线性消融术后额外的电信号引导消融能否降低长期持续性心房颤动导管消融后的复发率？一项前瞻性随机研究。

Does Additional Electrogram-Guided Ablation After Linear Ablation Reduce Recurrence After Catheter Ablation for Longstanding Persistent Atrial Fibrillation? A Prospective Randomized Study.

作者信息

Kim Tae-Hoon, Uhm Jae-Sun, Kim Jong-Youn, Joung Boyoung, Lee Moon-Hyoung, Pak Hui-Nam

机构信息

Yonsei University Health System, Seoul, Korea.

Yonsei University Health System, Seoul, Korea

出版信息

J Am Heart Assoc. 2017 Feb 7;6(2):e004811. doi: 10.1161/JAHA.116.004811.

BACKGROUND

Although circumferential pulmonary vein isolation (CPVI) catheter ablation may not be sufficient for long-standing persistent atrial fibrillation (L-PeAF), it is not clear which ablation strategy is beneficial in addition to CPVI. We sought to investigate whether additional complex fractionated atrial electrogram (CFAE)-guided ablation improves clinical outcomes in L-PeAF patients who exhibit continuous atrial fibrillation (AF) after CPVI and linear ablation (Line).

METHODS AND RESULTS

This study enrolled 137 L-PeAF patients (71.4% male, 61.6±10.9 years old) who underwent radiofrequency catheter ablation. We conducted CPVI+Line based on the Dallas lesion set (posterior box+anterior line) after baseline CFAE mapping in all patients. If AF was defragmented (terminated or changed to atrial tachycardia), the procedure was stopped (AF-Defrag group, n=29). If AF was maintained after CPVI+Line, we mapped the CFAE again and randomly assigned the patient to the CPVI+Line group (n=54) or the additional CFAE ablation group (CPVI+Line+CFAE group, n=54). L-PeAF was defragmented during CPVI+Line in 21.2% of patients (29/137, AF-Defrag group). The mean CFAE cycle length was prolonged (P<0.001), and CFAE area (CFAE cycle length <120 milliseconds) was reduced (P<0.001) after CPVI+Line in the remaining patients. Procedure time was longer in the CPVI+Line+CFAE group than the CPVI+Line group (P=0.023), but procedure-related complication rates did not vary. During 22.3±13.2 months of follow-up, the clinical recurrence rates were 17.2% in the AF-Defrag group, 18.5% in the CPVI+Line group, and 32.1% in the CPVI+Line+CFAE group (log rank, P=0.166).

CONCLUSIONS

Although CPVI+Line reduces and localizes CFAE area, additional CFAE ablation after CPVI+Line does not improve the clinical outcomes of catheter ablation in patients with L-PeAF.

背景

尽管环肺静脉隔离（CPVI）导管消融术对于长期持续性房颤（L-PeAF）可能并不足够，但尚不清楚除CPVI之外哪种消融策略有益。我们旨在研究在CPVI和线性消融（Line）后仍表现为持续性房颤（AF）的L-PeAF患者中，额外的碎裂心房电图（CFAE）引导下消融是否能改善临床结局。

方法与结果

本研究纳入了137例行射频导管消融的L-PeAF患者（男性占71.4%，年龄61.6±10.9岁）。所有患者在基线CFAE标测后，基于达拉斯消融线（后盒+前线）进行CPVI+Line消融。如果房颤解联律（终止或转变为房性心动过速），则停止手术（房颤解联律组，n = 29）。如果在CPVI+Line后房颤仍持续，我们再次进行CFAE标测，并将患者随机分配至CPVI+Line组（n = 54）或额外CFAE消融组（CPVI+Line+CFAE组，n = 54）。21.2%的患者（29/137，房颤解联律组）在CPVI+Line过程中房颤解联律。在其余患者中，CPVI+Line后平均CFAE周期长度延长（P<0.001），CFAE面积（CFAE周期长度<120毫秒）减小（P<0.001）。CPVI+Line+CFAE组的手术时间比CPVI+Line组更长（P = 0.023），但手术相关并发症发生率无差异。在22.3±13.2个月的随访期间，房颤解联律组的临床复发率为17.2%，CPVI+Line组为18.5%，CPVI+Line+CFAE组为32.1%（对数秩检验，P = 0.166）。