Jadidi Amir S, Lehrmann Heiko, Keyl Cornelius, Sorrel Jérémie, Markstein Viktor, Minners Jan, Park Chan-Il, Denis Arnaud, Jaïs Pierre, Hocini Mélèze, Potocnik Clemens, Allgeier Juergen, Hochholzer Willibald, Herrera-Siklody Claudia, Kim Steve, Omri Youssef El, Neumann Franz-Josef, Weber Reinhold, Haïssaguerre Michel, Arentz Thomas
Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
Circ Arrhythm Electrophysiol. 2016 Mar;9(3). doi: 10.1161/CIRCEP.115.002962.
Complex-fractionated atrial electrograms and atrial fibrosis are associated with maintenance of persistent atrial fibrillation (AF). We hypothesized that pulmonary vein isolation (PVI) plus ablation of selective atrial low-voltage sites may be more successful than PVI only.
A total of 85 consecutive patients with persistent AF underwent high-density atrial voltage mapping, PVI, and ablation at low-voltage areas (LVA < 0.5 mV in AF) associated with electric activity lasting > 70% of AF cycle length on a single electrode (fractionated activity) or multiple electrodes around the circumferential mapping catheter (rotational activity) or discrete rapid local activity (group I). The procedural end point was AF termination. Arrhythmia freedom was compared with a control group (66 patients) undergoing PVI only (group II). PVI alone was performed in 23 of 85 (27%) patients of group I with low amount (< 10% of left atrial surface area) of atrial low voltage. Selective atrial ablation in addition to PVI was performed in 62 patients with termination of AF in 45 (73%) after 11 ± 9 minutes radiofrequency delivery. AF-termination sites colocalized within LVA in 80% and at border zones in 20%. Single-procedural arrhythmia freedom at 13 months median follow-up was achieved in 59 of 85 (69%) patients in group I, which was significantly higher than the matched control group (31/66 [47%], P < 0.001). There was no significant difference in the success rate of patients in group I with a low amount of low voltage undergoing PVI only and patients requiring PVI+selective low-voltage ablation (P = 0.42).
Ablation of sites with distinct activation characteristics within/at borderzones of LVA in addition to PVI is more effective than conventional PVI-only strategy for persistent AF. PVI only seems to be sufficient to treat patients with left atrial low voltage < 10%.
复杂碎裂心房电图和心房纤维化与持续性心房颤动（AF）的维持有关。我们假设肺静脉隔离（PVI）加选择性心房低电压部位消融可能比单纯PVI更有效。
共85例持续性AF患者接受了高密度心房电压标测、PVI以及与单个电极上房颤周期长度的70%以上的电活动相关的低电压区域（房颤时LVA<0.5mV）消融（碎裂活动）或环绕标测导管周围多个电极上的（旋转活动）或离散快速局部活动（I组）。手术终点为房颤终止。将心律失常缓解情况与仅接受PVI的对照组（66例患者）进行比较（II组）。I组85例患者中有23例（27%）仅行PVI，其心房低电压面积较少（<左心房表面积的10%）。62例患者在PVI基础上进行了选择性心房消融，在11±9分钟的射频消融后，45例（73%）房颤终止。房颤终止部位80%位于LVA内，20%位于边界区域。I组85例患者中，在中位随访13个月时，59例（69%）实现了单次手术无心律失常，显著高于匹配的对照组（31/66[47%]，P<0.001）。I组中低电压量少且仅接受PVI的患者与需要PVI加选择性低电压消融的患者成功率无显著差异（P=0.42）。
除PVI外，消融LVA内/边界区域具有独特激活特征的部位，对于持续性房颤比传统的单纯PVI策略更有效。单纯PVI似乎足以治疗左心房低电压<10%的患者。
