Jais Pierre, Haissaguerre Michel, Hocini Mélèze, Clementy Jacques
Service de Rythmologie, Hôpital Cardiologique du Haut-Lévêque, Avenue de Magellan, 33604 Pessac.
Bull Acad Natl Med. 2005 Jan;189(1):17-29; discussion 29-30.
Atrial fibrillation, the most common cardiac arrhythmia, is frequently disabling and drug-resistant, and can be associated with major complications such as thromboembolic events. Non drug approaches, including surgery and catheter-based ablation, are used to treat the most severely symptomatic patients. These new treatment strategies have drastically improved our knowledge of the pathophysiology of this arrhythmia and, importantly, have shown that atrial fibrillation is curable. Since 1994, two main approaches have been used to modify the substrate responsible for AF maintenance, namely the creation of linear lesions, and ablation of triggers located within the pulmonary veins (about 90% of cases). Most teams worldwide now use approaches centered on PV isolation, which, although imperfect, are sufficiently effective to be offered routinely to selected patients in experienced centers. The importance of PVs in the initiation of AF has been clearly demonstrated, and there is also evidence of a role in AF maintenance. However, the existence of non venous foci or a prominent substrate for AF maintenance limits the success rate to about 70%. We are now using a combination of PV isolation and a linear lesion delivered to the mitral isthmus, from the mitral annulus to the ostium of the left inferior pulmonary vein. This more complex procedure carries a significantly higher success rate, about 82% of patients being cured and drug-free. The main problem is to identify patients requiring mitral isthmus ablation in addition to PV isolation. At present, AF ablation is restricted to symptomatic patients in whom at least two antiarrhythmic drugs have failed, but future technical improvements are likely to broaden the indications of ablation therapy for AF.
心房颤动是最常见的心律失常，常常使人丧失活动能力且具有耐药性，并可能伴有血栓栓塞事件等主要并发症。包括手术和导管消融在内的非药物方法用于治疗症状最为严重的患者。这些新的治疗策略极大地增进了我们对这种心律失常病理生理学的认识，重要的是，已表明心房颤动是可治愈的。自1994年以来，已采用两种主要方法来改变维持房颤的基质，即制造线性损伤以及消融肺静脉内的触发灶（约90%的病例）。目前全球大多数团队采用以肺静脉隔离为中心的方法，尽管并不完美，但在经验丰富的中心已足够有效，可常规应用于选定的患者。肺静脉在房颤起始中的重要性已得到明确证实，也有证据表明其在房颤维持中发挥作用。然而，非静脉起源灶或显著的房颤维持基质的存在将成功率限制在约70%。我们目前采用肺静脉隔离与从二尖瓣环至左下肺静脉开口的二尖瓣峡部线性损伤相结合的方法。这种更为复杂的手术成功率显著更高，约82%的患者可治愈且无需用药。主要问题是确定除肺静脉隔离外还需要二尖瓣峡部消融的患者。目前，房颤消融仅限于至少两种抗心律失常药物治疗无效的有症状患者，但未来技术的改进可能会扩大房颤消融治疗的适应证。
