Seitz Julien, Bars Clément, Théodore Guillaume, Beurtheret Sylvain, Lellouche Nicolas, Bremondy Michel, Ferracci Ange, Faure Jacques, Penaranda Guillaume, Yamazaki Masatoshi, Avula Uma Mahesh R, Curel Laurence, Siame Sabrina, Berenfeld Omer, Pisapia André, Kalifa Jérôme
Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France.
Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France; Service de Cardiologie, Institut Mutualiste Montsouris, Paris, France.
J Am Coll Cardiol. 2017 Jan 24;69(3):303-321. doi: 10.1016/j.jacc.2016.10.065.
The use of intracardiac electrograms to guide atrial fibrillation (AF) ablation has yielded conflicting results.
The authors evaluated the usefulness of spatiotemporal dispersion, a visually recognizable electric footprint of AF drivers, for the ablation of all forms of AF.
The authors prospectively enrolled 105 patients admitted for AF ablation. AF was sequentially mapped in both atria with a 20-pole PentaRay catheter. The authors tagged and ablated only regions displaying electrogram dispersion during AF. Results were compared to a validation set in which a conventional ablation approach was used (pulmonary vein isolation/stepwise approach). To establish the mechanism underlying spatiotemporal dispersion of AF electrograms, the authors conducted realistic numerical simulations of AF drivers in a 2-dimensional model and optical mapping of ovine atrial scar-related AF.
Ablation at dispersion areas terminated AF in 95% of the 105 patients. After ablation of 17 ± 10% of the left atrial surface and 18 months of follow-up, the atrial arrhythmia recurrence rate was 15% after 1.4 ± 0.5 procedures per patient versus 41% in the validation set after 1.5 ± 0.5 procedures per patient (arrhythmia free-survival: 85% vs. 59%; log-rank p < 0.001). Compared with the validation set, radiofrequency times (49 ± 21 min vs. 85 ± 34.5 min; p = 0.001) and procedure times (168 ± 42 min vs. 230 ± 67 min; p < 0.0001) were shorter. In simulations and optical mapping experiments, virtual PentaRay recordings demonstrated that electrogram dispersion is mostly recorded in the vicinity of a driver.
The clustering of intracardiac electrograms exhibiting spatiotemporal dispersion is indicative of AF drivers. Their ablation allows for a nonextensive and patient-tailored approach to AF ablation. (Substrate Ablation Guided by High Density Mapping in Atrial Fibrillation [SUBSTRATE HD]; NCT02093949).
使用心内电图指导心房颤动（AF）消融的结果存在矛盾。
作者评估了时空离散度（一种肉眼可识别的AF驱动因素的电信号特征）在各种形式AF消融中的作用。
作者前瞻性纳入了105例因AF消融入院的患者。使用20极Pentaray导管在双心房顺序标测AF。作者仅标记并消融AF期间显示电图离散度的区域。将结果与采用传统消融方法（肺静脉隔离/逐步消融法）的验证组进行比较。为确定AF电图时空离散度的潜在机制，作者在二维模型中对AF驱动因素进行了逼真的数值模拟，并对绵羊心房瘢痕相关AF进行了光学标测。
在105例患者中，95%在离散度区域消融后AF终止。在消融左心房表面面积达17±10%且随访18个月后，每位患者平均接受了1.4±0.5次手术，心律失常复发率为15%；而验证组每位患者平均接受了1.5±0.5次手术，心律失常复发率为（无心律失常生存率：85%对59%；对数秩检验p<0.001）。与验证组相比，射频时间（49±21分钟对85±34.5分钟；p=0.001）和手术时间（168±42分钟对230±67分钟；p<0.0001）更短。在模拟和光学标测实验中，虚拟Pentaray记录显示电图离散度大多记录在驱动因素附近。
表现出时空离散度的心内电图聚集表明存在AF驱动因素。对其进行消融可实现一种非广泛且个体化的AF消融方法。（心房颤动高密度标测指导下的基质消融[SUBSTRATE HD]；NCT02093949）
