Bassiouny Mohamed, Saliba Walid, Hussein Ayman, Rickard John, Diab Mariam, Aman Wahaj, Dresing Thomas, Callahan Thomas, Bhargava Mandeep, Martin David O, Shao Mingyuan, Baranowski Bryan, Tarakji Khaldoun, Tchou Patrick J, Hakim Ali, Kanj Mohamed, Lindsay Bruce, Wazni Oussama
From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
Circ Arrhythm Electrophysiol. 2016 Feb;9(2):e003596. doi: 10.1161/CIRCEP.115.003596.
Achieving long-term successful outcomes with ablation of persistent atrial fibrillation (AF) remains a clinical and procedural challenge. We aimed to assess 2 ablation strategies for persistent AF: pulmonary vein antral isolation (PVAI) in sinus rhythm after direct current cardioversion versus PVAI and ablation targeting complex-fractionated atrial electrograms while in AF.
Between June 2009 and July 2013, patients with continuous persistent AF for ≥3 months were prospectively randomized to either direct current cardioversion before PVAI and posterior wall/septum ablation while in sinus rhythm (group 1), versus same ablation in group 1 in addition to complex-fractionated atrial electrogram ablation while in AF (group 2). The procedural profiles and clinical outcomes of the 2 strategies were compared. Ninety patients were randomized to group 1 (n=46) or group 2 (n=44). There were no differences in baseline characteristics between groups. Over 365 days of follow-up after the index procedure, 16 patients (35%) in group 1 and 13 patients (30%) in group 2 remained arrhythmia-free off antiarrhythmic medications. Over long-term follow-up (median, 867 days), arrhythmia-free survival off antiarrhythmic medications was more likely in group 1 than in group 2 in Kaplan-Meier analysis (Log Rank P=0.04). Group 1 ablation was associated with significantly shorter procedural duration and fluoroscopy time (231±72 versus 273±76 min; P=0.008 and 54 [Q1-Q3: 46-67] versus 66 (Q1-Q3: 53-83] min; P=0.018, respectively).
In patients with persistent AF, PVAI in sinus rhythm after direct current cardioversion is associated with higher success and shorter procedural and fluoroscopy times compared with PVAI in AF with additional complex-fractionated atrial electrogram ablation.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT02429648.
通过消融持续性心房颤动（AF）实现长期成功结果仍然是一项临床和操作上的挑战。我们旨在评估两种持续性AF的消融策略：直流电复律后窦性心律下的肺静脉前庭隔离（PVAI）与AF时的PVAI及针对复杂碎裂心房电图的消融。
2009年6月至2013年7月期间，将持续持续性AF≥3个月的患者前瞻性随机分为两组，一组在PVAI及后壁/间隔消融前进行直流电复律且在窦性心律下操作（第1组），另一组在第1组相同消融基础上，在AF时增加复杂碎裂心房电图消融（第2组）。比较两种策略的操作情况和临床结果。90例患者被随机分为第1组（n = 46）或第2组（n = 44）。两组间基线特征无差异。在首次手术后365天的随访中，第1组16例患者（35%）和第2组13例患者（30%）在未服用抗心律失常药物的情况下无心律失常。在长期随访（中位数867天）中，Kaplan-Meier分析显示第1组未服用抗心律失常药物的无心律失常生存率高于第2组（对数秩检验P = 0.04）。第1组消融的操作时间和透视时间显著更短（分别为231±72分钟对273±76分钟；P = 0.008和54 [四分位数间距：46 - 67]分钟对66 [四分位数间距：53 - 83]分钟；P = 0.018）。
在持续性AF患者中，与AF时进行PVAI并额外消融复杂碎裂心房电图相比，直流电复律后窦性心律下的PVAI成功率更高，操作时间和透视时间更短。
