心房顫動(dòng)的研究現(xiàn)狀江洪

江洪武漢大學(xué)人民醫(yī)院心內(nèi)科心房顫抖的研究現(xiàn)狀A(yù)F發(fā)生機(jī)制的再認(rèn)識(shí)：對(duì)消融治療的指導(dǎo)AF發(fā)生機(jī)制的經(jīng)典假說(shuō)多發(fā)子波折返局灶驅(qū)動(dòng)學(xué)說(shuō)主折返環(huán)伴顫抖樣傳導(dǎo)局灶沖動(dòng)－肺靜脈SleeveHaissaguerreetal.NEnglJMed1998;339:659-66肺靜脈異常電活動(dòng)驅(qū)動(dòng)AF局灶沖動(dòng)－分布Haissaguerreetal.NEnglJMed1998;339:659-66局灶沖動(dòng)的機(jī)制－1、自律性增加？Perez-LugonesAetal,JCardiovascElectrophysiol2003;14:803-809Cheung–JPhysiol314:445,1980

FromdistalPVofsuperfusedguineapigatrium-lungprep(7/17)Approximately30bpm,increasesinratewith10-7MnorepinephrineWangetal–IntJofCardiol89:187,2003SuperfusedcaninePVpreparationsNoexamplesofspontaneousactivityobserved(N=50)Chenetal–CardiovascRes48:265,2000Automaticitypresentin12of14superfusedcaninePVpreparationsfollowingrapidchronicatrialpacing(780bpm)and9of17controlPVpreparationsAroraetal–Circulation107:1816,200466%inperfusedcanineatrium+PVpreparations,55–180bpminthepresenceof10-6MisoproterenolCheung–JPhysiol314:445,1980Wangetal–IntJofCardiol89:187,2003Chenetal–CardiovascRes48:265,2000Aroraetal–Circulation107:1816,2004自律性曾加—組織電生理研究NoDiastolicDepolarizationPVFocalFiringPattersonEandSunnyPo,JACC.2006無(wú)舒張期除極：不支持自律性增加LSPVLIPVPAAOFiringPAView肺靜脈口部消融終止Firing：不支持自律性增加PVRapidFiringMicro-reentryKalifa,Circulation.2003CD局灶沖動(dòng)的機(jī)制－2、PV內(nèi)微折返(Microreentry)?SunnyPo,JACC,20060ms32ms64ms128ms早搏刺激：支持微折返LAOProjectionLSPVLIPVHighDensity籃狀電極標(biāo)測(cè)PattersonE,SunnyPo,JCE,2007肺靜脈籃狀電極標(biāo)測(cè)：支持微折返LSPVLIPVPAAOFiringPAView肺靜脈口部消融終止Firing：不支持微折返A(chǔ)ctionPotentialIntracellularCalcium(CalciumTransient)Basedon2Propertiesof

PVMyocardialCellsShortactionpotentialduration-Intracellularcalciumconcentration(calciumtransient)remainshighafterrepolarizationPattersonetal,HeartRhythm2005;2:624局灶沖動(dòng)的機(jī)制－3、TriggeredActivitySinusRhythmRapidRhythmFollowedByPauseRapidRhythmCalciumLoadingPauseLargeCalciumReleaseFromSRActionPotentialCa++Ca++“Calcium-TransientTriggering”HypothesisEADNa+/Ca++Exchanger(3Na+In

1Ca++Out)NetInwardCurrent(+)EADTriggeredFiringEADActionPotentialTriggeredFiringIncreasedAutonomic(GP)ActivityAcetylcholineShortensActionPotentialNorepinephrineIncreasesCalciumLoadingEADsCa++Ca++SinusRhythmRapidRhythmFollowedByPause“Calcium-TransientTriggering”HypothesisAcetylcholine(10-7M)+Norepinephrine(10-8M)Pause-InducedTriggeredFiringCanineLSPVPreparation25-25-50-750200msSS1.5secEADEADLSPVMicro-ElectrodemVPatterson,Po,Scherlag,Lazzara,etalLSPVBipolarSSLast3Beatsof20BeatTrainCycleLength180ms(Rate333/min)TriggeredFiringCycleLength48ms(1240/min)AortaLALSPVLIPVIVCRVLVRIPV1ARGP5RASVCRPARSPVLassoCatheter234LOMPAViewInVivoStudyAutonomicMechanismforFocalFiringLuZ,JiangH,PoS.Unpublished.1=SLGP2=ILGP3=ARGP4=IRGP5=RPA-GPIIHBELSPVD2LSPV34LIPVD2LIPV34LAALARSPVD2RIPVD2RAARAAHAHAAHAAHA200msec2:1AVconductionblockbyHFS(1.5V)attheLSPVLuZ,JiangH,SunnyPo.Unpublished.S1-S2train(30ms)IIHBELSPVD2LSPV34LIPVD2LIPV34LAALARSPVD2RIPVD2RAARA200msecAVblockbyHFS(2.4V)justbeforeinitiationofAFLuZ,JiangH,SunnyPo.Unpublished.aVLHBERSPVD2RSPV34RSPV56RIPVD2RIPV34RIPV56RAAD2RAA34RAD2RA34300msecAFwasinitiatedbyHFS(1.5V)fromRSPVLuZ,JiangH,SunnyPo.Unpublished.aVLHBERSPVD2RSPV34RSPV56RIPVD2RIPV34RIPV56RAAD2RAA34RAD2RA34300msecNoAFbyHFS(12V)afterGPablationLuZ,JiangH,SunnyPo.Unpublished.MRAngiogram-PAProjectionPosteriorSurfaceAnteriorSurfaceSuperiorLeftGPInferiorLeftGPInferiorRightGPGPAxonsAnteriorRightGPGanglionatedPlexi(GP)多發(fā)子波折返主折返環(huán)伴顫抖樣傳導(dǎo)折返理論的根底－心房重構(gòu)AFBegetsAFWijffelsetal.Circulation1995;92:1954–68DurationofAFAFBegetsAF的機(jī)制－心房重構(gòu)Allessieetal.CardiovascularResearch2002心房電重構(gòu)Natteletal.JICE.2005ChenPSetal.AJP.2002FocalActivityinChronicPacinginducedAFFocalActivityinChronicPacinginducedAFChenPSetal.AJP.2002RightThoracotomyLeftThoracotomyIVCRARIPVRAAAnteriorRightGPInferiorRightGPRSPVSVCLVLPALSPVLIPVRVLASuperiorLeftGPInferiorLeftGPLAAPacing1200/minfor6hrsLAALuZ,JiangHandSunnyPo.Circ.2021心房電重構(gòu)的神經(jīng)機(jī)制14dogsEPTesting:ERP,AFInductionEPTesting:ERP,AFInductionEPTesting:ERP,AFInductionEPTesting:ERP,AFInduction6hrLAApacing(1200/min)GPAblation(ARGP+IRGP+SLGP+ILGP+LOM)6hrLAApacing(1200/min)GPAblation(ARGP+IRGP+SLGP+ILGP+LOM)Group1Group2Group1:ChangeinERPDuringAtrialPacing2001601208040123456BaselineDurationofRapidAtrialPacing(Hours)ERP(ms)LSPVERP2xThresholdERP10xThresholdLuZ,JiangHandSunnyPo.Circ.20212001601208040123456BaselineERP(ms)LSPVERP2xThresholdERP10xThresholdPost-AblGPAblationGroup1:ChangeinERPafterGPAblationDurationofRapidAtrialPacing(Hours)LuZ,JiangHandSunnyPo.Circ.2021123456Baseline∑WoV(ms)GPAblation040080012001600Post-AblGroup1:ChangeinAFInducibilityDurationofRapidAtrialPacing(Hours)LuZ,JiangHandSunnyPo.Circ.20212001601208040123456Post-AblERP(ms)LSPVGPAblationAfterGPAblationGroup2:ChangeinERPDuringAtrialPacingERP2xThresholdERP10xThresholdDurationofRapidAtrialPacing(Hours)LuZ,JiangHandSunnyPo.Circ.2021123456Post-Abl040080012001600GPAblationGroup2:NoChangeinAFInducibilityAfterGPAblation∑WoV(ms)DurationofRapidAtrialPacing(Hours)LuZ,JiangHandSunnyPo.Circ.2021MotherRotorsandFibrillatoryConductionJalife,etal.Circulation.1998,2000,2001ElectrogramAcrosstheAtriaDuringAFSVCRAABarrierIVCRAMidRSPVRIPVARGPIRGPAchRAAARAGPLuZ,JiangHandSunnyPo.JCE.2021IIRAARSPVRIPVRAAAMidGP100msRotorFiringRAFract++++++ElectrogramAcrosstheAtriaDuringAFLuZ,JiangHandSunnyPo.JCE.2021NotFibrillatoryConductionIIRAARSPVRIPVBeforeGPAblationAfterGP