About atrial fibrillation surgery

The theory, history, evolution, efficacy, side effects, controversy, and future of radiofrequency treatment of atrial fibrillation!

These things are very difficult and difficult. Even a cardiovascular graduate student who has just graduated 2-3 years ago cannot understand them. I read more than 500 English materials and spent a lot of effort to translate professional medical terms into something that ordinary people can understand. If you can understand the vernacular, I will try to write an article to solve the patient's understanding of radio frequency. If it is useful, thank you. Theories on the occurrence of atrial fibrillation

There are many hypotheses on the occurrence of atrial fibrillation. Why are they called "hypotheses"? Just not sure. What doctors say to patients sounds positive, but in fact doctors are not sure in their hearts. This is the case all over the world. Just like adults teach children that this is right and that is wrong, but in fact, adults themselves are not sure what is right in many things.

Before talking about these hypotheses, let me emphasize my interpretation of the mechanism of atrial fibrillation: the nerves in the atrium become a mess, with random discharges and random conductions.

There are three major hypotheses and four minor hypotheses for atrial fibrillation.

The three major hypotheses are: the multiple subwave reentry hypothesis, the focal activation theory, and the dominant reentry ring with tremor-like conduction theory.

The four small hypotheses are: the electrical structure and matrix of pulmonary veins, the electrical matrix of atrial fibrillation in atrial tissue, cardiac autonomic nervous system factors, and the nest of atrial fibrillation.

These hypotheses are discovered and proposed in a few years. A few years later, someone studies another hypothesis and proposes it. Each hypothesis is proposed one by one as a new discovery. They all only focus on one point. Who Come up with a hypothesis and invent a radio frequency method. In the end, you find that it is not ideal, and then continue to research. Everyone has little contact with each other, which is also a characteristic of Western medicine. If a person is hospitalized for a heart disease and also has high blood sugar, stomachache, headache, and upset, he or she needs to be consulted by an endocrinologist, a gastroenterologist, a neurologist, or a psychologist. , If you don’t diagnose, you won’t be able to treat the disease.

Today, I carefully summarize these hypotheses into a whole.

First of all, there is always a place to discharge and cause trouble first, and there is a leader. This is the "focal excitement theory";

Any troublemaker who succeeds must have a leader. The core members come to do the core things (if no one responds after the focal point is excited, it will be a premature beat and jump on its own). This focal point of excitement (that is, a premature beat) will circle along a core path and start running on its own. , this is the "leading reentry loop";

If you want to accomplish big things, you can't just rely on the core team. You also need to have countless small teams on the periphery that play and fight together, such as small groups of bandits, the Imperial Alliance Army, etc. , listen to the command of the main force, and coordinate operations around the main force. These small teams have their own command core and their own sphere of influence. That is to say, with the "leading reentry loop" as the core, there will be many "small reentry loops", and each small loop forms its own electric wave (we are talking about electrocardiogram). This is the "multiple sub-wave reentry hypothesis" ; A "local excitement" that took the lead in making trouble and raised its arms was responded to by the core team, and the current turned around to form a "leading reentry loop". Around the dominant reentry loop, many small teams formed "small reentry loops", and "small reentry loops" were formed. The radio waves formed by "reentrant loops" are called "multiple wavelets". It started to tremble.

These are the three mainstream hypotheses.

Those who love to make trouble have regional characteristics. The pulmonary veins lead to the left atrium. The veins are blood vessels and the atria are muscles. The connecting point must be that the muscles surround the blood vessels, which is the atrium surrounding the pulmonary veins. muscle. This lump is prone to causing trouble. The muscles and electrical properties of this place are different and have deteriorated. This is the "electrical structure and matrix of the pulmonary veins (deterioration hypothesis)";

It is easy to cause trouble. It comes from (mainly, not definitely not only) the pulmonary vein. Where do the small groups of bandits and the Imperial Army come from? Coming from places with unstable bases or no bases at all, people in these places have become bad and have evil intentions. That is to say, many atrial muscle tissues have deteriorated, and the corresponding electrical conduction properties have also deteriorated. This is "atrial fibrillation in the atrial tissue." "Electrical Substrate (Deterioration Hypothesis)";

There are some bandit dens that light a fire, pick up a gun and go out to fight for their lives after giving a small look. They are particularly easy to get excited and tremble. This is the "house" "trembling nest";

All parts of the heart are innervated by nerves, and nerves extend in all directions.

If the nerves are well directed, the area will be stable; if the nerves are not directed well, the area will be unstable; if the nerves are directed blindly, the area will be unstable; the active role of the nerves is not enough in the pulmonary veins that are prone to trouble, and in the atrial fibrillation nests that are easily ignited. , either too weak or rebellious. This is the "cardiac autonomic factor hypothesis."

Tip: Think about war-themed TV dramas and novels, think carefully, everything is the same.

This is a general introduction to the mechanism of atrial fibrillation. I can’t go into more details. The above is processed by me. It turns out that it is scattered in thousands of articles. One sentence is one sentence and one is one sentence, and it is not systematic. .

The history and evolution of radiofrequency treatment of atrial fibrillation

In 1991, a foreign surgeon invented the maze surgery, which was performed by surgery;

1994 In 2008, on the basis of the above surgical procedure, catheter radiofrequency ablation was developed, which was performed by internal medicine, with intubation and no surgery;

In 1998, radiofrequency ablation for pulmonary veins began to develop;

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In 1999, in addition to targeting the pulmonary veins, the entire atrium was ablated;

...

A hundred flowers bloomed in this, because the principle of ablation is to burn the normal myocardium to death. scald! Therefore, there are lasers, freezing, ultrasound, and radio frequency. The energies are different, but they all burn anyway!

......

Then, and then, until now, the world continues to explore and try various "burning methods."

First, here is a schematic diagram of radio frequency:

Let’s talk about these explorations in general:

The principle of the surgical maze is: cage tactics, using railways and roads to capture the bandits , the Imperial Alliance Army was separated. Even if it trembled after the separation, it was only a small tremor, not a big tremor. This does not change the nature of the tremor, it just prevents a few small tremors from becoming a major tremor;

Because most of the tremors are at the junction of the pulmonary veins and the atrium, pulmonary vein ablation involves burning a circle along the pulmonary veins, so that If you can't send telex messages about trouble, isn't your village dishonest? If you dig a deep trench around the village, you can only make trouble in the village and cannot leave the village. In medical terms, it is called "complete electrical isolation", which means it is completely burned to death and no electricity can be transmitted at all. The problem is that it is very difficult to burn thoroughly. If the burn is not thorough, there will be leakage (white burn). After the burning, there will be scars. The scars are shrinking, and they become narrower when they shrink, so there will be pulmonary vein stenosis. Once the pulmonary veins are narrowed, there will be pulmonary vein stenosis. Of course it will lead to many new problems. In short, the effect is not satisfactory.

Then people discovered that it was not only the muscles around the pulmonary veins that had problems, but also the area in front of the pulmonary veins. It was not that one village had the problem, but that one village was the worst, and several surrounding villages had problems. They were not very good either, so they started to burn down the surrounding villages. But I found that the effect was not good. It was not good just after it was done, and it will not be good in the future!

The effect is not good, but the burning is not severe! So on the premise of burning one circle of pulmonary veins, we started to burn three lines and dig three trenches in the entire atrium. I want to separate the main force from the bandit Imperial Army, but there are problems. Without adding these three lines of radiofrequency, it is easy for atrial tachycardia to occur after radiofrequency surgery (the atrial fibrillation is gone, but there is more atrial tachycardia). Adding these three lines can increase the success rate of radiofrequency for atrial fibrillation and make the postoperative Decreased atrial velocity. But, but, these three wires must be burned completely, and no good meat should be left (good meat can conduct electricity). If the burning is incomplete, there will be leakage of electricity, and if there is leakage of electricity, it will be more likely to cause atrial tachycardia! This is called two rings and three wires, burning two circles and three additional wires, but every place cannot be missed and must be burned thoroughly! Still not satisfied.

Some Japanese have adopted a more powerful three-light policy based on the two rings and three lines, completely burning the top, bottom, left and right. Some hospitals are doing this now, but it’s not clear how effective it is.

For some paroxysmal atrial fibrillations, less than half are not caused by trouble in the area where the pulmonary veins and atria meet, but in other places. During radiofrequency, we directly burn that other place, which was effective at the time. But there is a rule, that is, there are bad guys everywhere. When the big bandit den is destroyed, the little bandits will emerge. If you don't press the gourd, you won't be able to pick up the gourd.

Because he was not satisfied with the results of digging trenches and burning them, in 2004 a foreigner came up with a method of killing villages to check which villages were unstable. Instead of digging trenches around the villages, he burned the entire village. It fell off, but there was no response after being burned. In medicine, it is called "fragmentation potential ablation", and the euphemistic name is "atrial matrix improvement", which is the same as human race improvement.

Of course, the heart muscle must have been burned to death. This method was just to eliminate the enemy. I didn't expect that we were fighting on our own land. We used nuclear bombs to kill the traitors in our own country and leveled our own cities. pollution for many years. The point is, the effect is not good either. The success rate of radio frequency after one year is only 33%.

The relationship between cardiac sympathetic nerves and atrial fibrillation is very close and is recognized throughout the world (this is the theoretical basis of Beijing Xingshan Tang, and Ma Baolin has been studying this for almost 20 years). Therefore, some people burned the nerves in their atria. Last year, Xingshantang met two patients with atrial fibrillation. One had the nerves cut by a surgeon, and the other had a radiofrequency burn by an internal medicine department. As a result, it’s still shaking! Nerves are responsible for electrical discharge and conduction. Because one of the order soldiers became a traitor, all the order soldiers were killed. This is not acceptable. Good messengers are no longer effective. To maintain good order, a large number of good messengers are still needed.

People were almost at their wits end, so they punched the old master to death. All of the above methods are applied, burn more, burn thoroughly, and after the burn is completed, the examination found that the remaining ones are still alive... This is called "progressive and individualized ablation strategy", and the success rate is higher (all are burned to death, and the entire atrium is too fast). It's burnt, but won't it stop trembling?), but there was too much atrial tachycardia. Note, it's atrial tachycardia again. Without atrial fibrillation, atrial tachycardia returns. In fact, for patients, there is not much difference between atrial tachycardia and atrial fibrillation, and according to Our research over the years has shown that sooner or later atrial tachycardia will turn into atrial fibrillation. Because the burning is so severe, the left atrial appendage is often completely burned to the point of being unable to move (called complete electrical isolation in medicine), and the fluid does not rot. If the left atrial appendage becomes immobile, thrombosis will easily form. Therefore, many hospitals now remove the left atrial appendage after radiofrequency, and the atrium is burning. Do you dare not take anticoagulants? ! The burned areas will become scarred and can easily form blood clots.

......

There are many radio frequency methods around the world. Anyway, they are different combinations of the above. Some are not effective, and some are said to be effective but not credible (not that I don’t believe it) , but Western medicine colleagues do not believe it).

Nowadays, the radio frequency in various hospitals across the country does not fall outside this circle. The efficacy and side effects of radiofrequency treatment of atrial fibrillation (what everyone is most concerned about!)

It is difficult to write about the efficacy. When talking about the efficacy, you must first understand the criteria for judging the efficacy. How is it considered effective? What makes it effective? What makes it effective? I checked some information (formal academic information, what doctors read). The result once again verified what I have always known: there is no clear standard!

The first is the evaluation standard for "the efficacy of radiofrequency treatment of atrial fibrillation"

1. In 2016, I checked some articles and found that the standard for effective evaluation in regular public hospitals is "24 days after radiofrequency treatment" Each episode of atrial fibrillation within an hour should not exceed 5 minutes." In other words, after radiofrequency treatment, atrial fibrillation occurred 10 times a day, each time lasting 4 minutes and 58 seconds. This is considered a success! Explanation: I trust my memory, but I couldn’t find this article today! I checked countless medical papers, but no one mentioned this! How to calculate premature beats, atrial tachycardia, and paroxysmal supraventricular tachycardia after radiofrequency treatment? No one mentioned this!

2. In some domestic hospitals, the success standard of radiofrequency is defined as: "Without the use of or the use of previously ineffective antiarrhythmic drugs, there will be no atrial fibrillation attack or less than one attack per month that lasts for a long time." More than 1 minute". In other words, when Western medicine is not used, or Western medicine is used before radiofrequency, but no matter what happens, it is still used after radiofrequency. In this case, if the tremor stops after the radiofrequency treatment, or if the tremor does not tremble, but less than once a month and less than one minute each time, this is considered a success! How to calculate premature beats, atrial tachycardia, and paroxysmal supraventricular tachycardia after radiofrequency treatment? No one mentioned this! Why do I mention it? Due to exposure to a large number of patients, frequent premature beats, atrial tachycardia, paroxysmal supraventricular tachycardia, etc. occurred after radiofrequency treatment. The patient must have thought it was unsuccessful, and I also wonder what the hospital that does radiofrequency counts as this?

3. The 2015 Atrial Fibrillation Guidelines (what are guidelines and what are they, will be discussed later) says this:

The definition of radiofrequency success is: "After 3 months of radiofrequency, there is no atrial fibrillation, atrial flutter, or atrial tachycardia."

What if there are frequent bedtime breakfasts? Didn’t say it! Since it is not mentioned, if there is no atrial fibrillation, atrial flutter, or atrial tachycardia after ejaculation, but a large number of frequent atrial fibrillations or paroxysmal episodes of supraventricular tachycardia occur, it must be considered a success.

Recurrence of atrial fibrillation: Atrial fibrillation, atrial flutter, and atrial tachycardia occurring 3 months after radiofrequency, if the duration is ≥30 seconds, are regarded as recurrence of atrial fibrillation.

That is, if each attack lasts for 20 seconds, it does not count as a recurrence, regardless of whether you have one attack or 100 attacks a day. How to calculate the first 3 months after radiofrequency treatment? They defined 3 months after radiofrequency ablation of atrial fibrillation as the blank period, and atrial fibrillation, atrial tachycardia, and atrial flutter that occurred during this period were not defined as recurrence.

Do you understand? The first 3 months after radiofrequency treatment are not counted, nor are the episodes lasting less than 30 seconds after 3 months!

The above is considered good, there are more weird standards, let’s talk about one, foreign:

After 3 months of radiofrequency, atrial fibrillation and atrial flutter attacks will not last more than 24 hours. ; There were no atrial arrhythmias lasting more than 30 seconds, hospitalization or electrical cardioversion.

Explain that the first three months are not counted. After 3 months, if there is atrial fibrillation, it will be considered successful if it takes less than 24 hours each time; or if there is atrial tachycardia but less than 30 seconds, it will be considered successful. ; Or it is considered a success if you do not come to the hospital; or it is considered a success if you are not shocked (very few people give electric shocks to atrial fibrillation now, but it is rare).

In short, the success criteria of radio frequency are different everywhere. If you want to know a clear explanation, no way!

What does guide mean?

Many famous experts studied together, many, many. After the study, they all agreed and wrote a document. Anyway, the martial arts masters discussed the sword first and then decided the rules of the world.

For example:

In 2012, the European Society of Cardiology (ESC) released its "Guidelines for the Diagnosis and Treatment of Atrial Fibrillation";

In 2014, the American Heart Association, American Heart Association The Society of Physiology and Heart Rhythm Society released the "2014 Guidelines for the Diagnosis and Treatment of Patients with Atrial Fibrillation";

Then, in 2014, Canada released the "Revised Guidelines for Atrial Fibrillation" to revise the previous guidelines!

China also has its own guidelines, and Japan also has its own guidelines. Most of us in the country follow the guidelines of the United States.

Many, many rules set by great experts are called "Guidelines". If there are not too many experts, it would not be qualified to call it a guide. It doesn't matter, just call it "Expert Knowledge". It has the same meaning as the guideline, but it is not as strong. Radiofrequency, medicine, and whether it can be covered by medical insurance are all related to this. The country’s money cannot be spent indiscriminately. Major experts agree that this should be the case, and the country will reimburse you. There are many associations in this.

These guides are very interesting. Sometimes the European ones are completely opposite to the American ones, not completely opposite, but completely opposite in a certain point of view. Therefore, there is a saying that "you can't find north by following the guide."

After talking about the criteria for judging the efficacy, it’s time to talk about the efficacy. The efficacy of radiofrequency in the treatment of atrial fibrillation

After experiencing the standard torture, it is not over yet, let’s continue. Before looking at the efficacy, I would like to state again that you don’t have to worry about how the efficacy is calculated. Let’s just look at the numbers. Let me list some first so that everyone will know what is going on:

There is a 2009 patient named Cappato. Year said: The success rate of paroxysmal atrial fibrillation is 83.2%, and the success rate of sustained atrial fibrillation is 75%. The European Heart Rhythm Association (EHRA) studied 72 hospitals in 10 European countries and said the success rate was 30.2%;

A friend from the Hamburg Center in Germany said: After one radiofrequency, the success rate in 5 years is 20.3%, and the success rate after multiple shots is 40.5%;

Another foreigner also studied for 5 years (after radiofrequency 5 years of observation) said: the success rate of one time is 20%, and the success rate of multiple radiofrequency is 45%;

There is a research called RASTA, which has been studied for 1 year (the longer the research period, the more time-consuming and labor-intensive it is) Said: The success rates are 49%, 58% and 29% (don’t study the success rates corresponding to the three different situations, just take a look);

The "New England Journal of Medicine" said: Research After visiting 12 countries and observing for one and a half years, the success rates were 59%, 49% and 46% (three different radio frequency methods correspond to three numbers);

...Do you know anything? ...

As for China, in 2016, an expert I personally recognized said that the success rate there was 52.1% or 67%.

In short, the efficacy of radiofrequency is different from each other. If you want to know a clear explanation, there is no way!

This was all last year and before last year...

I wrote this article this year, carefully checked a lot of information, and found that the success rate of radiofrequency in China has improved by leaps and bounds, and many hospitals said it is successful. The rate is more than 90%. They are all well-known public tertiary hospitals (I still have photos here, so I won’t post them), and they provide direct publicity to patients. Of course, it is still of a popular science nature. There is no such high level in the professional literature I checked.

When looking at the curative effect, we should also pay attention to it. After patients go home after radiofrequency treatment, some return to the hospital for regular check-ups; some have doctors calling to ask; some cannot be contacted; some have atrial fibrillation and do not know it. ; Patients cannot carry Holter on their backs every day. Some patients have no symptoms before radiofrequency and no symptoms after radiofrequency. You don’t know whether they are shaking or not. This is inevitable in research. Side effects of radiofrequency for atrial fibrillation

I will first review the published results in academic literature, and then write about some of the situations we discovered ourselves.

Side effects are basically divided into three types: those caused by puncture (piercing the catheter into the blood vessel is called puncture), those caused by the catheter, and those caused by discharge burning.

The side effects of vascular puncture include: local bleeding, hematoma, infection; pneumothorax (piercing the lung); thrombosis, embolism, etc.;

Cause caused by the force of the catheter being inserted Examples include: aortic valve regurgitation, myocardial perforation (the atrial muscles are actually very thin and can leak when the force is too strong), pericardial tamponade, etc.;

Caused by radiofrequency discharge: atrioventricular block (atrial block) The normal channel was accidentally injured, and a pacemaker could only be installed), myocardial infarction, etc.

There are statistics of 16,309 cases in 521 hospitals in 24 countries:

Explanation:

Stroke is cerebral thrombosis, and TIA is Transient cerebral infarction may be caused by a small blood clot that blocked for a while and then opened again. The main cause of stroke and TIA is still caused by detached thrombus, so appropriate anticoagulation therapy should be carried out after ablation.

Atrial tachycardia, premature beats, paroxysmal supraventricular tachycardia, etc. that occur after radiofrequency are not included in complications, recurrence, or failure, but in fact there are quite a lot.

Let me talk about the situation I discovered myself. Some patients feel weak all over their body after radiofrequency. One patient has no energy after radiofrequency. It has been 7 years now. The whole body feels weak, just like after a major surgery. People all know that surgery can damage vitality, but they don’t know that catheter radiofrequency can also damage vitality. Now it’s clear. Another one just finished doing it and was fine. After 3 months, he became more and more unmotivated and lasted for more than a year.

When a person encounters something happy, he immediately feels refreshed and energetic; when encountering a problem, he immediately becomes listless and panicked; when encountering something worrying, he feels lack of energy and powerlessness.

Why is this? This is because the heart can definitely secrete some positive energy. If the radiofrequency burns the heart half to death, it will not be able to secrete it, and there will be problems. Western medicine has discovered some of these secreted things, such as a thing called atrial diuretic peptide. Not only has it been discovered, but it has also been artificially synthesized to treat heart failure, using things secreted by the heart itself to treat heart failure. What's the meaning? The heart itself has a lot of positive energy.

There are also some radio frequencies that are extremely uncomfortable. There are all kinds of discomforts, such as tingling in the precordium, chest tightness, shortness of breath, etc. In fact, in addition to the recurrence of atrial fibrillation, the most common cases are frequent premature beats and atrial tachycardia, and some also suffer from paroxysmal supraventricular tachycardia.

Controversy and the future of radiofrequency treatment of atrial fibrillation

I will not participate in the debate. I will only be the porter of the debate and write a few sentences about the controversy in published medical professional papers.

One is that the results of clinical studies around the world are different from the real thing. The real thing is worse than the research. This real thing is called "real world research" in medical terminology. This kind of real thing is different. Evidence research may become the mainstream of medical research in the future (the current paper required for doctor promotion is called "evidence-based medical research").

For paroxysmal atrial fibrillation, burning in a circle along the pulmonary veins is quite effective (as mentioned at the beginning, the burning must be thorough, and it should be noted that less than half of the paroxysmal atrial fibrillations are not at the junction of the pulmonary veins) The one who led the trouble). The debate about catheter ablation of persistent atrial fibrillation has never stopped.

Atrial fibrillation radiofrequency has been used for 20 years, from this theory to that theory, from this radiofrequency method to that radiofrequency method.

However, the success rate of existing methods is still low, and there is still a long way to go in the future.

On the morning of November 15, 2016, U.S. time, there was a special session on atrial fibrillation at the 2016 American Heart Association Scientific Annual Meeting. Global atrial fibrillation celebrities gathered to discuss the treatment of atrial fibrillation. A foreigner named Dr. Calkin believed that AF ablation is unlikely to cure AF.

Professor Hu Dayi said: Radiofrequency ablation is destined not to be the dominant mainstream solution for atrial fibrillation.

A well-known expert from a well-known hospital said in an interview with medical professional media: A small number of patients with financial conditions and willingness can try catheter ablation.

The above arguments are all published publicly, but most of them are in professional medical media and cannot be seen by ordinary people. I also have to register on professional websites and spend money to download them, and many of them are in English.

Everything written in this article has its source and comes from research all over the world. I did not write it randomly, I just made it popular. Including my research on using biological needles to influence cardiac sympathetic nerves to treat atrial fibrillation, I was not researched from beginning to end by myself. This treatment was researched by me (the only one among scorpion daddies in the country), but cardiac sympathetic nerves and The relationship with atrial fibrillation is very clear and has been studied extensively around the world. The future of radiofrequency treatment for atrial fibrillation?

I don’t know.

Looking forward to... To summarize:

There are many causes of atrial fibrillation, and they are all hypotheses (hypotheses are not necessarily wrong. In fact, I think they are basically correct, but no one has comprehensively summarized them. Let’s look at them together);

There are many radio frequency methods, and they are constantly being updated;

The effective standards of radio frequency are not unified;

The and effectiveness of radio frequency There is no uniformity, and there are great differences around the world;

What is said in the paper (medical professional paper) is not consistent with the actual situation;

The opinions in the European, American and Chinese guidelines are not uniform;

The opinions of different experts are not uniform.

Ma Baolin answered.