Willems S, Drewitz I, Steven D, Hoffmann B A, Meinertz T, Rostock T
Universitäres Herzzentrum Hamburg, Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie, Universitätsklinikum Hamburg-Eppendorf.
Dtsch Med Wochenschr. 2010 Mar;135 Suppl 2:S48-54. doi: 10.1055/s-0030-1249209. Epub 2010 Mar 10.
Recently, significant progress has been made treating atrial fibrillation (AF) with catheter ablation emerging as an increasingly important technique. Electrical disconnection of the pulmonary veins (PV) is a widely accepted endpoint for interventional treatment of paroxysmal AF (PAF). According to the current guidelines, catheter ablation can be considered as a therapeutic option in patients who failed antiarrhythmic drug treatment for PAF. The procedural endpoint for PVI is achievement of permanent electrical isolation of the PVs, which in the vast majority of patients harbor triggered electrical activity inducing and maintaining PAF. The success rate of this approach in patients with PAF ranges between 60 and 80% after a single procedure and augments to > 80 % in patients undergoing a repeat procedure to abolish recovered PV connection. However, it is now evident that persistent or long-standing persistent AF may not be successfully treated by PVI alone since the majority of patients have AF maintaining substrate beyond the PV. From a pathophysiological perspective this is explained by structural and electrical remodeling of the atrial myocardium in patients with persistent AF. Therefore, it is today widely accepted that additional substrate modification is required to effectively address persistent AF using catheter ablation. It has been shown that a combined approach of PV isolation, ablation of fractionated atrial electrograms and application of lines to treat atrial macro-reentrant tachycardias ("stepwise approach") aiming for restoration of sinus rhythm is a favorable strategy to treat persistent AF. However, significant expertise is needed to accomplish all steps within these complex procedures. Therefore, catheter ablation for persistent AF cannot yet be considered "clinically established" and should only be performed in high volume centers. Additional data is needed to verify the beneficial effect of this strategy and determine "predictors" identifying patients profiting most from these ablation strategies. In patients with PAF, catheter ablation has emerged as an established therapy also in comparison to antiarrythmic drug treatment. Recent studies have shown that catheter ablation for PAF is superior to antiarrhythmic drug treatment with regard to mid-term suppression of any atrial arrhythmia. Overall, catheter ablation for AF has still to be considered as a symptomatic treatment since evidence for beneficial effects with regard to more robust clinical endpoints such as death, rehospitalization and ischemic cerebral events are not yet available.
最近，在采用导管消融治疗心房颤动（AF）方面取得了重大进展，导管消融正成为一项日益重要的技术。肺静脉（PV）电隔离是阵发性房颤（PAF）介入治疗广泛接受的终点。根据当前指南，对于PAF抗心律失常药物治疗失败的患者，可考虑将导管消融作为一种治疗选择。肺静脉隔离（PVI）的手术终点是实现PV的永久性电隔离，在绝大多数患者中，PV存在诱发和维持PAF的触发电活动。这种方法在PAF患者中的单次手术成功率在60%至80%之间，在接受重复手术以消除恢复的PV连接的患者中，成功率增至80%以上。然而，现在很明显，单纯PVI可能无法成功治疗持续性或长期持续性房颤，因为大多数患者的房颤维持基质超出了PV。从病理生理学角度来看，这可以用持续性房颤患者心房心肌的结构和电重构来解释。因此，如今人们普遍认为，使用导管消融有效治疗持续性房颤需要进行额外的基质改良。研究表明，采用PV隔离、碎裂心房电图消融以及应用线性消融治疗心房大折返性心动过速（“逐步方法”）以恢复窦性心律的联合方法是治疗持续性房颤的有利策略。然而，要在这些复杂手术中完成所有步骤需要相当专业的知识。因此，持续性房颤的导管消融尚未被认为是“临床确立的”，仅应在大容量中心进行。需要更多数据来验证该策略的有益效果，并确定能从这些消融策略中获益最多的患者的“预测因素”。在PAF患者中，与抗心律失常药物治疗相比，导管消融也已成为一种既定的治疗方法。最近的研究表明，PAF的导管消融在中期抑制任何房性心律失常方面优于抗心律失常药物治疗。总体而言，AF的导管消融仍应被视为一种对症治疗，因为关于更有力的临床终点如死亡、再次住院和缺血性脑事件的有益效果证据尚不充分。
