Kettering Klaus, Weig Hans-Joerg, Busch Mathias, Laszlo Roman, Schreieck Juergen
Department of Cardiology, University of Mainz, Mainz, Germany.
Pacing Clin Electrophysiol. 2008 Jun;31(6):652-9. doi: 10.1111/j.1540-8159.2008.01067.x.
Catheter ablation has become the first line of therapy in patients with symptomatic recurrent, drug-refractory atrial fibrillation (AF). The occurrence of an atrioesophageal fistula is a rare but serious complication after AF-ablation procedures. This risk is even present during segmental pulmonary vein (PV) ablation procedures because the esophagus does frequently have a very close anatomical relationship to the right or left PV ostia. The aim of the present study was to analyze whether the exclusion of areas adjacent to the esophagus does have a significant effect on the success rates after segmental pulmonary vein ablation procedures.
Forty-three consecutive patients with symptomatic paroxysmal AF were enrolled in this study. In all patients, a segmental PV ablation procedure was performed. The procedures were facilitated by a 3D real-time visualization of the circumferential mapping catheter placed in the pulmonary veins using the NavX system (St. Jude Medical, St. Paul, MN, USA; open irrigated tip ablation catheter; 43 degrees C; 30 W). In 21 patients, a complete ostial PV isolation was attempted regardless of the anatomical relationship between the ablation sites and the esophagus (group A). In the remaining 22 patients, the esophagus was marked by a stomach tube and areas adjacent to the esophagus were excluded from the ablation procedure (group B). After discharge, patients were scheduled for repeated visits at the arrhythmia clinic at 1, 3, and 6 months after the ablation procedure.
The segmental pulmonary vein ablation procedure could be performed as planned in all patients. In group A, all pulmonary veins could be isolated successfully in 14 out of 21 patients (67%). A mean number of 3.7 pulmonary veins (SD +/- 0.5 PVs) were isolated per patient. The main reasons for an incomplete PV isolation were: small diameter of the PVs, side branches close to the ostium, or poorly accessible PV ostia. In group B, all PVs could be isolated successfully in only 12 out of 22 patients (55%; P = 0.54). A mean number of 3.2 PVs (SD +/- 0.9 PVs) were isolated per patient (P = 0.05). This was mostly due to a close anatomical relationship to the esophagus. The ablation strategy had to be modified in 16/22 patients in group B because of a close anatomical relationship between the left (n = 10) or right (n = 6) PV ostia and the esophagus. After 3 months, the percentage of patients free from an AF recurrence was not significantly different between the two groups (90% vs 95%; P = 0.61). After 6 months, there was no significant difference between the success rates either (81% vs 82%; P = 1.0). There were no major complications in both groups.
The exclusion of areas adjacent to the esophagus results in a moderately higher percentage of incompletely isolated PVs. However, it does not have a significant effect on the AF recurrence rate during short-term and mid-term follow-up.
导管消融已成为症状性复发性、药物难治性心房颤动（AF）患者的一线治疗方法。心房食管瘘的发生是AF消融术后一种罕见但严重的并发症。即使在节段性肺静脉（PV）消融手术过程中也存在这种风险，因为食管与右侧或左侧PV开口通常具有非常紧密的解剖关系。本研究的目的是分析排除食管相邻区域是否对节段性肺静脉消融术后的成功率有显著影响。
本研究纳入了43例连续性症状性阵发性AF患者。所有患者均接受了节段性PV消融手术。使用NavX系统（美国明尼苏达州圣保罗市圣犹达医疗公司；开放式灌注尖端消融导管；43℃；30W）对置于肺静脉中的圆周标测导管进行三维实时可视化，以辅助手术。21例患者中，无论消融部位与食管之间的解剖关系如何，均尝试进行完全的PV开口隔离（A组）。其余22例患者中，通过胃管标记食管，并将食管相邻区域排除在消融手术之外（B组）。出院后，安排患者在消融术后1、3和6个月到心律失常门诊进行复诊。
所有患者均能按计划进行节段性肺静脉消融手术。A组中，21例患者中有14例（67%）所有肺静脉均成功隔离。每位患者平均隔离3.7条肺静脉（标准差±0.5条PV）。PV隔离不完全的主要原因是：PV直径小、靠近开口的侧支或PV开口难以到达。B组中，22例患者中只有12例（55%；P = 0.54）所有PV均成功隔离。每位患者平均隔离3.2条PV（标准差±0.9条PV）（P = 0.05）。这主要是由于与食管的解剖关系密切。由于左（n = 10）或右（n = 6）PV开口与食管之间的解剖关系密切，B组22例患者中有16例的消融策略不得不进行修改。3个月后，两组患者无AF复发的百分比无显著差异（90%对95%；P = 0.61）。6个月后，成功率也无显著差异（81%对82%；P = 1.0）。两组均无严重并发症。
排除食管相邻区域导致不完全隔离的PV比例略高。然而，在短期和中期随访期间，它对AF复发率没有显著影响。
