Boriani Giuseppe, Diemberger Igor, Biffi Mauro, Martignani Cristian, Ziacchi Matteo, Bertini Matteo, Valzania Cinzia, Bronzetti Gabriele, Rapezzi Claudio, Branzi Angelo
Institute of Cardiology, University of Bologna, Azienda Ospedaliera S. Orsola-Malpighi, Bologna, Italy.
Pacing Clin Electrophysiol. 2007 Mar;30(3):422-33. doi: 10.1111/j.1540-8159.2007.00685.x.
This viewpoint article discusses the potential for incorporation of atrial defibrillation capabilities in modern multi-chamber devices. In the late 1990s, the possibility of using shock-only therapy to treat selected patients with recurrent atrial fibrillation (AF) was explored in the context of the stand-alone atrial defibrillator. The failure of this strategy can be attributed to the technical limitations of the stand-alone device, low tolerance of atrial shocks, difficulties in patient selection, a lack of predictive knowledge about the evolution of AF, and, last but not least, commercial considerations. An open question is how atrial defibrillation capability may now assume a specific new role in devices implanted for sudden death prevention or cardiac resynchronization. For patients who already have indications for implantable devices, device-based atrial defibrillation appears attractive as a "backup" option for managing AF when preventive pharmacological/electrical measures fail. This and several other personalized hybrid therapeutic approaches await exploration, though assessment of their efficacy is methodologically challenging. Achievement of acceptance by patients is an essential premise for any updated atrial defibrillation strategy. Strategies that are being investigated to improve patient tolerance include waveform shaping, pharmacologic modulation of pain, and patient-activated defibrillation (patients might also perceive the problem of discomfort somewhat differently in the context of a backup therapy). The economic impact of implementing atrial defibrillation features in available devices is progressively decreasing, and financial feasibility need not be a major issue. Future studies should examine clinically relevant outcomes and not be limited (as occurred with stand-alone defibrillators) to technical or other soft endpoints.
这篇观点文章讨论了在现代多腔设备中纳入心房除颤功能的可能性。在20世纪90年代后期，在独立心房除颤器的背景下，探讨了使用单纯电击疗法治疗部分复发性心房颤动（AF）患者的可能性。该策略的失败可归因于独立设备的技术局限性、心房电击的耐受性低、患者选择困难、对房颤演变缺乏预测性认识，以及最后但同样重要的商业考虑因素。一个悬而未决的问题是，心房除颤功能现在如何在用于预防猝死或心脏再同步化的植入设备中发挥特定的新作用。对于已经有植入设备指征的患者，当预防性药物/电治疗措施失败时，基于设备的心房除颤作为管理房颤的“备用”选择似乎很有吸引力。尽管评估其疗效在方法上具有挑战性，但这种以及其他几种个性化的混合治疗方法有待探索。获得患者的接受是任何更新的心房除颤策略的基本前提。正在研究以提高患者耐受性的策略包括波形整形、疼痛的药物调节和患者激活除颤（在备用治疗的背景下，患者对不适问题的感知可能也会有所不同）。在现有设备中实施心房除颤功能的经济影响正在逐渐降低，财务可行性不必成为一个主要问题。未来的研究应检查临床相关结果，而不应像独立除颤器那样局限于技术或其他软性终点。
