Romero Jorge, Gianni Carola, Natale Andrea, Di Biase Luigi
Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA.
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA.
Curr Treat Options Cardiovasc Med. 2017 May;19(5):35. doi: 10.1007/s11936-017-0534-6.
Special attention must be paid to detect, diagnose, and optimize management of reversible or treatable causes of long-standing persistent atrial fibrillation (LSPAF) such as obesity, obstructive sleep apnea (OSA), hypertension, hypo or hyperthyroidism, inflammatory and infectious diseases, and stress. Though, we strongly believe that the role of the pulmonary veins (PVs) is more pronounced in paroxysmal atrial fibrillation (AF) than in persistent AF, performing an adequate pulmonary vein isolation is still key in LSPAF. Patients with LSPAF will frequently require a more aggressive mapping and ablative approach. We do not encourage the use of empiric lines or complex fractionated atrial electrograms. Ablation of sites associated with non-PV triggers such as the entire posterior wall, the roof, the anterior part of the left atrium septum, left atrial appendage (LAA), the CS and SVC has been shown to improve the freedom from AF at follow-up when combined with PVs isolation. During the isoproterenol challenge, non-PV triggers are detected in most patients with AF. Mapping non-PV triggers is guided by multiple catheters positioned along both the right and left atriums: a 10-pole circular mapping catheter in the left superior PV recording the far-field LAA activity, the ablation catheter in the right superior PV that records the far-field interatrial septum and a 20-pole catheter with electrodes spanning from the SVC to the CS. With this simple catheter setup, when focal ectopic atrial activity is observed (a single ectopic beat is enough) their activation sequence is compared to that of sinus rhythm, allowing to quickly identify their area of origin. For significant non-PV triggers (repetitive isolated beats, focal atrial tachycardias or beats triggering AF/atrial flutter, a more detailed activation mapping is performed in the area of origin. They are subsequently targeted with focal ablation, exception being the triggers originating from the SVC, LAA or CS, in which cases complete isolation of these structures is the ablation strategy of choice. We truly believe the LAA deserves special consideration when managing patients with persistent AF and LSPAF.
必须特别注意检测、诊断和优化对长期持续性房颤（LSPAF）可逆或可治疗病因的管理，如肥胖、阻塞性睡眠呼吸暂停（OSA）、高血压、甲状腺功能减退或亢进、炎症和感染性疾病以及压力。尽管如此，我们坚信肺静脉（PVs）在阵发性房颤（AF）中的作用比在持续性房颤中更为显著，但在LSPAF中进行充分的肺静脉隔离仍然是关键。LSPAF患者通常需要更积极的标测和消融方法。我们不鼓励使用经验性线路或复杂碎裂心房电图。与非肺静脉触发灶相关部位的消融，如整个后壁、房顶、左心房间隔前部、左心耳（LAA）、冠状窦（CS）和上腔静脉（SVC），已显示与肺静脉隔离联合使用时，可在随访中提高无房颤率。在异丙肾上腺素激发试验期间，大多数房颤患者可检测到非肺静脉触发灶。非肺静脉触发灶的标测由沿左右心房放置的多个导管引导：左上肺静脉内的10极环形标测导管记录远场左心耳活动，右上肺静脉内的消融导管记录远场房间隔，以及一个20极导管，其电极从SVC延伸至CS。通过这种简单的导管设置，当观察到局灶性异位心房活动（单个异位搏动就足够）时，将其激动顺序与窦性心律的激动顺序进行比较，从而快速确定其起源部位。对于显著的非肺静脉触发灶（重复性孤立搏动、局灶性房性心动过速或触发房颤/房扑的搏动），在起源部位进行更详细的激动标测。随后对其进行局灶性消融，但起源于SVC、LAA或CS的触发灶除外，在这些情况下，这些结构的完全隔离是首选的消融策略。我们坚信，在管理持续性房颤和LSPAF患者时，左心耳值得特别关注。
