???????????(Scherf ?,1953)

1
?????????

• ????????????
• ? ? ?

2
??????

• ?????????????????????
• ???????????
• ????????????????,??????????
• ???????????
• ?????????????
• ??????????,???????????

3
?????????

• ????????2.2???? 1.7
• 70????????????????
• ??30???????????
• ???????????????,?????????????

4
???????

• ?????????????????????????????????????????
• ?????????????????????????????????????????????????
  ????
• ???????????????????????????????????
• ??????????,????????

5
???????????????

• ??????????
• ???????????(Scherf ?,1953)
• ??????????(Moe?,1959)
• ?????????????AVNRT?AVRT?
• ????????????
• ???????

6
???????????????

• ??????????
• ???(90????????????)?
• ?????????????????????????(muscular sleeve)??,???
• ???????????????????????????????? Marshall
  ????????

7
???????????????

• ??????????
• ??????????????(???)
• ????????
• ?????????
• ????????
• ???????????????????????????
• ????????????(?????)

8
Initiation of AF
sudden onset
PACs
8
30
32
5
25
reinitiation
tachycardia
bradykardia
9
?????????
PV
Lighter (trigger)
LA
Wood (substrate)
10
???????

• ?????(????lt7d)???????,??????
• ???????48?????????????????????
• ???????????(7d)???
• ???????,???????????,?????????????????

11
Atrial fibrillation accounts for 1/3 of all
patient discharges with arrhythmia as principal
diagnosis.
Arrhythmia as principal diagnosis
6 PSVT
6 PVCs
18 Unspecified
4 Atrial Flutter
9 SSS
34 Atrial Fibrillation
8 Conduction Disease
10 VT
3 SCD

• 2 VF

Data source Baily D. J Am Coll Cardiol.
199219(3)41A.
12
Hospitalization from AF
150
Cardiac arrest
110
VF
VT
410
Atrial fibrillation
900
Atrial flutter
100
300
Sick sinus syndrome
0
200
400
600
800
1000
1200
Hospital days
Bialy et al, J Am Coll Cardiol 92
13
Mortality
Framigham Study
55 - 74 years
75 94 y
Benjamin EJ et al, Framigham Heart Study,
Circulation 98 98 946-952
14
?????????

• ????????????????????????????
• ????????????????????
• ???????
• ?????????,????????????????

15
? ? ? ? ? ? ? ? ?

• ??????????
• ?????????
• ??????????
• ?????????
• ?????????????

16
?????????

• ??????????????????
• ???????,?????????????????????
• ??????,?????????,??????

17
????????

• ????????????????????????,?????????????,
  ???????????,???????????????
• ????????????????????????????????????

18
?????????

• ??????????
• ??????
• ?40?50????
• ?????????,????????
• ?????????????????
• ?????????????
• ß?????? ?????????????

• ??????????
• ??????????
• ??????
• ?????????
• ????
• ????????(?90?/min)??
• ß??????????????

19
Treatment strategies for AF
Atrial Defibrillator
Hybrid therapy
MAZE-surgery
Alate and bpace
Atrial fibrillation
Catheter ablation
Preventive Pacing
Antiarrhythmic drugs
ACE-inhibitor
20
?????????

• ?????
• ???????
• ???????
• ???????
• ???????????
• ?????????
• ??????????(?)

21
???????????

• ??????????????????
• ???????,?????,????
• ?????????????
• ??????????????????
• ????????

22
???????????

• ? ?
• ???????????,???????????
• ?????,?????????
• ????????????????

• ? ?
• ??????,????????
• ??????????
• ??????,?????????????
• ????????

23
????????

• ?????????????
• ??????60--80?/min
• ???90--115?/min

24
??????????

• ????
• ?????????????????ß??????????????????????
• ?????
• ???????/???????
• ????
• ????
• ????
• ?????

25
??????????

• ??????????ß???
• ?????????,?????????,???????????????ß???????
• ????????,???????
• ?????????????
• ?????????,???????
• ???????????,????????????????

26
??????????

• ????
• ?????????????????ß??????????????????????

27
???????????

• ??????????????
• 1)????2)???????3)????????
• 4)??????????
• ?????????????????
• ??????---???????

28
???????????

• ????????????
• ????
• ?????????????????
• ??????????????
• ?????????????
• ???????,?????????
• ?????????????

29
???????

• ???????
• ???? Ibutilide? Dofetilide?Flecainide?????????
  
• ?????????????
• ?-????????????????? Disopyramide

30
???????????

• ????????????????gt70
• ??????????????
• ????????????????????
• ??????????????EF????
• ???????????,???C?????
• ??????????????????

31
???????????

• ??????48h????????,???
• ?????????????
• ????????, ???????????
• ????????
• ? ??????????????,????????
• ???????????
• ?????????????,??????
• ????????????

32
??????????

• ?????????????????
• ????????????????????
• ????????????????
• ?????????????????????
• ????????????(??????????
• ?????) ?????? (????????????)

33
????????????

• ????????
• ??? ?C????????dofetilide???????
• ????
• ??????
• ???????,??????,?????????
• ?,??????????,??????????
• ??????
• ????????,?????????? dofetilide?ß
• ??????????????????,??????
• ???????,?????

34
? ? ? ? ? ? ? ?

• ?????????????
• ????????????(????????)
• ????????????,??????
• ???????,????????
• ?????????????
• ?????????,????,???????
• ??????????
• ??????,?????????,????????,??????

35
?????????

• ????????????????????????
• ?????????
• ?????????????
• ??????????????????????
• ??????????????????????????????????????????????
• ??????????????????,???????????????????
• ?????????????????

36
??????????

• ??????????????????
• ????????????/????
• ?????????INR?2.0-3.0??(??)
• ???????,INR???3.0-4.0(??)
• ??INR???1.5-2.1??,???????
• ???????????,325mg/d???????
• ????????????????????????
• ????????????????????

37
??????????

• ?????????--???????
• ???????--?????? ????
• ?????????95??????,??????
• ??????????,???????????

38
????????????

• ?????????,?????????????
• ??????????48h, ?????
• ??1)????????3?,INR2-3???2) TEE/Heparin
  ??????????(INR 2)
• ?????????4?(???????????????)

39
??????????

• ???????????25-35
• ???????????????,?????
• ?????
• ??????????,??????????,
• ?????
• ????????????ß???
• ?????????????????????

40
?????/??????????

• ?????????
• RACE (Rate control vs.Electrical cardioversion
  for persistent atrial fibrillation)
• PIAF (The Pharmacological Intervention in Atrial
  Fibrillation)
• STAF(The Strategies of Treatment of Atrial
  Fibrillation)
• AFFIRM (The Atrial Fibrillation Follow-up
  Investigation of Rhythm Management)

41
RACE

• ???522?
• ????1997-1999???????
• ?????????????????
• ??????2.3?
• ??????????????????????????????????????
• ???????,????????????
• (1)?????????
• (2)??????
• ?????????????????
• ???????
• ?????????,??????

42
PIAF

• ???????????????????????
• ????
• ??????????????
• ???????????
• ????????????????

43
STAF

• ??????????????
• ???200?
• ??????19?
• ??
• (1)?????
• (2)??????
• ?? ??????????
• ???????????????(?????
• ?????????)

44
AFFIRM Clinical Trial

• AFFIRM A Large, Multicenter Trial Studying Rate
  Versus
• Rhythm Control
• ???4060?
• ????1995-1999?????????213???
• ??????3.5?
• ??????70?
• ???????,????????????
• (1)?????
• (2)??????
• ACC Annual Scientific Session 2002
  on March 18, 2002

45
AFFIRM (4060 pts) rate vs rhythm control
AFFIRM Investigators N Engl J Med 2002, 347
1825-33
46
AFFIRM Clinical Trial

• ????
• ???????????,??????????????(356vs.310)
• ????????????????
• ??????????
• ?????????????,????????????

47
AFFIRM Clinical Trial

• ??
• ???????????????,?????????????????
• ???????????,????????
• ?????????????,??????????????

48
AFFIRM Clinical Trial

• ??????????????????
• ??????,???????,???????
• ?????????????????,???
• ???????????
• ??????????????????????
• ??????????????????(????)

49
Analysis of Cause-Specific Mortality in AFFIRM
Study

• --------------------------------------------------
  ----------------------------------------
• Rate Control
  Rhythm Control
• Mode of Death n2027
  n2033 p
• --------------------------------------------------
  ----------------------------------------
• Total deaths
  310 356
  0.07
• Cardiac
  130 129
  0.95
• Arrhythmic
  79 77
  0.88
• Nonarrhythmic 43
  46 0.75
• CHF or shock,with MI 7
  7
• CHF or shock,noMI 26
  27
• Cardiac surgery/procedure 6
  5
• Other/unknown 4
  7
• Uncertain
  8 6
  0.60
• Vascular
  37 35
  0.82
• CNS
  28 28
  gt0.99
• Ischemic stroke
  17 15
  
• CNS hemorrhage 11
  13
• Other
  9 7
• Noncardiovascular 113
  169 0.008

50
Analysis of Cause-Specific Mortality in AFFIRM
Study

• ?????
• Cardiac deaths 129(9) vs 130(10)
• Vascular Deaths 35(3) vs 37(3)
• Noncardiovascular Deaths 69(47.5) vs
  113(36.5) (p0.0008)
• Pulmonary causes 39(4) vs 23(3) (p0.04)
• Cancer(most commen type--Lung cancer)
• 81(6) vs
  52(4) (p0.01)
• Rhythm control
• ?????????????????
• ????????????(5?)-----??????????

51
Effectiveness of rhythm control in AF with OAP
and AAD after linear RACA

• Hybrid therapy utilizing cathter RA maze
  procedures with OAP and AAD can be performed
  safely and can reestablish rhythm control in
  selected patients with refractory persistent or
  permanent AF
• OAP overdrive atrial pacing AAD
  antiarrhythmic durg

52
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53
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54
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55
?????????

• ???????
• ???????????????
• ????????????
• ??????????ß-Block
• ????????,?????
• ???????????AVN???
• ????????DC shock
• ???????????????????AF
• ???????????

56
?????????

• ?????????
• ???????????,???????,?????/???
• ??????INR??2-3
• ?????????????INR??3-4
• ?TIA?????????????????????????????????
• ?????????????(????????)
• ????325mg/d???????????????????????

57
?????????

• ?????????
• ????????????????????,Ic??????
• III?????,??????TdP
• ??????????
• ??????????????????????
• ??????????,?????,??????
• ???48h,?????????????

58
?????????

• ????????????
• ????III???????????(TdP?)
• ??????????????????????
• ???????
• ??????????????????
• ???????,???,??????(?????)????????????

59
?????????

• ????
• ??????????????????????????
• ?????,?????????,????????????
• ?????????????????????????????????,???????????????

60
?????????

• ?????????
• ??????????????????????,???????????????????????????
  ????????????
• ???????,?????
• ????????????????????????????????????

61

Thank You!
62
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63
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64
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65
(No Transcript)
66
(No Transcript)