Division of Experimental and Clinical Electrophysiology, Department of Cardiology and Angiology, University Hospital, Muenster, Germany.
Heart Rhythm. 2012 Oct;9(10):1660-6. doi: 10.1016/j.hrthm.2012.06.007. Epub 2012 Jun 6.
Antral pulmonary vein isolation (PVI) for treatment of atrial fibrillation may induce left atrial tachycardias (ATs).
To determine the prevalence, time course of occurrence, mechanisms, and correlation with the electrocardiogram as well as the outcome of ablation of these tachycardias.
Out of the 839 patients who underwent circumferential antral radiofrequency PVI guided by a circumferential pulmonary vein catheter at our institution between February 2005 and April 2011, 35 patients (4%) developed AT during follow-up. Six patients with left AT and a previous PVI at other institutions were also included. Of these 41 patients (26 men, 63%; age 59 ± 10 years), 26 (63%) had underlying paroxysmal atrial fibrillation and 15 (37%) had persistent atrial fibrillation. AT ablation was performed 47 ± 60 weeks after initial PVI, within the first 3 months in 16 patients (39%). The tachycardia mechanism was focal in 15 patients (37%), macroreentry in 25 patients (61%), and undetermined in 1 (2%). Focal tachycardias had an isoelectric line between distinct P waves in 13 of the 15 patients (87%), while only 4 (16%) with a macroreentrant mechanism had an isoelectric line (P <.001). Although difficult to measure, a P-wave width of >140 ms had the highest sensitivity and specificity to identify macroreentrant mechanism. Ablation was acutely successful in 32 patients (78%) and not successful in 4 (10%). In 5 patients, success could not be determined as the tachycardia terminated or degenerated during mapping. During a mean follow-up of 31 ± 17 months, 11 patients (27%; n = 9 [82%] with macroreentry) underwent repeat ablation procedure for AT. Eight patients had true recurrence, for example, the same AT, and 3 patients had a second mechanism of AT.
With the use of an identical ablation protocol, it was found that approximately 4% of the patients developed AT after mere circumferential antral PVI. The majority of ATs developed within a few months after ablation but occurred as late as several years after the initial PVI. Macroreentry was more frequent than a focal mechanism. Broad P waves and isoelectric lines between P waves help to distinguish a focal mechanism from a macroreentrant mechanism. Ablation has a high acute success rate, and AT recurrence occurs predominantly in macroreentrant AT.
心房颤动的治疗中，进行肺静脉口部的环形消融（PVI）可能会引发左房性心动过速（AT）。
确定这些心动过速的发生率、发生时间、机制以及与心电图的相关性，并评估消融治疗的效果。
在 2005 年 2 月至 2011 年 4 月期间，我们对 839 例行环形肺静脉导管引导下环形肺静脉口部消融术的患者进行了随访，其中 35 例（4%）在随访中出现了 AT。另外，我们还纳入了 6 例曾在其他机构行左房 AT 消融术且再次出现 AT 的患者。这些患者共 41 例（26 例男性，63%；年龄 59 ± 10 岁），其中 26 例（63%）为阵发性心房颤动，15 例（37%）为持续性心房颤动。在初次 PVI 后 47 ± 60 周进行 AT 消融术，其中 16 例（39%）在初次 PVI 后 3 个月内进行。心动过速机制为局灶性 15 例（37%）、大折返性 25 例（61%）和不明机制 1 例（2%）。局灶性心动过速的 15 例患者（87%）中，各 P 波之间有等电线，而大折返性机制的 25 例患者中仅有 4 例（16%）有等电线（P <.001）。虽然难以测量，但 P 波宽度＞140 ms 对识别大折返机制具有最高的敏感性和特异性。32 例（78%）患者即刻消融成功，4 例（10%）患者消融失败。在 5 例患者中，由于心动过速在标测过程中终止或转变为其他类型，因此无法确定消融效果。平均随访 31 ± 17 个月后，11 例患者（27%；其中 9 例[82%]为大折返性）因 AT 复发而再次行消融术。8 例患者为真正的复发，即出现相同的 AT，3 例患者出现了第二种 AT 机制。
采用相同的消融方案，我们发现，仅仅进行环形肺静脉口部消融后，约有 4%的患者会发生 AT。大多数 AT 在消融术后几个月内发生，但也有少数患者在初次 PVI 后数年才出现 AT。大折返性机制比局灶性机制更为常见。宽 P 波和 P 波之间的等电线有助于区分局灶性机制和大折返性机制。消融治疗即刻成功率高，AT 复发主要发生于大折返性 AT。
