Szilágyi Judit, Marcus Gregory M, Badhwar Nitish, Lee Byron K, Lee Randall J, Vedantham Vasanth, Tseng Zian H, Walters Tomos, Scheinman Melvin, Olgin Jeffrey, Gerstenfeld Edward P
Section of Cardiac Electrophysiology and Arrhythmia Service, Division of Cardiology, University of California, San Francisco, CA, USA.
J Cardiovasc Electrophysiol. 2017 Jul;28(7):754-761. doi: 10.1111/jce.13230. Epub 2017 Jun 23.
The cornerstone of atrial fibrillation (AF) ablation is isolation of the pulmonary veins (PVs). Patients with recurrent AF undergoing repeat ablation usually have PV reconnection (PVr). The ablation strategy and outcome of patients undergoing repeat ablation who have persistent isolation of all PVs (PVi) at the time of repeat ablation is unknown.
We studied consecutive patients with recurrent AF undergoing repeat ablation and compared patients with PVi to those with PVr. One hundred fifty-two patients underwent repeat ablation, and of these, 25 patients (16.4%) had PVi. Patients with PVi underwent ablation targeting any isoproterenol induced AF triggers, atrial substrate, or inducible atrial tachycardias or flutters. Patients with PVi compared to PVr were more likely to have a history of persistent AF (64% vs. 26%; P < 0.0001), obesity (BMI 30.4 vs. 28.2; P = 0.05), and prior use of contact force sensing catheters (28% vs. 0.8%, P < 0.0001). After a mean follow-up of 19 ± 15 months, 56% of PVi patients remained in sinus rhythm compared to 76.3% of PVr patients (P = 0.036). In a multivariable model, PVi patients and those with cardiomyopathy had a higher risk of recurrent atrial tachyarrhythmias (HR = 3.6 95%, CI 1.6-8.3, P = 0.002 and HR = 6.2, 95% CI 2.3-16.3, P < 0.0001, respectively).
In patients who have all PVs isolated at the time of the redo AF ablation, a strategy of targeting non-PV AF triggers and inducible flutters can still lead to AF freedom in more than half of patients. Patients with PVr, however, have a better long-term outcome.
房颤（AF）消融的基石是肺静脉（PVs）隔离。接受再次消融的复发性房颤患者通常存在肺静脉重新连接（PVr）。再次消融时所有肺静脉均保持隔离（PVi）的接受再次消融患者的消融策略和结果尚不清楚。
我们研究了连续接受再次消融的复发性房颤患者，并将PVi患者与PVr患者进行比较。152例患者接受了再次消融，其中25例（16.4%）有PVi。PVi患者接受针对任何异丙肾上腺素诱发的房颤触发因素、心房基质或可诱发的房性心动过速或扑动的消融。与PVr患者相比，PVi患者更可能有持续性房颤病史（64%对26%；P<0.0001）、肥胖（BMI 30.4对28.2；P=0.05）以及既往使用接触力传感导管（28%对0.8%，P<0.0001）。平均随访19±15个月后，56%的PVi患者维持窦性心律，而PVr患者为76.3%（P=0.036）。在多变量模型中，PVi患者和患有心肌病的患者发生复发性房性快速性心律失常的风险更高（HR=3.6，95%CI 1.6 - 8.3，P=0.002和HR=6.2，95%CI 2.3 - 16.3，P<0.0001）。
在再次房颤消融时所有肺静脉均已隔离的患者中，针对非肺静脉房颤触发因素和可诱发扑动的策略仍可使超过半数患者实现房颤缓解。然而，PVr患者的长期预后更好。
