Jaïs Pierre, Hocini Mélèze, Sanders Prashanthan, Hsu Li-Fern, Takahashi Yoshihide, Rotter Martin, Rostock Thomas, Sacher Frédéric, Clementy Jacques, Haissaguerre Michel
Hôpital Haut-Lévèque and Université Victor Ségalen, Bordeaux II, Bordeaux, France.
Heart Rhythm. 2006 Feb;3(2):140-5. doi: 10.1016/j.hrthm.2005.11.012.
Pulmonary vein (PV) isolation and linear lesions are effective in eliminating paroxysmal atrial fibrillation (AF), but linear lesions probably are not required in all patients. Noninducibility of AF has been shown to be associated with freedom from arrhythmia in 87% of patients.
The purpose of this study was to prospectively evaluate the role of noninducibility in guiding a stepwise approach tailored to the patient.
In 74 patients (age 53 +/- 8 years) with paroxysmal AF, PV isolation was performed during induced or spontaneous AF. If AF was inducible after PV isolation, one to two additional linear lesions were placed at the mitral isthmus and/or left atrial roof, with the endpoint of noninducibility of AF or atrial flutter. Inducibility (AF/atrial flutter, lasting > or = 10 minutes) was assessed using burst pacing at an output of 20 mA down to refractoriness from the coronary sinus and both atrial appendages.
In 42 patients (57%), PV isolation restored sinus rhythm and rendered AF noninducible. In the 32 patients with persistent or inducible AF after PV isolation, a single linear lesion achieved noninducibility in 20, whereas two linear lesions were required in 12 and resulted in conversion to sinus rhythm and noninducibility in 10. Using this stepwise approach, a total of 69 patients (93%) were rendered noninducible. During follow-up of 18 +/- 4 months, 67 patients (91%) were free from arrhythmia without antiarrhythmic drugs. Repeat procedures were performed in 23 patients: repeat ablation was required to consolidate prior targets in 15 patients (20%), and "new" linear lesions, which were not predicted by inducibility during the index procedure, were required in 8 (11%).
Noninducibility can be used as an endpoint for determining the subset of patients with paroxysmal AF who require additional linear lesions after PV isolation. This tailored approach is effective in 91% of patients while preventing delivery of unnecessary linear lesions.
肺静脉（PV）隔离和线性消融对于消除阵发性心房颤动（AF）有效，但可能并非所有患者都需要进行线性消融。已有研究表明，房颤不能被诱发与87%的患者心律失常缓解相关。
本研究旨在前瞻性评估房颤不能被诱发在指导针对患者的逐步治疗方法中的作用。
对74例（年龄53±8岁）阵发性房颤患者，在诱发或自发房颤期间进行肺静脉隔离。如果肺静脉隔离后房颤仍可诱发，则在二尖瓣峡部和/或左心房顶部额外放置一到两条线性消融线，终点为房颤或房扑不能被诱发。使用20 mA输出的短阵猝发刺激从冠状窦和两个心耳进行刺激，直至不应期，评估诱发情况（房颤/房扑，持续≥10分钟）。
42例患者（57%）肺静脉隔离后恢复窦性心律且房颤不能被诱发。在肺静脉隔离后仍有持续性或可诱发房颤的32例患者中，单一线性消融使20例患者房颤不能被诱发，12例患者需要两条线性消融，其中10例患者转为窦性心律且房颤不能被诱发。采用这种逐步治疗方法，共有69例患者（93%）房颤不能被诱发。在18±4个月的随访期间，67例患者（91%）在未使用抗心律失常药物的情况下无心律失常发作。23例患者进行了再次手术：15例患者（20%）需要重复消融以巩固先前的靶点，8例患者（11%）需要“新的”线性消融，这些在初次手术期间的诱发情况未预测到。
房颤不能被诱发可作为确定阵发性房颤患者在肺静脉隔离后是否需要额外线性消融的终点。这种个体化方法在91%的患者中有效，同时可避免不必要的线性消融。
