Dilling-Boer Dagmara, Van Der Merwe Nico, Adams Jozef, Foulon Stefaan, Goethals Hubert, Willems Rik, Ector Hugo, Heidbuchel Hein
Department of Cardiology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium.
J Cardiovasc Electrophysiol. 2004 Feb;15(2):200-5. doi: 10.1046/j.1540-8167.2004.03385.x.
Focally induced atrial fibrillation (AF) often is due to ectopic activity in the pulmonary veins (PV). Although initial approaches were aimed at ablating only the ectopic foci, more extensive ablation approaches have evolved that isolate all PVs empirically and/or create circumferential ablation lines in the left atrium (LA). These techniques last longer and may be associated with more risks. We retrospectively evaluated the outcome and risks of ablation for focally induced AF in a single-center patient population.
We report on 47 patients (32 men and 15 women; age 47 +/- 10 years) in whom 52 ablations were performed. In 19 patients (22 sessions), ablation was directed at the site(s) of overt ectopic activity ("selective" group), whereas in 28 patients (30 sessions) without sufficient ectopy to determine the culprit PV a mean of 3.5 PVs were empirically targeted for bidirectional disconnection from the LA ("extensive" group). On a preprocedural Holter recording, the "selective" group had significantly more isolated atrial ectopy (3,276 +/- 2,933 vs 620 +/- 937 beats/24 hours) and runs of atrial tachycardia (330 +/- 202 vs 53 +/- 87 runs/24 hours) than the "extensive" group (P < 0.01 for both). Only 11% had persistent AF before ablation. Acute procedural success was 81% (elimination of all ectopy) and 83%, respectively (bidirectional and fully circumferential isolation of all targeted PVs). Procedure and fluoroscopy times were significantly shorter in the "selective" group. There were no major complications, but 7 minor complications and 2 acute PV stenoses > 50% in the 30 "extensive" procedures were observed. Mean follow-up was 8.4 +/- 8.5 months (median 6.9). Kaplan-Meier analysis, excluding recurrences during only the first month ("delayed cure"), showed AF recurrence in 45% after 6 months and in 55% after 1 year. Outcome was not dependent on ablation approach ("selective" or "extensive") nor was time to first AF (22 +/- 64 days and 30 +/- 69 days). AF recurrence tended to be higher in patients with larger LA (P = 0.08), underlying heart disease or hypertension (P = 0.08), and those "extensive" patients in whom not all 4 PVs were targeted (P = 0.07).
Trigger-directed ablation for focally induced AF is associated with a relatively high recurrence rate during follow-up. Apart from recurrence of the ectopic trigger, this may point to underlying structural changes in the atrial substrate not addressed by the ablation. Prospective evaluation of the risk-to-benefit profile of any technique (selective, extensive, including linear lines) is required.
局灶性诱发的心房颤动（房颤）通常源于肺静脉（PV）的异位活动。尽管最初的方法仅旨在消融异位病灶，但后来发展出了更广泛的消融方法，即经验性地隔离所有肺静脉和/或在左心房（LA）创建环形消融线。这些技术维持时间更长，且可能伴随着更多风险。我们回顾性评估了单中心患者群体中局灶性诱发房颤消融的结果和风险。
我们报告了47例患者（32例男性和15例女性；年龄47±10岁），共进行了52次消融。19例患者（22次手术）的消融针对明显异位活动部位（“选择性”组），而28例患者（30次手术）没有足够的异位活动来确定罪犯肺静脉，平均经验性地针对3.5条肺静脉进行与左心房的双向隔离（“广泛”组）。在术前动态心电图记录中，“选择性”组的孤立性房性异位活动（3276±2933次与620±937次/24小时）和房性心动过速发作（330±202次与53±87次/24小时）显著多于“广泛”组（两者P均<0.01）。消融前仅11%的患者为持续性房颤。急性手术成功率分别为81%（消除所有异位活动）和83%（所有目标肺静脉的双向和完全环形隔离）。“选择性”组的手术时间和透视时间明显更短。没有严重并发症，但在30次“广泛”手术中观察到7例轻微并发症和2例急性肺静脉狭窄>50%。平均随访时间为8.4±8.5个月（中位数6.9个月）。Kaplan-Meier分析排除仅在第一个月内的复发（“延迟治愈”）后，显示6个月后房颤复发率为45%，1年后为55%。结果不依赖于消融方法（“选择性”或“广泛”），首次房颤发作时间也无差异（22±64天和30±69天）。左心房较大的患者（P = 0.08）、有潜在心脏病或高血压的患者（P = 0.08）以及未对所有4条肺静脉进行靶向治疗的“广泛”组患者房颤复发率往往更高（P = 0.07）。
针对局灶性诱发房颤的触发灶导向消融在随访期间复发率相对较高。除了异位触发灶复发外，这可能表明消融未解决的心房基质潜在结构变化。需要对任何技术（选择性、广泛，包括线性消融线）的风险效益概况进行前瞻性评估。
