Department of Medicine, University of California, San Diego, San Diego, California; Veterans Affairs Medical Center, San Diego, California.
Department of Medicine, University of California, San Diego, San Diego, California; Veterans Affairs Medical Center, San Diego, California.
J Am Coll Cardiol. 2014 May 6;63(17):1761-8. doi: 10.1016/j.jacc.2014.02.543. Epub 2014 Mar 13.
The aim of this study was to determine if ablation that targets patient-specific atrial fibrillation (AF)-sustaining substrates (rotors or focal sources) is more durable than trigger ablation alone at preventing late AF recurrence.
Late recurrence substantially limits the efficacy of pulmonary vein isolation for AF and is associated with pulmonary vein reconnection and the emergence of new triggers.
Three-year follow-up was performed of the CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial, in which 92 consecutive patients with AF (70.7% persistent) underwent novel computational mapping. Ablation comprised source (focal impulse and rotor modulation [FIRM]) and then conventional ablation in 27 patients (FIRM guided) and conventional ablation alone in 65 patients (FIRM blinded). Patients were followed with implanted electrocardiographic monitors when possible (85.2% of FIRM-guided patients, 23.1% of FIRM-blinded patients).
FIRM mapping revealed a median of 2 (interquartile range: 1 to 2) rotors or focal sources in 97.7% of patients during AF. During a median follow-up period of 890 days (interquartile range: 224 to 1,563 days), compared to FIRM-blinded therapy, patients receiving FIRM-guided ablation maintained higher freedom from AF after 1.2 ± 0.4 procedures (median 1; interquartile range: 1 to 1) (77.8% vs. 38.5%, p = 0.001) and a single procedure (p < 0.001) and higher freedom from all atrial arrhythmias (p = 0.003). Freedom from AF was higher when ablation directly or coincidentally passed through sources than when it missed sources (p < 0.001).
FIRM-guided ablation is more durable than conventional trigger-based ablation in preventing 3-year AF recurrence. Future studies should investigate how ablation of patient-specific AF-sustaining rotors and focal sources alters the natural history of arrhythmia recurrence. (The Dynamics of Human Atrial Fibrillation; NCT01008722).
本研究旨在确定针对特定于患者的房颤（房颤）维持基质（转子或灶源）的消融是否比单独消融触发灶更能持久地预防晚期房颤复发。
晚期复发极大地限制了肺静脉隔离治疗房颤的效果，并且与肺静脉再连接和新触发灶的出现有关。
对 CONFIRM（房颤伴或不伴灶性冲动和转子调制的常规消融）试验进行了 3 年随访，该试验中 92 例连续房颤患者（70.7%持续性）接受了新型计算映射。消融包括源（灶性冲动和转子调制[FIRM]），然后对 27 例患者进行常规消融（FIRM 引导），对 65 例患者进行单纯常规消融（FIRM 盲法）。当可能时，通过植入式心电图监测仪对患者进行随访（FIRM 引导组患者的 85.2%，FIRM 盲法组患者的 23.1%）。
在房颤期间，FIRM 图谱在 97.7%的患者中显示中位数为 2 个（四分位间距：1 至 2）转子或灶源。在中位随访 890 天（四分位间距：224 至 1563 天）期间，与 FIRM 盲法治疗相比，接受 FIRM 引导消融的患者在 1.2 ± 0.4 次消融后（中位数 1 次；四分位间距：1 至 1）维持更高的无房颤率（77.8% vs. 38.5%，p = 0.001）和单次消融后（p < 0.001）以及更高的无所有房性心律失常率（p = 0.003）。消融直接或偶然通过源时的无房颤率高于错过源时（p < 0.001）。
与基于触发灶的常规消融相比，FIRM 引导消融在预防 3 年房颤复发方面更持久。未来的研究应探讨消融特定于患者的房颤维持转子和灶源如何改变心律失常复发的自然史。（人类房颤动力学；NCT01008722）。
