atrial fibrilasi
TRANSCRIPT
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ATRIAL FIBRILATION
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Revina Rizky Angelia
Irsyam Wahidi
Jaka Pebrian
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Atrial Fibrilasi
Fibrilating : bergetar => bergetarnya otot jantung
Atrial fibrilasi adalah aritmia atau kelainan irama jantung yang bermasalah dengan kecepatan atau ritme detak jantung. Kelainan sistem listrik jantung ini disebabkan adanya atrium yang berdetak/bergetar tidak beraturan
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Faktor resiko
• CHF
• Valve disease
• Hypertension
• Diabetes mellitus
• Obesity
• Alcohol comsumption
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AF mortality
• Kematian penderita dengan AF 2x dan stroke Stroke 2-7x
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Atrial fibrilation • Aktivitas atrial yang sangat tidak teratur - Atrial activity continuous, chaotic (kacau),
uncoordinated - 400-600 bpm (rate atrial)
• Sepenuhnya berada di dalam atria (re-entry nya)
• Gel P tidak jelas pada surface EKG - Gel P digantikan dgn ‘fibrilatory waves’ - Berbeda dalam ukuran, bentuk, waktu
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• Irregular ventricular response
- QRS complex biasanya sempit (dbn)
- Response rate tergantung dari AVN function
- Slow ventricular response (<60 bpm)
- Normo ventricular response ( 60 – 100 bpm)
- Rapid ventricular response ( >100bpm)
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Classification 1. Paroxysmal (tingkat keberhasilan 80 %)
- Terminates spontaneosly < 7 days
- Treatment strategy = rhythm control
- Often associated with normal hearts
> Hilang dan timbul secara spontan => tanpa intervensi
2. Persistent
- Often lasts > 7 days, rare spontaneous termination
- Treatment strategy = rhytm control
- Often associated with heart disease
> Tidak dapat terkonversi secara spontan menjadi SR => perlu kardioversi untuk menjadi SR, baik farmakologik maupun non farmakologik
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3. Permanent
- chronic, unable to terminate
- Teratment strategy = rate control
- Often associated with heart disease
Tdk dapat dikonversi menjadi irama sinus
Sumber lain :
4. AF episode : adanya episode AF pada saat ECG monitoring dimana <30s dan disertai adanya sinus rhytm sebagai irama dasarnya
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Klasifikasi berdasarkan ada tidaknya penyakit
a. AF primer
Terjadi bila tidak disertai penyakit jantung atau penyakit iskemik lainnya
b. AF sekunder
disertai adanya penyakit jantung atau penyakit iskemik lainnya (valvular HD, CAD, HT, HCM)
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Pembagian berdasarkan bentuk gelombang P , AF :
1. AF coarse (kasar)
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2. AF fine (halus)
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Clinical Manifestation • Can be symptomatic or asymptomatic
• Symptoms vary with : - Ventricular rate - AF duration - Individual patient perception => anamnesa
• Persistently elevated ventricular rates may
produce cardiomiopaty (bila ventrikel rate terus menerus meningkat akan menimbulkan cardiomipaty)
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Common Symptoms
• Palpitaions
->Rapid or irregular ventricular rate
• Presyncope
->Slow ventricular rate
• Dyspnea, fatigue, lightheadedness,syncope
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Causes of AF • Acute/temporary causes of AF
- alcohol, surgery, myocarditis
- Post-op (complication of MI and cardiac or thoracic surgery)
• AF with associated heart disease
- Valvular HD (mitral especially)
- CAD
- HT (especially with LVH)
- HCM / DCM
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Atrial Pathology
• Patchy areas of fibrosis (jaringan ikat yang bertumpuk)
• Fatty infiltration (tebalnya myocard atrium)
• Myocarditis
• Atrial dilation (dilatasi atrial)
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AF mechanism
• “Focal” Triggering mechanism” melibatkan sifat automaticity atau multiple reentrant wavelets, tetapi satu sama lain tidak sendirian dan mungkin secara bersamaan yang mengakibatkan micro reentry multiple
• Kehadiran dari gelombang multiple reentrant akan menyebar secara simultan di atrium
• Merambatnya sumber focal tersebut sangatlah cepat
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• Pencetus AF antara lain saraf simpatis (meningkatkan HR dan tekanan darah ) dan parasimpatis (sebaliknya), bradikardi, takikardi, accessory pathway dan adanya fokus ektopik di lapisan dinding atrium di vena pulmonalis atau vena cava junctions. Daerah ini dalam lingkungan yang normal memiliki aktifitas listrik yang sinkron, namun pada regangan akut dan aktifitas impuls cepat dapat menyebabkan timbulnya after-depolarisation lambat dan aktifitas triggered
# trigger = automaticity, memiliki masa perlambatan di fase 3 dan fase 4 dari aksi potensial
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• Triggered yang dijalarkan kedalam miokard atrium akan menyebabkan inisiasi lingkaran-lingkaran gelombang re-entry yang pendek (wavelets of reentry) dan multiple. Lingkaran reentry yang terjadi pada AF terdapat banyak tempat dan berukuran mikro, sehingga menghasilkan gelombang P yang banyak dalam ukuran yang rendah (microreentrant tachycardia)
• Sumber abnormal ini biasanya berasal dari daerah LA ->PV
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Management of AF
• Rate control: mengkontrol rate ventrikel, tetapi tidak mengembalikannya ke sinus rhytm
• Prevention of thromboembolism: antithrombolitic therapy
• Correction of the rhythm: perbaikan atau mengembalikan ke SR
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Treatment of AF
Pharmacological Treatment
Prinsipnya : Menjaga irama sinus, menekan gejala, meningkatkan kapasitas latihan dan fungsi hemodinamik, dan mencegah takikardia-induced cardiomyopathy karena AF.
Amiodarone and dofetilide are recommended.
Non-pharmacological Treatment
Surgical Ablation
Catheter Ablation (AF -> 3D)
Suppression of Atrial Fibrillation Through Pacing
Internal Atrial Defibrillators
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Tatalaksana Ablasi • Persiapan pasien 1. Fisik
• Status hemodinamik
• Iv line cairan isotonik
• Urine catheter
• Bersihkan area penusukan (fokus infeksi)
• Cek obat-obat premedikasi
• Keluhan saat ini
Obat anti aritmia tidak usah di stop pada AF karena tidak berpengaruh pada Ablasi
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2. Adminisstrasi
Surat persetujuan tindakan (Inform Consent)
Surat perjanjian pembiayaan (administrasi)
3. Mental
Pemberian penjelasan / pendidikan oleh dokter (medis ) tentang pemeriksaan ini (manfaat, keuntungan , kerugian dll)
Support menthal
4. Pemeriksaan penunjang : TEE
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Alat dan preparasi pasien A. Alat :
• Mesin X-ray
• EP machine
• Stimulator
• DC Shock & trolly Emergensi
• Pulse Oksimetri
• Dinamap (NIBP)
• RF Generator (Mesin Ablasi)
• Junction box(Conection EP cath)
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• Syring pump
• Indeferent patch (Valley lab)
• Catheter :
• lasso kateter 7F ditempatkan di PV,
• 7 F decapolar di CS
• 7F 4 mm ablasi catheter
• Transeptal : kateter mulin, needle transeptal, wire inoue
• Long sheath 8 F
• 3D monitor + navx patch
• Antikoagulasi dengan ketat ( ACT 250 )
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Chateter lasso (dua decapolar)
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Ablation Strategy
a: Circumferential PV Ablation
b: Additional Linear Ablation
c: Figure 8 ablation plus additional linear and SVC ablation
d: Complex Fractionated Electrogram(CFE)
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PV on Angiogram
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Venous structure
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Trans-Septal Procedure
RAO 45° LRO 45°
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Kateter mullin Needle transpetal
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Transeptal location PV Angiogram
• RPV LPV
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Anatomi LA 3D
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PV Mapping
• Bisa menggunakan 2D atau 3D mapping
• Keuntungan mapping 3D :
• Bisa memberi tanda atas RFA / lesi
• Posisi kateter untuk terminasi lebih baik
• Meminimalkan dampak dari X-ray
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PV mapping
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• 3D carto
• 3D ensite
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Geometry Creation and Lesion Line
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Remember !!!
• Normal electrical heart Conduction from :
• SA node
• AV node
• Purkinje Fibers
How about PVP ??
PVP(pulmonary vein potensial)= abnormal
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Pulmonary Vein Isolation (PVI) Ablation at the left atrial -pulmonary vein junction electrically isolates the PV, so that they can not excite the left atrium.
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PV potential induced AF
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Illustration of 3D Mapping System
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End Point
• disconnection
PVP abolition (complete elimination of PVP)
PVP dissociation (PVP dissociated from LA)
• Confirm by entrance block
• Impuls yang di LA harus didahului oleh RA dgn pacing melalui kateter CS
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Komplikasi
• Temponade/perforasi
• Kematian jaringan
• Kematian ( apabila tembus ke esofagus)
• PV stenosis
• Stroke, microemboli
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Terimakasih