Lalani Gautam G, Coysh Thomas, Baykaner Tina, Zaman Junaid, Hopper Kenneth, Schricker Amir A, Trikha Rishi, Clopton Paul, Krummen David E, Narayan Sanjiv M
Kaiser Permanente, San Diego, California, USA.
University of Cambridge, UK.
J Cardiovasc Electrophysiol. 2016 Jun;27(6):661-9. doi: 10.1111/jce.12964. Epub 2016 Apr 5.
Recurrent atrial fibrillation (AF) after ablation is associated with reconnection of initially isolated pulmonary vein (PV) trigger sites. Substrates are often targeted in addition to PVI, but it is unclear how substrates progress over time. We studied if substrates in recurrent AF are conserved or have developed de novo from pre-ablation AF.
Of 137 patients undergoing Focal Impulse and Rotor Mapping (FIRM) at their index procedure for AF, 29 consecutive patients (60 ± 8 years, 79% persistent) recurred and were also mapped at repeat procedure (21 ± 20 months later) using carefully placed 64-pole baskets and RhythmView(TM) (Topera, Menlo Park, CA, USA) to identify AF sources and disorganized zones. Compared to index AF, recurrent AF had a longer cycle length (177 ± 21 vs. 167 ± 19 milliseconds, P = 0.01). All patients (100%) had 1 or more conserved AF rotors between procedures with surrounding disorganization. The number of sources was similar for recurrent AF post-PVI versus index AF (3.2 ± 1.4 vs. 3.1 ± 1.0, P = 0.79), but was lower for recurrent AF after FIRM+PVI versus index AF (4.4 ± 1.4 vs. 2.9 ± 1.7, P = 0.03). Overall, 81% (61/75) of AF sources lay in conserved regions, while 19% (14/75) were detected de novo.
Electrical propagation patterns for recurrent AF after unsuccessful ablation are similar in individual patients to their index AF. These data support temporospatial stability of AF substrates over 1-2 years. Trials should determine the relative benefit of adding substrate mapping and ablation to PVI for recurrent AF.
消融术后复发性心房颤动（AF）与最初隔离的肺静脉（PV）触发位点重新连接有关。除肺静脉隔离（PVI）外，基质通常也是消融靶点，但目前尚不清楚基质如何随时间进展。我们研究了复发性AF中的基质是保留下来的还是由消融前的AF重新产生的。
在137例因AF接受首次局灶性冲动与转子标测（FIRM）的患者中，连续29例（60±8岁，79%为持续性AF）复发，并在再次手术时（21±20个月后）使用精心放置的64极篮状电极和RhythmView™（美国加利福尼亚州门洛帕克市Topera公司）进行标测，以识别AF起源和紊乱区域。与首次AF相比，复发性AF的周期长度更长（177±21 vs. 167±19毫秒，P = 0.01）。所有患者（100%）在两次手术之间均有1个或更多保留的AF转子以及周围的紊乱区域。PVI术后复发性AF与首次AF的起源数量相似（3.2±1.4 vs. 3.1±1.0，P = 0.79），但FIRM + PVI术后复发性AF的起源数量低于首次AF（4.4±1.4 vs. 2.9±1.7，P = 0.03）。总体而言，81%（61/75）的AF起源位于保留区域，而19%（14/75）是重新检测到的。
消融失败后复发性AF的电传导模式在个体患者中与其首次AF相似。这些数据支持AF基质在1 - 2年内的时空稳定性。试验应确定对于复发性AF，在PVI基础上增加基质标测和消融的相对益处。
