感谢作者的文章严格审查女士张曼玉瓦尔纳（Atritech公司/波士顿科学）。作者要感谢他的行政支持和版权许可组织，先生，马赫什Deshpanade（波士顿科学）。 视频是由波士顿科学不受限制的资金支持。

1。守望设备<ol><li>镍钛记忆合金（镍/钛合金）守望设备框架构造和组成的，旨在确保在左心耳（图1）设备设备周边的10个固定锚。 </li></ol>帽的织物面料聚醚聚酯（PET），建造作为一个160微米的过滤器，防止有害栓子在愈合过程中退出。 <ol start="2"><li>该器件在5种不同的尺寸:21，24，27，30，33毫米，设备可容纳最左心耳解剖学的轮廓形状。 </li><li>守望跨室间隔接入系统是可用双或单曲线风格（法国14（六）外径（OD）4.7毫米），内径75厘米长（图2）12F（编号））。 </li><li> 12F的输送导管内预装设备（限制）。注:守望输送系统是兼容所有5器件尺寸（12F外径）（图3）。步骤: </li></ol> 2。基于TEE的看守设备大小的测定<ol><li>启动程序之前，经食道超声心动图（TEE）是执行文件没有在左心耳血栓，确定适当的大小看守设备被植入。推荐的国际标准化比值应≥1.5进行植入手术。 </li><li>下清醒镇静的病人（如咪唑2-5毫克），通过超声探头进入食道。 </li><li>确认洛杉矶/左心耳血栓的情况下。 </li><li>评估LAA，以下功能:开口的大小和形状，叶数量，位置，在左心耳的长度，和梳状功能。 LAA，最大开口尺寸应&gt; 17mm或&lt;31毫米适应可用的守望器件尺寸。 </li><li>要做到这一点，测量左心耳开口，至少在4个TEE的意见。首先测量在0度左冠状动脉开口动脉从左上肺静脉缘尖点2厘米。然后测量它在45，90，和135度二尖瓣（MV）环至2厘米，左上肺静脉（LUPV）缘尖点上方。 </li><li>测量近似LAA，可用长度从开口处行左心耳的顶点。 /可用LAA长度应等于或大于最大测量距离。 </li><li>为了帮助规划方法，分类的左心耳类型:最可归类为"风向袋型"，"ChickenWing型"或"西兰花型"。与左心耳的形式分类，植入手术的难度可估计。 </li><li>风向袋型左心耳（图4左），是在一个足够长的优势叶是主要的结构解剖。在这些情况下，大多数的植入过程是相对容易执行。 </li><li> ChickenWing类型LAA是一个解剖，其主要特点是急弯中的主导左心耳解剖叶从知觉的左心耳开口（图4，中心）有一段距离。 </li><li>如果近端部分的最广泛的直径比植入手术很简单。然而，如果近端部分是短于左心耳口的最大宽度，可程序复杂。 </li><li>西兰花型左心耳是一种解剖，其主要功能是一个更复杂的内部特征（图4右）的总长度有限的左心耳。当这个解剖目前，设备往往难以植入，因为有几个瓣覆盖和左心耳的长度是有限的。 </li></ol> 3。植入前准备<ol><li>守望的左心耳封闭设备安置过程应进行局部或全身麻醉下，在导管实验室诊断成像设备，用于支持导尿过程。 </li><li>首先准备亲导管室cedure。应该提供以下设备: </li><li>静脉介绍人，一个标准的跨室间隔接入系统（TAS），1 0.035"导丝交换长度/额外的支持，猪尾导管（4-5 F）的对比注射器（60CC）（如消融超级僵硬260厘米），和强制加压滴灌室/不育系的盐水袋。 </li><li>相应的扩张，单人或双人，守望的配送系统，以及可选的守望闭孔，这是在左心耳解剖有助于急性弯适当看守访问护套。 </li><li>它被推荐用于测量压力，5F动脉访问鞘，标志着跨室间隔穿刺，快速并发症管理过程中的主动脉根部，如果需要的话。 </li><li>此外，在下列材料并发症的情况下应提供:心包托盘，设备检索为14-16F的鞘，一个循环，bioptome，引导导管冠状动脉，血栓设备（如美敦力公司出口猫海特），冠脉导丝。 </li><li>此外，该过程需要血压计，心电图（心电图）设备，并作为镇静最低脉搏血氧饱和度，加上补充气道装置，如喉罩通气道（LMA），气管内管（ET）的喉镜用于紧急情况。 </li><li>使用超声心动图成像是必需的，建议食管超声心动图。如果可以的话，应使用双翼透视。 </li><li>一旦房间准备好了，有病人放下他或她回单位。有双臂脑后病人的地方。然后表带病人的胳膊和腿到位，同时注意避免伤到手臂神经丛。 </li><li>对于analgosedation管理5毫克咪达唑仑和1％异丙酚，根据病人的体重。然后，管理1丸，随后每小时5至10毫克/公斤体重静脉持续输注异丙酚毫克/公斤。 </li><li>立即手术前开始，管理20毫升1％利多卡因局部麻醉在腹股沟区。 </li></ol> 4。守望的设备植入<ol><li>一旦病人完全麻醉，清洁和准备的股静脉插管地区。 </li><li>找到股静脉，然后一个标准的跨室间隔准入制度内侧的股静脉和股静脉插入静脉介绍人。一旦它的地方是，股静脉插入0.035"导丝和血管扩张器访问的心。 </li><li>然后，引入股静脉1 5F护套。将猪尾导管中的一个里程碑和主动脉根部压力监测。 </li><li>到上腔静脉，推进跨室间隔鞘和针。监测中心静脉压。然后，拉回来，直到露营房间隔针针鞘在发球。 </li><li>使用TEE，确定中期降低后隔的一部分。这是跨室间隔路口的最佳场所。复检侧位透视下使用的位置，然后提前进入左心房的针和护套，并推进到上肺静脉鞘。 </li><li>提前0.0035&#39;&#39;僵硬导丝（如消融超级僵硬260厘米），左上肺静脉和消除跨室间隔准入制度，留在地方的导丝。 </li><li>在100 IU / kg体重管理的肝素取得活化凝血时间（ACT）的200-300秒。需要每30分钟监测ACT水平。 </li><li>在无菌条件下，从包装中取出守望准入制度和扩张，并检查是否有损坏整个系统。 </li><li>用生理盐水守望访问鞘侧端口插入注射器。用生理盐水冲洗装置。取下注射器从侧面端口，插入扩张结束，并再次刷新，其余的小号艾琳。 </li><li>下一步，推进守望访问鞘和导丝进入左心房扩张器取出扩张器，同时在LUPV保持鞘的位置。 </li><li>冲洗猪尾导管和推进在守望访问护套线，并通过它。然后，取出导丝和连接注射器造影剂的小辫子。 </li><li>为了尽量减少引入鞘管内空气的潜力，使流血，然后拧紧阀门访问鞘。 </li><li>在超声心动图的控制下，拉猪尾导管鞘从LUPV，把它逆时针，直到它到达的左心耳。注意:逆时针扭矩准入制度对齐鞘较前。顺时针扭矩准入制度对齐鞘后。 </li><li>一旦猪尾导管已达左心耳，获得前右斜（饶）造影，尾椎20-30°20-30°。 </li><li>执行与一个发球最小的0-135度扫描。这是最重要的，当鞘附近的墙壁或LAA，先端先进，同时促进更远端的任何解剖。 </li><li>精心操作，在最优越的叶2点钟左右，在血管造影导管/鞘，在T恤135°最肝右叶。 </li><li>以确认LAA，尺寸，使用TEE测量LAA，在4次最大尺寸为0，45，90和135°作为前。 </li><li>猪尾导管远端部分透视引导下的左心耳挺进。仔细推进猪尾导管鞘访问，作为指导访问鞘上使用标记带。该设备的着陆区表示最近的标记带33毫米，27毫米的中间标记，或标记的21毫米看守设备的近端。着陆区为24毫米和30毫米设备，在标记之间。 </li><li>选择适当大小的守望装置的基础上的T恤measureme新界南总区采取的。然后，在无菌条件下，从包装中取出适当大小看守设备，检查是否有损坏。打开止血阀和收回约1厘米，以确认该设备的芯线连接的设备。 </li><li>远端尖部对准标记带的设备，然后按下设备，直到远端尖部对准输送导管。确保守望设备，不突出。 </li><li>将大60毫升注射器，用生理盐水多次冲洗系统以除去整个系统的空气流体。然后，淹没在盐水输送导管尖端拍打，以消除泡沫。 </li><li>一旦设备准备，复查血管造影访问鞘的位置。访问鞘阀松开，慢慢取出猪尾导管鞘。介绍守望设备系统。 </li><li>为了避免引入的空气，访问鞘枢纽淹没在盐水或允许鞘回流血。日EN注入生理盐水冲洗端口，以便它从输送导管引入到接入鞘中淌。 </li><li>透视引导下，缓缓挺进访问鞘输送导管直到访问护套线的最远端的标记带输送导管上的标记带。然后，稳定的输送导管。 </li><li>收回访问鞘和捕捉到输送导管。不提前访问鞘，一旦输送系统已接入鞘抢购。使用透视，重申交付导管尖端的位置。 </li><li>如果需要重新定位，取出输送系统，并重新插入猪尾导管提前进入位置接入鞘。 </li><li>松开守望输送导管上的阀门。部署的设备，观察设备的末端，以确保没有向前推进或开口的定位相对发生。持有部署旋钮stationaRY，慢慢地缩回访问导管鞘/交付超过3-5秒内缓慢稳定的运动大会。 </li><li>离开芯线连接，退出访问鞘/输送导管装配设备从几厘米，以配合左心耳。 </li><li>一旦设备已部署，使用透视及TEE确认设备释放标准已经达到。它们是:位置，锚，尺寸和密封（PASS.） </li><li>位置:要确认该设备被正确定位，确保设备的最大直径的平面或远端的左心耳口，它跨越了整个左心耳开口。 </li><li>主播:要确认设备是挂靠在地方，撤回访问鞘/交付导管组装1 - 2厘米，从设备的脸。轻轻缩回释放部署旋钮。设备与LAA应该异口同声地移动。 </li><li>大小:要确认设备的大小，衡量的最大diamete的平​​面r是可见的设备中使用标准的4次0，45，90和135度的T恤，确保线程插入。该装置应是原始大小的80-92％。 </li><li>密封:使用彩色多普勒，确保所有裂片远端设备是密封的。理想的情况下，应无彩色血流检测装置附近。如果一个非常小的差距，可见左心耳和设备之间的墙，没有调整是必要的。 </li><li>如果有一个缺口或大于5毫米左右的设备喷气，应重新定位设备或完全收复和更换。 </li><li>如果释放所有条件得到满足，移动接入鞘/输送导管面对设备和逆时针旋转旋钮3-5部署变成释放。 </li><li>释放后，执行与造影剂造影，记录该设备目前仍在进行之中。然后，用T恤，复检的大小和密封。左心房取出护套组装。 </li></ol><ol><li>如果该设备是太远端的左心耳，推进访问鞘/输送导管组装设备的一角。不要unsnap。 </li><li>用右手拿着部署旋钮，轻轻地推进访问鞘/输送导管装配设备的肩膀。然后右手拇指，稳定的立场，反对输送导管枢纽。 </li><li>继续推进大会，而不是过去的固定锚。阻力会觉得作为设备的肩膀崩溃。当阻力感到了第二次，表明锚接触，停止，并拧紧止血阀。 </li><li>透视下观察，拉回来的设备和护套几毫米。一旦设备被收回，重新部署它像以前一样。 </li><li>请检查，如果释放标准已经达到。如果发行条件已得到满足，释放设备。 </li></ol> 6。全植入收复<ol><li>如果该设备是放在太近端左心耳开口或设备发布标准，不符合的，完全夺回设备。 </li><li>推进大会尖设备的脸。再次，不要unsnap。用右手拿着部署旋钮，组装设备的肩膀，轻轻地推进。交货导管稳定的立场，反对右手拇指。 </li><li>继续推进大会，直到设备完全倒塌，并夺回。阻力会觉得作为设备的肩膀崩溃。 </li><li>撤回设备，直到远端齿近端标记带。然后拧紧止血阀。 </li><li>同时保持位置，unsnap访问鞘输送系统。然后，慢慢地取出输送系统。插入猪尾导管和/或闭孔祭出LAA，如果有必要访问鞘。 </li></ol> 7。后的程序<ol><li>一旦妥善安置的device已证实，取出护套。应得到当地止血。 </li><li>程序，定期检查，根据机构指引血肿和/或出血。患者应集中监控。 </li><li>应测量连续血压，心率， 氧饱和度，直到病人是清醒的。 </li><li>一旦病人是清醒的，进行神经系统检查。应监测病人血压和心率监测至少6小时。 </li><li>患者应保持至少45天，后植入手术（内部标准化比值（INR）2.0-3.0）华法林和81mg阿司匹林。病人应给予预防性抗生素，根据美国心脏协会的指引。注意:不建议发布程序肝素。 </li><li>病人可以住院过夜，翌日康复出院。 ATTE通常前解雇等。 </li><li>在45天，评估守望设备安置使用TEE。停止warfarin的医生决定，LAA是完全封闭和设备上的血栓被排除。如果流量超过5毫米的设备周围指出，应考虑给予warfarin的病人保持，直到它已下降到小于5毫米。 </li><li>停止华法林的患者应每日开始氯吡格雷75毫克阿司匹林和通过植入后6个月，并继续服用阿司匹林每日无限期。 </li><li>规定为6个月后，植入适当性心内膜炎的预防。超过6个月的持续性心内膜炎的预防是在医生决定。 </li></ol> 8。结果/代表结果保护AF临床试验进行比较华法林治疗的守望的装置植入的安全性和有效性。 707符合条件的患者被随机分配在要么皮的左心耳封闭的比例为2:1，随后停用华法林（干预，N = 463）或华法林治疗（对照; N = 244）。 图5可以看出，主要功效的事件发生率（评估中风，心血管死亡和全身性栓塞的主要复合终点）进行了比较患者在接受左心耳封闭守望设备（干预组）和患者接受华法林治疗（控制组）。主要功效的发生率为3.0每100病人年（95％可信区间[CRI] 1.9-4.5）干预组和对照组中每100病人年4.9（2.8-7.1）。缺血性中风发生率在干预组和对照组的1.6（0.6-3.0）2.2（1.2-3.5）。心血管/不明原因的死亡率为0.7（0.2-1.5）在干预组和对照组的2.7（1.2-4.4）。出血性中风率为0.1（0.0-0.5），干预组和1.6（0。6-3.1）在对照组。全身性栓塞率分别为0.3（0.0-0.8），干预组和对照组为0。两者合计，这反映在心血管不良事件，表明左心耳封闭并不逊色warfarin治疗的38％的跌幅。 视频1。 <a href="http://www.atritech.net/animation.html" target="_blank">http://www.atritech.net/animation.html~~V</a> <img alt="图1" src="/files/ftp_upload/3671/3671fig1.jpg" /> 图1。守望的设备。守望的设备是与聚四氟乙烯膜表面上的镍钛记忆合金笼，并在周边固定锚<img alt="图2" src="/files/ftp_upload/3671/3671fig2.jpg" /> 图2。跨室间隔接入系统。守望引进鞘双和单曲线不同的解剖情况。 图3。看守输送系统。守望设备内交付系统，这是兼容所有5器件尺寸的限制。 <img alt="图4" src="/files/ftp_upload/3671/3671fig4.jpg" /> 图4左心耳打字。 （左）的风向袋型LAA是在一个足够长的优势叶是主要的结构解剖。 （中心）的ChickenWing类型LAA是一个解剖，其主要特征是在LAA，解剖一些知觉的左心耳开口的距离优势叶急弯。 （右），西兰花型LAA是一个解剖，其主要功能是限制了LAA，总长度更复杂的内部特征。 <img alt="图5" src="/files/ftp_upload/3671/3671fig5.jpg" /> 图5。Kaplan-Meier曲线STU的发病率干预组和对照组的DY终点。 =比率421。发病概率为意向性治疗分析显示，作为主要疗效终点（A）的主要安全终点（二），（三）所有行程天以来的随机计算的时间，和所有原因的死亡率（四<a href="http://jove.unicartagenaproxy.elogim.com/files/ftp_upload/3671/3671fig5large.jpg" target="_blank">点击这里为更大的数字</a> ）。 <table border="1"><tbody><tr><td> 左心耳开口最大（毫米） </td><td> 设备尺寸（mm） （未压缩的直径） </td></tr><tr><td> 17-19 </td><td> 21 </td></tr><tr><td> 20-22 </td><td> 24 </td></tr><tr><td> 23-25 </td><td> 27 </td></tr><tr><td> 26-28 </td><td> 30 </td></tr><tr><td> 29-31 </td><td> 33 </td></tr></tbody></table> 表1。确定选择正确的设备。该装置的Sizing是基于在左心耳最大直径。 LAA，最大开口尺寸应&gt; 17mm或&lt;31毫米，以适应可用的设备大小。 /可用LAA长度应等于或大于的开口。

<ol>
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博士莫比乌斯温克勒，博士Dähnert和教授舒勒参与保护AF审判。 莫比乌斯的温克勒博士守望植入Atritech公司和波士顿科学监考。

经皮植入守望的过程左心耳封堵器在这里描述，在临床试验中已被证明是可行的16，非劣warfarin治疗2，安全17。虽然在所有的研究，有较高的并发症率在接受植入2,16,17组，从保护AF审判和第注册表的研究，安全评估的数据表明，与守望植入相关的并发症主要归因于运营商的经验不足。最初安全事件发生率的频率高，但17随着时间的推移下降。 这里介绍的方法，强调在预防手术并发症的几个关键步骤。在试点研究中，三个安全事件发生的设备故障。两科栓塞的设备，并在一个主题的电线断裂过程中的植入TION程序。虽然这些事件发生在第一代设备，并没有发生在第二代设备，看守系统应始终被彻底检查，使用前16日 。 与程序相关的最常见的并发症是心包积液，需要干预和空气栓塞。成像数据的分析表明，在保护自动对焦审判严重心包积液，造成操作错误在操作由守望设备的，跨室间隔穿刺或左心耳内护套，以达到最佳的植入过程的操纵。通过使用猪尾导管鞘尖的左心耳穿孔的风险可以大大减少。一个心包积液最有可能导致一场轰轰烈烈的"拔河试验"进行检查，在左心耳设备的稳定性。出于这个原因，关键是使用TEE和整个过程的透视监视我mplantation过程。检查稳定时，对比度应注入了LAA，可视化室，或过程中应不断监测与TEE。通过观察，没有进一步的拖船相关积液已被观察到。程序有关的中风发生3例，作为一个从大12F跨室间隔访问护套空气栓塞的结果。因此，关键是要在勤于正确冲洗鞘确保空气内没有被困鞘17。此外，空腹程序之前，可能会导致在植入过程中低左心房压力，这可能会导致空气栓塞造成的脱水。因此，部署设备之前，生理盐水应注入患者的左心房压力增加约10毫米汞柱。 尽管LAA，闭塞的安全事件相比，华法林治疗率较高，LAA，闭塞的发病率/死亡率方面的整体结果是IM事实证明17。左心耳封闭，因此是一种很有前途的有效替代不断warfarin治疗非瓣膜性房颤患者。

the watchman left atrial appendage closure device for atrial fibrillation

心房颤动（AF）是最常见的心律失常，影响估计有600万在美国的1人。由于自动对焦主要影响老年人，其发病率随着年龄的增加平行。正因为如此，它预计将于2050年2 15.9万美国人的影响。每年5％的非抗凝的房颤患者发生缺血性中风。目前的治疗方法，包括为AF率控制，节奏控制和预防中风3。 美国心脏病学会，美国心脏协会和欧洲心脏病学会目前推荐率控制自动对焦，3治疗的第一期培训班。率控制，实现管理的药物制剂，如β-受体阻滞剂，心率降低，直到它到达一个不太对症的状态3。节奏控制的目的是恢复其正常的窦性节律的心脏，通常是通过抗心律失常药物，如胺碘酮，电复律或消融治疗的管理。节奏控制的方法，但是，还没有被证明是优于速率控制方法4-6。事实上，某些抗心律失常药物已被证明与住院率较高，严重的不利影响，甚至在结构性心脏缺陷7患者的死亡率增加相关。因此，与抗心律失常药物治疗时，更常用的速率控制药物无效或有禁忌。率控制和抗心律失常药物减轻房颤的症状，包括心悸，气短，疲劳8，但不可靠地防止血栓事件6。 与抗凝药华法林治疗显着降低中风或栓塞9,10率。然而，相关的问题，因为其使用，少于50％患者治疗。受治疗剂量的药物，饮食和代谢相互作用，因此需要详细的监测。此外，华法林有可能造成严重，有时致命的出血2。作为一种替代方法，常用的阿司匹林。虽然阿司匹林通常是很好的耐受性，这是远远低于有效预防中风10。其他的替代品，如华法林达比加群11或利伐沙班12证明非劣效华法林栓塞事件（事实上，达比加群高剂量为150毫克，一天两次已经显示的优越性）。虽然这些药物比华法林的优势，消除饮食的关注和消除需要定期监测血，大出血和并发症，而少了几分，仍然是一个问题13-15。 由于90％AF相关的笔触从栓子，ARISE左心耳（LAA），2，warfarin治疗的一个替代办法已经排除LAA，使用植入设备捕获血液凝块，他们退出之前。在这里，我们展示了植入左心耳封闭装置的守望过程。跨室间隔导管通过股静脉插入，透视引导下，横渡间房间隔。一旦进入到左心房已经实现，导丝放置在上肺静脉和先进的守望访问鞘和扩张线进入左心房。导丝被删除，访问鞘仔细超过猪尾导管远端部分的左心耳先进的。 prepped守望配送系统，插入接入鞘，缓慢先进。守望的设备，然后部署到左心耳。设备释放标准是我确认通过透视及食管超声心动图（TEE）和设备小号公布。

Watch this Scientific Journal Video about The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation at JoVE.com

The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation

随行的视频介绍了经皮守望安置程序，左心耳（LAA），设备。守望的是镍钛设备设计，永久植入，或稍远，左心耳（LAA），捕获血液凝块，才退出左心耳，防止血栓栓塞性中风的开幕。

守望的左心耳封闭装置心房颤动

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting an estimated 6 million people in the United States 1. Since AF affects primarily ...

the-watchman-left-atrial-appendage-closure-device-for-atrial

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

83.3K 次观看.  University of Leipzig Heart Center. 随行的视频介绍了经皮守望安置程序，左心耳（LAA），设备。守望的是镍钛设备设计，永久植入，或稍远，左心耳（LAA），捕获血液凝块，才退出左心耳，防止血栓栓塞性中风的开幕。

视频: The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation

A New Single Chamber Implantable Defibrillator with Atrial Sensing: A Practical Demonstration of Sensing and  Ease of Implantation

Implantable cardioverter-defibrillators (ICDs) terminate ventricular tachycardia (VT) and ventricular fibrillation (VF) with high efficacy and can protect patients from sudden cardiac death (SCD). However, inappropriate shocks may occur if tachycardias are misdiagnosed. Inappropriate shocks are harmful and impair patient quality of life. The risk of inappropriate therapy increases with lower detection rates programmed in the ICD. Single-chamber detection poses greater risks for misdiagnosis when compared with dual-chamber devices that have the benefit of additional atrial information. However, using a dual-chamber device merely for the sake of detection is generally not accepted, since the risks associated with the second electrode may outweigh the benefits of detection. Therefore, BIOTRONIK developed a ventricular lead called the LinoxSMART S DX, which allows for the detection of atrial signals from two electrodes positioned at the atrial part of the ventricular electrode. This device contains two ring electrodes; one that contacts the atrial wall at the junction of the superior vena cava (SVC) and one positioned at the free floating part of the electrode in the atrium. The excellent signal quality can only be achieved by a special filter setting in the ICD (Lumax 540 and 740 VR-T DX, BIOTRONIK). Here, the ease of implantation of the system will be demonstrated.

Dual-chamber implantable cardioverter-defibrillators (ICDs) may improve detection of atrial fibrillation as well as differentiation of tachycardias. However, this advantage is undermined by complications associated with the second electrode, which is required in conventional dual chamber devices. Therefore, BIOTRONIK has developed a new electrode called the LinoxSMART S DX that, when used in conjunction with the Lumax DX ICD, offers dual-chamber detection without the risks associated with the second electrode.

心房遥感新的单一商会植入去纤颤器:一个实用的遥感示范和易于植入

Implantable cardioverter-defibrillators (ICDs) terminate ventricular tachycardia (VT) and ventricular fibrillation (VF) with high efficacy and can protect ...

科研

医学

Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and disordered electrical activity in the atria gives rise to palpitations, fatigue, dyspnea, chest pain and dizziness with or without syncope 4, 5. Patients with AF have a five-fold higher risk of stroke 6.
Oral anticoagulation (OAC) with warfarin is commonly used for stroke prevention in patients with AF and has been shown to reduce the risk of stroke by 64% 7. Warfarin therapy has several major disadvantages, however, including bleeding, non-tolerance, interactions with other medications and foods, non-compliance and a narrow therapeutic range 8-11. These issues, together with poor appreciation of the risk-benefit ratio, unawareness of guidelines, or absence of an OAC monitoring outpatient clinic may explain why only 30-60% of patients with AF are prescribed this drug 8.
The problems associated with warfarin, combined with the limited efficacy and/or serious side effects associated with other medications used for AF 12,13, highlight the need for effective non-pharmacological approaches to treatment. One such approach is catheter ablation (CA), a procedure in which a radiofrequency electrical current is applied to regions of the heart to create small ablation lesions that electrically isolate potential AF triggers 4. CA is a well-established treatment for AF symptoms 14, 15, that may also decrease the risk of stroke. Recent data showed a significant decrease in the relative risk of stroke and transient ischemic attack events among patients who underwent ablation compared with those undergoing antiarrhythmic drug therapy 16.
Since the left atrial appendage (LAA) is the source of thrombi in more than 90% of patients with non-valvular atrial fibrillation 17, another approach to stroke prevention is to physically block clots from exiting the LAA. One method for occluding the LAA is via percutaneous placement of the WATCHMAN LAA closure device. The WATCHMAN device resembles a small parachute. It consists of a nitinol frame covered by fabric polyethyl terephthalate that prevents emboli, but not blood, from exiting during the healing process. Fixation anchors around the perimeter secure the device in the LAA (Figure 1). To date, the WATCHMAN is the only implanted percutaneous device for which a randomized clinical trial has been reported. In this study, implantation of the WATCHMAN was found to be at least as effective as warfarin in preventing stroke (all-causes) and death (all-causes) 18. This device received the Conformit&eacute; Europ&eacute;enne (CE) mark for use in the European Union for warfarin eligible patients and in those who have a contraindication to anticoagulation therapy 19.
Given the proven effectiveness of CA to alleviate AF symptoms and the promising data with regard to reduction of thromboembolic events with both CA and WATCHMAN implantation, combining the two procedures is hoped to further reduce the incidence of stroke in high-risk patients while simultaneously relieving symptoms. The combined procedure may eventually enable patients to undergo implantation of the WATCHMAN device without subsequent warfarin treatment, since the CA procedure itself reduces thromboembolic events. This would present an avenue of treatment previously unavailable to patients ineligible for warfarin treatment because of recurrent bleeding 20 or other warfarin-associated problems.
The combined procedure is performed under general anesthesia with biplane fluoroscopy and TEE guidance. Catheter ablation is followed by implantation of the WATCHMAN LAA closure device. Data from a non-randomized trial with 10 patients demonstrates that this procedure can be safely performed in patients with a CHADS2 score of greater than 1 21. Further studies to examine the effectiveness of the combined procedure in reducing symptoms from AF and associated stroke are therefore warranted.

Catheter ablation is combined with placement of the WATCHMAN Left Atrial Appendage Closure Device to prevent ischemic stroke in a patient with non-valvular atrial fibrillation.

结合消融房颤左心耳封堵

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and ...

Robotic Ablation of Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between pulmonary vein (PV) and left atrium (LA) is created. This conduction block prevents AF, which is triggered by irregular electric activity originating from the PV. However, transmural atrial lesions are required which can be challenging. Re-conduction and AF recurrence occur in 20 - 40% of the cases. Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new remote catheter system (RCS), is presented. Objective of this article is to show feasibility of robotic AF ablation with a novel system. Materials and Methods: After interatrial trans-septal puncture is performed using a long sheath and needle under fluoroscopic guidance. The needle is removed and a guide wire is placed in the left superior PV. Then an ablation catheter is positioned in the LA, using the sheath and wire as guide to the LA. LA angiography is performed over the sheath. A circular mapping catheter is positioned via the long sheath into the LA and a three-dimensional (3-D) anatomical reconstruction of the LA is performed. The handle of the ablation catheter is positioned in the robotic arm of the Amigo system and the ablation procedure begins. During the ablation procedure, the operator manipulates the ablation catheter via the robotic arm with the use of a remote control. The ablation is performed by creating point-by-point lesions around the left and right PV ostia. Contact force is measured at the catheter tip to provide feedback of catheter-tissue contact. Conduction block is confirmed by recording the PV potentials on the circular mapping catheter and by pacing maneuvers. The operator stays out of the radiationfield during ablation. Conclusion: The novel catheter system allows ablation with high stability on low operator fluoroscopy exposure.

Pulmonary vein isolation (PVI) with an ablation catheter is a curative treatment for atrial fibrillation (AF). Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new robotic catheter system is presented. The goal of the procedure is electrical block between pulmonary vein and left atrium.

房颤消融机器人

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between ...

Non-fluoroscopic Catheter Tracking for Fluoroscopy Reduction in Interventional Electrophysiology

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that the application of this non-fluoroscopic catheter visualization system (NFCV) reduces fluoroscopy time and dose by 90-95% in a variety of electrophysiology (EP) procedures. This can be of relevance not only to the patients, but also to the nurses and physicians working in the EP lab. Furthermore, in a subset of indications such as supraventricular tachycardias, NFCV enables a fully non-fluoroscopic procedure and allows the lab staff to work without wearing lead aprons. With this protocol, we demonstrate that even complex procedures such as ablations of atrial fibrillation, that are typically associated with fluoroscopy times of &#62;30 min in conventional settings, can safely be performed with a reduction of &#62;90% in fluoroscopy exposure by the additional use of NFCV.

Radiation exposure is an underestimated risk in complex ablation procedures. Here, we describe a protocol to significantly decrease fluoroscopy time and dosage for both the patient and the lab staff by using a novel non-fluoroscopic catheter visualization system.

非透视导管跟踪透视减少介入电

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that ...

Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale (PFO) detection, for patient selection for transcatheter ASD/PFO closure,&#160;for intraoperative guidance and for long-term follow-up. The size, shape, location and the number of the atrial communications schould be determined. The accuracy of PFO detection can be improved by using agitated saline together with maneuvers to transiently increase the right atrial (RA) pressure. The appearance of microbubbles in the left atrium (LA) within 3 cardiac cycles after opacification of the RA is considered positive for the presence of an intracardiac shunt. Three dimensional TEE identifies further septal fenestrations and describes the dynamic morphology of ASD/PFO and atrial septal aneurysm. Follow-up evaluations with TTE is recommended at 1, 6, and 12 months after the procedure, with a subsequent evaluation every year. Previous studies showed an increased incidence of atrial arrhythmias early after device closure. Speckle tracking analysis may help to understand functional left atrial remodeling following percutaneous closure and its impact on atrial arrhythmias.

Transthoracic (TTE) and transesophageal (TEE) echocardiography represent the basic imaging tools for interatrial septum examination. Three dimensional (3D) TEE provides incremental information in the assessment of the interatrial septum. Further advanced echocardiography techniques using speckle tracking echocardiography are applied for sensitive volumetric and functional assessment of the heart chambers.&#160;

经导管闭合前心房通路的超声心动图评估

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale ...

Use of a Percutaneous Ventricular Assist Device/Left Atrium to Femoral Artery Bypass System for Cardiogenic Shock

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the left ventricle by draining blood from the left atrium (LA) and returning it to the systemic arterial circulation via the femoral artery. It can provide flows ranging from 2.5-5 L/min depending on the size of the cannula. Here, we discuss the mechanism of action of LAFAB, available clinical data, indications for its use in cardiogenic shock, steps of implantation, post-procedural care, and complications associated with the use of this device and their management.
We also provide a brief video of the procedural component of device therapy, including the pre-placement preparation, percutaneous placement of the device via transseptal puncture under echocardiographic guidance and the post-operative management of device parameters.

The following article describes the stepwise procedure for placement of a device (e.g., Tandemheart) in cardiogenic shock (CS) that is a percutaneous left ventricular assist device (pLVAD) and a left atrial to femoral artery bypass (LAFAB) system that bypasses and supports the left ventricle (LV) in CS.

使用经皮心室辅助装置/左心房至股动脉旁路系统治疗心源性休克

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the ...

Cox-Maze IV Procedure Concomitant with Valvular Surgery In Situs Inversus Dextrocardia: A Single-Center Experience in China

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The use of ablation technologies made the Cox-Maze IV procedure (CMP-IV) technically easier, faster, becoming the gold standard for the surgical treatment of AF. However, the efficacy and safety of CMP-IV in situs inversus dextrocardia are largely unknown. This paper summarizes the CMP-IV procedure performed concomitantly with valvular surgery in patients with situs inversus dextrocardia at this institution.
From February 2016 to September 2020, three dextrocardia patients with persistent AF and valvular diseases were referred to this institution for valvular and CMP-IV surgery. CMP-IV was performed using either cryoablation with a nitrous oxide (N2O)-based cryoprobe or a bipolar radiofrequency clamp and bipolar radiofrequency pen. Mechanical valve replacement or mitral vavuloplasty was performed in another patient in addition to tricuspid annuloplasty. Transmurality of the ablated atrial tissues was evaluated by electron microscopy. Heart function was assessed by transthoracic echocardiography. Cardiac rhythm was monitored by 24 h Holter at 3, 6, 12, 18, 24, and 48 months follow-up. 
All the AF was successfully eliminated in the ablation procedure without recurrence or other complications during hospitalization. The mean bypass and crossclamp times were similar in all the patients. The postoperative ventilator support time, the duration of stay in the ICU, and postoperative residence time were also not significantly different among the patients. Transmural atrial necrosis was detected in the ablated atrial tissues. Sinus rhythm maintenance was achieved at 3, 6, 12, 18, 24, and 48 months follow-up in all the patients. All valve protheses switched freely; no tricuspid regurgitation was observed. The results of the present study demonstrate that the CMP-IV is safe and effective in eliminating AF in dextrocardia patients concomitant with valvular surgery.

We summarize the Cox-Maze IV procedure concomitant with valvular surgery performed in patients with situs inversus dextrocardia at this institution.

Cox-Maze IV手术与瓣膜手术在位内与右旋心动过速中同时进行:中国的单中心经验

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The use of ablation technologies made the Cox-Maze IV procedure (CMP-IV) technically ...

Closure of a Patent Foramen Ovale (PFO): An Intervention Sequence

A patent foramen ovale (PFO) persists in about one-quarter of people and is the source of up to 25% of all ischemic strokes, especially strokes in young adults. PFO can be easily diagnosed by transthoracic contrast and/or transesophageal echocardiography. Interventional closure of the PFO via the femoral vein is a commonly used cardiological procedure since several trials have demonstrated the superiority of PFO closure over standard medical therapy in patients with PFO and who have experienced post ischemic, cardioembolic, or cryptogenic stroke. The current paper and video show the procedure of PFO closure in a step-by-step manner.

Closure of a Patent Foramen Ovale PFO: An Intervention Sequence

The closure of a patent foramen ovale (PFO) is a catheter-based intervention to prevent PFO-associated stroke. The PFO-occlusion device is advanced through the femoral vein and deployed across the interatrial septum using transesophageal echocardiography (TEE) and fluoroscopic guidance. The following protocol provides a step-by-step guide for the PFO-closure intervention using a double-disc device.

闭合卵形孔（PFO）:干预序列

A patent foramen ovale (PFO) persists in about one-quarter of people and is the source of up to 25% of all ischemic strokes, especially strokes in young ...

Benefits of Cardiac Resynchronization Therapy in an Asynchronous Heart Failure Model Induced by Left Bundle Branch Ablation and Rapid Pacing

It is now well recognized that heart failure (HF) patients with left bundle branch block (LBBB) derive substantial clinical benefits from cardiac resynchronization therapy (CRT), and LBBB has become one of the important predictors for CRT response. The conventional tachypacing-induced HF model has several major limitations, including absence of stable LBBB and rapid reversal of left ventricular (LV) dysfunction after cessation of pacing. Hence, it is essential to establish an optimal model of chronic HF with isolated LBBB for studying CRT benefits. In the present study, a canine model of asynchronous HF induced by left bundle branch (LBB) ablation and 4 weeks of rapid right ventricular (RV) pacing is established. The RV and right atrial (RA) pacing electrodes via the jugular vein approach, together with an epicardial LV pacing electrode, were implanted for CRT performance. Presented here are the detailed protocols of radiofrequency (RF) catheter ablation, pacing leads implantation, and rapid pacing strategy. Intracardiac and surface electrograms during operation were also provided for a better understanding of LBB ablation. Two-dimensional speckle tracking imaging and aortic velocity time integral (aVTI) were acquired to validate the chronic stable HF model with LV asynchrony and CRT benefits. By coordinating ventricular activation and contraction, CRT uniformed the LV mechanical work and restored LV pump function, which was followed by reversal of LV dilation. Moreover, the histopathological study revealed a significant restoration of cardiomyocyte diameter and collagen volume fraction (CVF) after CRT performance, indicating a histologic and cellular reverse remodeling elicited by CRT. In this report, we described a feasible and valid method to develop a chronic asynchronous HF model, which was suitable for studying structural and biologic reverse remodeling following CRT.

The establishment of a chronic asynchronous heart failure (HF) model by rapid pacing combined with left bundle branch ablation is presented. Two-dimensional speckle tracking imaging and aortic velocity time integral are applied to validate this stable HF model with left ventricular asynchrony and the benefits of cardiac resynchronization therapy.

心脏再同步治疗在左束分支消融和快速起搏诱发的异步心力衰竭模型中的益处

It is now well recognized that heart failure (HF) patients with left bundle branch block (LBBB) derive substantial clinical benefits from cardiac ...

生物学

<meta charset="utf8"></head><body>通过后皮瓣旋转有效修复供体左心房缺损

Donor Posterior Atrial Flap Rotation for Left Atrial Cuff Reconstruction in Lung Transplantation

We describe in detail a novel surgical technique for repairing donor anterior left atrial wall defect in vivo by rotating the posterior atrial flap during lung transplantation. This method can safely and effectively address the most common type of donor left atrial cuff defect: the anterior wall defect, with the intact posterior wall, typically retained when the donor heart is also used. During atrial cuff anastomosis in lung transplantation, the excess donor posterior atrial wall is trimmed into an atrial flap. After the posterior wall anastomosis is completed, the atrial flap is rotated 180&#176; and used as a patch for anterior wall reconstruction anastomosis. 
After restoring blood flow, the flow rate of the pulmonary vein is normal and smooth as confirmed by transesophageal echocardiography. Compared with the traditional patch reconstruction method, the new method effectively reduces the atrial cuff anastomosis time. Our results showed no significant difference in pulmonary vein obstruction after reconstruction. Pulmonary artery systolic blood pressure was significantly lower and pulmonary function improved postoperatively in all groups, with no significant differences among the groups. The new technique provides a feasible strategy for the reconstruction of left atrial cuff defects and can improve the effective utilization rate of donor lungs.

<meta charset="utf8"></head><body>供体后心房皮瓣旋转用于肺移植中左心房袖口重建

This protocol describes a new method for effectively reconstructing donor atrial cuff anterior wall defects during lung transplantation through the rotation of the donor posterior atrial flap.

供体后心房皮瓣旋转用于肺移植中左心房袖口重建

We describe in detail a novel surgical technique for repairing donor anterior left atrial wall defect in vivo by rotating the posterior atrial flap during ...