Jaïs Pierre, Sanders Prashanthan, Hsu Li-Fern, Hocini Mélèze, Sacher Frederic, Takahashi Yoshihide, Rotter Martin, Rostock Thomas, Bordachar Pierre, Reuter Sylvain, Laborderie Julien, Clémenty Jacques, Haïssaguerre Michel
Hôpital Haut-Lévèque, Université Victor Ségalen, Bordeaux II, Bordeaux-Pessac, France.
J Cardiovasc Electrophysiol. 2006 Mar;17(3):279-85. doi: 10.1111/j.1540-8167.2005.00292.x.
Organized atrial arrhythmias following atrial fibrillation (AF) ablation are typically due to recovered pulmonary vein (PV) conduction or reentry at incomplete ablation lines. We describe the role of nonablated anterior left atrium (LA) in arrhythmias observed after AF ablation.
A total of 275 consecutive patients with paroxysmal (n = 200) or chronic (n = 75) AF had PV isolation with/without additional linear ablation at the mitral isthmus (n = 106), LA roof (n = 23), or both (n = 88). Organized arrhythmias occurring after ablation were evaluated utilizing activation and entrainment mapping.
Fourteen patients (11 female, 65 +/- 13 years, 10 chronic AF, 10 structural heart disease) demonstrated tachycardia localized to the anterior LA, an area not targeted by prior ablation. Eight had ECG features during sinus rhythm suggestive of impaired anterior LA conduction at baseline. These arrhythmias demonstrated a distinctive ECG flutter morphology in 7 of 10 (70%) with discrete -/+ or +/-/+ aspect in inferior leads. Mapping the anterior LA revealed electrograms spanning the entire tachycardia cycle length (325 +/- 125 msec). Entrainment was possible in all with a postpacing interval exceeding the tachycardia cycle length by 9 +/- 10 msec. Electroanatomic mapping in 6 demonstrated small reentrant circuits rotating clockwise in 4 and counterclockwise in 2. Low-amplitude, fractionated mid-diastolic potentials with long duration (200 +/- 80 msec) occupying 63 +/- 22% of the cycle length were targeted for ablation resulting in termination and subsequent noninducibility.
Organized arrhythmias occurring after AF ablation can be due to reentrant circuits localized to the anterior LA, predominantly in females with chronic AF, structural heart disease, and abnormal atrial conduction. They are characterized by a distinctive surface ECG and highly responsive to RF ablation at the slow conduction area.
房颤（AF）消融术后出现的有组织的房性心律失常通常是由于肺静脉（PV）传导恢复或不完全消融线处的折返。我们描述了未消融的左心房前部（LA）在AF消融术后观察到的心律失常中的作用。
总共275例阵发性（n = 200）或慢性（n = 75）AF患者接受了PV隔离，伴或不伴在二尖瓣峡部（n = 106）、LA顶部（n = 23）或两者（n = 88）进行额外的线性消融。利用激动标测和拖带标测评估消融后出现的有组织的心律失常。
14例患者（11例女性，65±13岁，10例慢性AF，10例有结构性心脏病）表现为局限于LA前部的心动过速，该区域先前未进行消融。8例在窦性心律时的心电图特征提示基线时LA前部传导受损。这些心律失常在10例中有7例（70%）表现出独特的心电图扑动形态，下壁导联有离散的-/+或+/-/+形态。对LA前部进行标测显示，局部电图跨越整个心动过速周期长度（325±125毫秒）。所有患者均能进行拖带，拖带后间期超过心动过速周期长度9±10毫秒。6例患者的电解剖标测显示，4例存在顺时针旋转小折返环，2例存在逆时针旋转小折返环。低振幅、碎裂的舒张中期电位持续时间长（200±80毫秒），占心动周期长度的63±22%，被作为消融靶点，结果心律失常终止且随后不能被诱发。
AF消融术后出现的有组织的心律失常可能是由于局限于LA前部的折返环，主要见于患有慢性AF、结构性心脏病和心房传导异常的女性。它们的特征是独特的体表心电图，并且对慢传导区域的射频消融高度敏感。
