International Circulation: In the early career EP clinical session， you gave a lecture about “Ten Mistakes to Avoid in Interpretation of Intracardiac Electrograms”， which is very important for early career physicians. Could you please briefly explain this to Chinese doctors as well?

　　《国际循环》：在职业生涯早期医生的培训课程中，您介绍了心腔内心电图解读应避免的10大误区，这对初入职场的医生而言非常重要。能否请您也向中国的医生简要讲解一下？

　　Dr. Packer: So the question that I was asked was， “How do you identify electrograms allowing you to determine the kind of rhythm problem that is existing and how do you avoid making mistakes?” I took it in a slightly different way. I took it from the standpoint of how do you use those electrograms correctly so that you do not make the mistakes， and there are a number of different things that we talked about. There are a couple of different key points that I believe I can make. One is you need to know what the surface ECG says， because by looking at the surface ECG and I think we are all comfortable at looking at that surface ECG， then you have a clue as to what an electrogram is going to tell you. You correlate between the surface ECGs and then you look at the page or screen and identify which electrograms are immediately correlating with those， and you use that to identify what that electrogram is. Now you at least know what the electorgram is， you know what is less problematic with the electrogram and you are starting from a position of knowledge. The second thing is that it is very important to have some kind of idea of what the arrhythmia is because we know that certain arrhythmias have certain kind of electrograms that go with them and if you know what the arrhythmia is then you have a sense as to what the electorgram should look like and where it should be located. I think that is all very important. The next thing is to use probes. In other words， if you are not sure about an electorgram and you are not sure what the electorgram is telling you， pace somewhere. You may pace to move that electorgram around， and if you pace， for example， in someone who has a narrow complex tachycardia and you do ventricular pacing， then you may show retrograde pre-excitation oftubation without changing the activation sequence. That is characteristic of WPW (Wolff-Parkinson White). If you do pacing and you pace repetitively and then you entrain the arrhythmia and then after that you see V-A-H-V pattern， you will have a pretty good idea that that is going to be AV node reentry or AV reentrant tachycardia. If you do pacing and see a V-A-A pattern， then those electrograms are going to tell you that it is probably an atrial tachycardia， so use a probe and pace. The next thing is that you need to know what is in the neighborhood of the arrhythmia. You need to know if you are dealing with say， a pulmonary vein， because if you are dealing with a pulmonary vein， you know that on the right side is the right atrium， on the left side is the vein of marshall and the left atrial appendage. If you are going to try to make some sense out of an electorgram you need to be able to exclude far field electrograms that are coming from those other structures. If you do not know what the other structure is， if you do not know where it is， then it is very difficult to exclude that and you may make decisions about continuing to ablate at a time when you shouldn’t. So those are kind of the 4 leading ones. There are a number of others that would take us a half an hour to go through but I think those are the 4 most important things to avoid making mistakes that will confuse you in terms of trying to understand arrhythmia， what kind of arrhythmia it is， and what the true physiology is.

　　要想避免解读误区，需要注意非常关键的几点。第一，需知道可令受检者感到更舒适的体表心电图结果，因为通过体表心电图结果医生可以发现问题所在，了解疾病诊疗的线索。第二，知道心律失常的心电图表现，只有知道特定心律失常的心电图表现才能通过心电图判断患者存在哪种类型的心律失常并对其进行定位，这一点非常重要。第三，如何应用探头。换句话说，如果对心电图及其信息不确定的话，可起搏后再做心电图。例如，对存在狭窄型复杂心动过速的患者而言，进行心室起搏可见逆行性tubation预激，但激活顺序不变，这是WPW的特征表现。如果反复起搏后心律失常消失，出现V-A-H-V模式，则提示存在房室结折返或房室折返性心动过速。如果进行起搏后发现V-A-A模式，则提示为房性心动过速。因此，用好探头和起搏也非常重要。第四，需要知道心律失常伴随症状，是否存在肺静脉，因为如果周围存在肺静脉，需要知道其右侧是右心房，左侧是marshall静脉和左心耳。这时要想理顺心电图的表现确定其意义，则需要除外周边结构的影响。如果不知道周边结构，不知道探头位置，则难以进行排除，可能导致在不必要时仍进行持续消融。上述是需要重点注意的四大方面。上述四点是在通过解读心电图确定心律失常类型及生理基础时避免误区最重要的四个方面。

　　International Circulation: How should we measure effectiveness of recurrence， burden， quality of life， or mortality after catheter ablation for atrial fibrillation?

　　《国际循环》：对于房颤导管消融后的复发、负担、生活质量或死亡率，应如何进行有效评估？

　　Dr. Packer: Well one of the questions that comes up all the time is if you are conducting a clinical trial， what should your endpoint be? Should it be the time to first recurrence? Should it be the time or burden of atrial fibrillation? Should it be quality of life? Should it be mortality? The answer is it depends on what you are trying to get out of the clinical trial. For atrial fibrillation there are many studies that have shown what happens in a one year study in patients that are completely healthy. We know what the recurrence rate is going to be， we know what the recurrence rate will be over that time frame but that does not tell us anything about recurrence rates over 5 years or even 10 years. It is very important to know what you are trying to get out of the trial to begin with. For studies like CABANA and EAST， we want to know about mortality. We want to know about stroke， we want to know about major complications， we want to know about cost and we want to know about quality of life， so those are all extremely important. You cannot get those from a study that just looks at the endpoint of one recurrent episode of atrial fibrillation. AF burden should be very interesting; it should be very helpful if the amount of time that somebody is in atrial fibrillation multiplied by the number of AF events that they have had. That does not tell you much about the quality of life， and it does not give you a weighted sense about which quality of life issues are the very most important. Now having said all that， I think that CABANA and EAST are actually looking at all four of those， so that we can see whether there is one that is particularly helpful and those circumstances under which they are helpful.

　　有关导管消融一直存在一个疑问，就是开展相关临床试验时，应选择什么样的研究终点。是应该选择首次复发、心房颤动持续时间、心房颤动所带来的负担、生活质量还是死亡率？实际上，医生们需要根据临床试验目的决定选择怎样的研究终点。很多有关心房颤动的研究已让临床了解，完全正常的心房颤动患者一年内会发生什么，其复发率是多少，一年之后的复发率又是多少，但并没有说明5年甚至十年后的复发率。非常重要的是，试验开始时就应明确研究目的。例如，CABANA和 EAST研究这两项研究旨在了解死亡率以及卒中、主要并发症发生率和治疗成本及生活质量，而这些无法从一项仅以心房颤动复发为终点的研究中获悉，而用患者处于心房颤动的时间乘以曾发生过的心房颤动的事件数就对评估心房颤动负担非常有用。但是，这并不能阐明患者的生活质量以及哪种生活问题对患者而言最重要。总之， CABANA研究及EAST研究实际上对上述四个方面都进行了研究，因此有助于确定以哪项指标作为终点更重要以及在何种情况下能发挥作用。

　　International Circulation: As the complications of AF ablation， how to diagnose and manage pulmonary vein stenosis?

　　《国际循环》：谢谢，第三个问题是，我们应如何诊断和管理心房颤动导管消融治疗的并发症肺静脉狭窄？

　　Dr. Packer: One of the major problems of ablating is the occurrence of pulmonary vein stenosis and it is a problem now to a much greater extent than it used to be. The reason why it is a problem because people stopped looking， so the best way to manage a patient with atrial fibrillation is to do a baseline CT or MRI study and at 3 to 6 months do another one. At 3 to 6 months you will get an idea about whether or not there is narrowing. The problem that is occurring now is that people have stopped looking. Patients have forgotten that they had an ablation and their doctors are forgotten that they have had an ablation. Then one year out or two years out， they have symptoms like bronchitis. The problem with symptoms like bronchitis is that they go see a pulmonary doctor and the pulmonary doctor does not even know that they were ablated. The pulmonary doctor finds that there is a mass and it looks like the patient has cancer. The problem with that is then they try to biopsy it and what it really is is hemorrhage， because of pulmonary vein stenosis， so that is a real problem and I’m finding that there are more and more of those patients. So how do you manage them? Get a CT or an MRI at 3 to 6 months. After that， tell the patients if they have any pulmonary symptoms at all to make sure they go see their EP doctor and that it is considered to be pulmonary vein stenosis until proven otherwise. If you do not look， you won’t find it. If you do not ask the patient， you won’t know， and if you miss it and the pulmonary vein stenosis is so serious and it cannot be treated because the veins are completely occluded. I think we need to rethink the whole concept of pulmonary vein stenosis and we need to make sure that we are following those patients and that they have something that is an indicator to them that they need to come back for a relook.

　　肺静脉狭窄是心房颤动导管消融治疗的一个主要并发症，与既往相比，现在形势更为严峻，因为临床管理心房颤动患者时不再像原来那样担心消融后3~6个月时会发生狭窄而分别在基线及消融治疗3~6个月后行CT或磁共振检查。于是，消融治疗1~2年后，患者开始出现支气管炎症状。这时候通常患者会到呼吸内科就诊，而这些医生可能并不知道患者曾进行消融治疗。通过检查，医生可发现像癌症患者那样的团块，然后就试图进行活检，而实际上这只是肺静脉狭窄所致的出血而已，如此就给患者的诊疗带来很大问题。因此，对行导管消融治疗的心房颤动患者，应在消融术后3~6个月行CT或磁共振检查，然后告诉患者如果出现任何肺部症状一定要咨询电生理医生，在确诊为其他问题前，应考虑是否为肺静脉狭窄所致。若不行CT及磁共振检查就无法及时发现肺静脉狭窄，这时如果不仔细问诊可能就不知道患者曾接受导管消融治疗而漏诊。因此，临床需重新审视肺静脉狭窄的整体概念，务必定期对患者进行随访，务必告诉患者在出现何种情况时应复诊进行重新评估。

　　International Circulation: My last question， do you think pulmonary vein isolation still the cornerstone of atrial fibrillation ablation? What novel techniques emerged in AF ablation?

　　《国际循环》：最后一个问题是，您认为肺静脉隔离在房颤消融中是否仍占据基石地位？房颤消融中出现了哪些疗效更佳的新治疗技术？

　　Dr. Packer : One of the questions that comes up in trying to design a trial or when trying to do pulmonary vein ablation is to know whether you should just do pulmonary vein isolation. I think that has been the hallmark， that has been the bedrock， and that has been what we have been doing for years and years. I still think that is very important. I think with patients that have atrial fibrillation and when you go in to ablate， you should isolate the pulmonary veins and you should spend as much time as it takes to do a very very good job in isolating the pulmonary veins. Do a very good job in isolating the veins and making sure that it is going to be constant or persistent. Having said that， now that we are thinking more about rotors， those rotors are not coming from the pulmonary veins， and we are finding that in patients with persistent or long standing persistent atrial fibrillation that we need to take care of those rotors and we need to treat them and we need to ablate them. I would say that pulmonary vein isolation is the starting point but I think we are learning more and more that it is not the only thing that is important. It is not the only thing that is going to be critical for a patient long term. If you look at five year recurrence rates， it may be 50 to 60 percent and that is with pulmonary vein isolation so there has to be more to it than just pulmonary vein isolation. We have learned that from the rotor studies， we have learned that from some of the posterior wall ablations， and so I think it is going to take a little bit more to do a little bit better job as we go on in the future.

　　目前在设计试验或进行肺静脉消融时，医生们应确定是否仅需要进行肺静脉隔离就足够。肺静脉隔离是房颤消融治疗的里程碑和基石，应用多年仍然非常重要。对心房颤动患者进行消融时应进行肺静脉隔离，并花尽可能多的时间来进行持续肺静脉隔离。现在临床需考虑更多病灶，而不仅是肺静脉中的病灶。对持续性或长期持续性心房颤动患者而言，需针对这些病灶进行治疗和消融。虽然肺静脉隔离是基点，但实践中越来越发现，肺静脉隔离并非是对患者长期结局至关重要的唯一干预措施。仅进行肺静脉隔离，其5年复发率可达50%~60%，因此心房颤动消融治疗不仅需肺静脉隔离。病灶研究发现，后壁消融可能在肺静脉隔离基础上实现更好的消融效果。