli

64、n Electrophysiol. 1997 Feb;20(2 Pt 1):343-8 Ventricular fibrillation and sudden death after radiofrequency catheter ablation of the atrioventricular junctionEuropean Heart Journal (2008) Long-term survival in patient

65、s undergoing cardiac resynchronization therapy: the importance of performing atrio-ventricular junction ablation in patients with permanent atrial fibrillationEuropace (2012) Cardiac resynchronization therapy after atr

66、ioventricular junction ablation for symptomatic atrial fibrillation: a meta-analysisJournal of the American College of Cardiology Vol. 59, No. 8, 2012 AV Junction Ablation in Heart Failure Patients With Atrial F

67、ibrillation Treated With Cardiac Resynchronization TherapyCirc Arrhythm Electrophysiol 2009 Pulmonary Vein Isolation for the Maintenance of Sinus Rhythm in Patients With Atrial Fibrillation : A Meta-Analysis of Rando

68、mized, Controlled TrialsHeart Rhythm, Vol 9, No 8S, August Supplement 2012 Managing atrial fibrillation in the CRT patient: Controversy or consensus?European Journal of Heart Failure 9 (2007) 92–97 Clinical trials u