《国际循环》：您对本届HRS @ GW-ICC联合论坛的哪些热点内容最感兴趣？

　　International Circulation: What hot topics of the current HRS @ GW-ICC Joint Forum are you most interested in?

　　Curtis教授：本届联合论坛上最令人振奋的当属是有关无线起搏器或皮下ICDs的进展。自首次在人类中应用以来，可植入装置就面临着一个很大的问题，那就是引线是其较为薄弱的环节。不论是将起搏器还是除颤器放入人体时，都存在一个问题，那就是发生器可能是好的，也比较易于更换，但问题是随着时间的推移引线常常会发生故障，尤其是在患者需要配戴设备很多年的时候。引线坏了的时候也需要更换，这时候通常需要将引线提取出来，这样做可导致一些并发症的发生。这就是植入装置的弱点所在。现在我们则有了两种比较令人振奋的发展与突破，其中皮下ICD至少在美国已经在使用了，随着它也需要应用引线，但其放置在靠近胸骨旁的皮肤下，无需放置至心脏内，故心脏内并不存在引线。这就意味着，其发生感染的风险更小，其发生障碍及需要更换的风险更小。第二个令人兴奋的进展就是无线起搏器，这种非常小的装置可直接放置至心室，作为一个VVI起搏器来发挥作用且不需要引线。

　　Dr Curtis: The most exciting developments that we are talking about at this Congress have to do with either leadless pacemakers or subcutaneous ICDs. One of the biggest problems we have had with implantable devices ever since they were first used in humans， is that the leads are the weak link. So whether you are putting a pacemaker or a defibrillator in somebody， the problem is that the generators may be fine and are easy enough to change out， but the leads often break down over time， especially if a patient needs a device for many years. When the leads are bad， they need to be replaced and lead extractions are often done and they can be associated with complications. That has always been the weakness of an implantable device. Now we have two exciting developments， one of which is already available for use at least in the United States. That is the subcutaneous ICD whereby we use a lead but it is tunneled underneath the skin next to the breastbone and there are no leads inside the heart. That means we are going to have less risk of infection and also less risk if the leads break down and need to be replaced. The second exciting development is the leadless pacemaker， which is a very tiny device that is deployed directly into the ventricle and that functions as a VVI pacemaker without any need for any other leads at all.

　　《国际循环》：对合并高血压及冠心病的老年持续性房颤患者而言，预防卒中时应如何在传统口服抗凝剂、新型口服抗凝剂及左心耳封堵术之间进行选择？上述治疗方案各有哪些优缺点？

　　International Circulation: For elderly patients with persistent atrial fibrillation accompanied by hypertension and coronary heart disease， how should we choose between traditional oral anticoagulants， novel oral anticoagulants and left atrial appendage occlusion when preventing stroke? What are their respective advantages and disadvantages?

　　Curtis教授：对伴有高血压等其他合并症的老年心房颤动患者而言，我们需要积极预防卒中的发生。传统的治疗方法就是应用华法林，其优势在于价格较为便宜，但不足之处在于剂量调整是非常困难的，且与其他药物及食物之间存在相互作用会导致一些问题。近年来，我们在新型抗凝药方面取得了很大的进步。这些新型抗凝药可针对凝血级联反应中的不同环节发挥作用，具有非常显著的优势。最主要的优势就是应用过程中要想实现充分抗凝并不需要进行血液监测。但是，需要注意的是，其经由肾脏代谢，故需要根据患者的肾功能进行剂量调整，在晚期肾脏疾病患者中则是不可以应用的。左心耳封堵术则仍处于进一步研究阶段。我们还不是十分清楚其最终会对患者产生怎样的影响。当然，对于无法长期坚持进行抗凝治疗的患者而言，左心耳封堵术是一个非常有吸引力的选择，但这仍有待进一步证实。目前，合并其他问题的老年心房颤动患者而言，我们可以选择应用华法林治疗，或是考虑应用新型抗凝剂因为其应用更方便且能避免应用华法林可导致的一些问题。

　　Dr Curtis: When we have patients who are older who have atrial fibrillation with other comorbidities such as hypertension， we do need to prevent stroke from occurring in those patients. The traditional way that patients have been treated has been with warfarin and we know that it is inexpensive for the drug itself but the monitoring becomes expensive and the adjustment of the dose can often be difficult. There are many drug-drug and drug-food interactions with that drug that also create problems. We have had some great advances recently with the novel anticoagulants. They act on different aspects of the coagulation cascade and have some very distinct advantages. One of the major ones is that you don’t need to monitor blood tests in order to anticoagulate the patient adequately. They are cleared by the kidneys so you have to adjust doses to renal function and in some cases， with advanced kidney disease， you can’t use them at all. The left atrial appendage occlusion device is something that is still under investigation. We are not quite sure yet what the ultimate role will be in patients. Certainly， for patients who can’t take anticoagulation long-term， it is an attractive option， but it is still released yet. In the meantime， we would either use warfarin in older patients with atrial fibrillation and other problems， or strongly consider the novel anticoagulants because of their ease of use and the ability to avoid some of the problems we have had with warfarin.