Voskoboinik Aleksandr, Moskovitch Jeremy T, Harel Nadav, Sanders Prashanthan, Kistler Peter M, Kalman Jonathan M
Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Baker IDI Heart & Diabetes Institute, Melbourne, Australia; Heart Centre, Alfred Hospital, Melbourne, Australia.
Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.
Heart Rhythm. 2017 May;14(5):661-667. doi: 10.1016/j.hrthm.2017.01.003.
Early studies demonstrated relatively low success rates for pulmonary vein isolation (PVI) alone in patients with persistent atrial fibrillation (PeAF). However, the advent of new technologies and the observation that additional substrate ablation does not improve outcomes have created a new focus on PVI alone for treatment of PeAF.
The purpose of this study was to systematically review the recent medical literature to determine current medium-term outcomes when a PVI-only approach is used for PeAF.
An electronic database search (MEDLINE, Embase, Web of Science, PubMed, Cochrane) was performed in August 2016. Only studies of PeAF patients undergoing a "PVI only" ablation strategy using contemporary radiofrequency (RF) technology or second-generation cryoballoon (CB2) were included. A random-effects model was used to assess the primary outcome of pooled single-procedure 12-month arrhythmia-free survival. Predictors of recurrence were also examined and a meta-analysis performed if ≥4 studies examined the parameter.
Fourteen studies of 956 patients, of whom 45.2% underwent PVI only with RF and 54.8% with CB2, were included. Pooled single-procedure 12-month arrhythmia-free survival was 66.7% (95% confidence interval [CI] 60.8%-72.2%), with the majority of patients (80.5%) off antiarrhythmic drugs. Complication rates were very low, with cardiac tamponade occurring in 5 patients (0.6%) and persistent phrenic nerve palsy in 5 CB2 patients (0.9% of CB2). Blanking period recurrence (hazard ratio 4.68, 95% CI 1.70-12.9) was the only significant predictor of recurrence.
A PVI-only strategy in PeAF patients with a low prevalence of structural heart disease using contemporary technology yields excellent outcomes comparable to those for paroxysmal AF ablation.
早期研究表明，对于持续性心房颤动（PeAF）患者，单独进行肺静脉隔离（PVI）的成功率相对较低。然而，新技术的出现以及额外的基质消融并不能改善预后这一观察结果，使得人们将新的关注点放在了单独使用PVI治疗PeAF上。
本研究的目的是系统回顾近期医学文献，以确定仅采用PVI方法治疗PeAF时的当前中期预后。
2016年8月进行了电子数据库检索（MEDLINE、Embase、Web of Science、PubMed、Cochrane）。仅纳入了使用当代射频（RF）技术或第二代冷冻球囊（CB2）进行“仅PVI”消融策略的PeAF患者的研究。采用随机效应模型评估汇总的单次手术12个月无心律失常生存率这一主要结局。还检查了复发的预测因素，若≥4项研究对该参数进行了检查，则进行荟萃分析。
纳入了对956例患者的14项研究；其中，45.2%的患者仅接受了RF-PVI，54.8%的患者接受了CB2-PVI。汇总的单次手术12个月无心律失常生存率为66.7%（95%置信区间[CI] 60.8%-72.2%），大多数患者（80.5%）停用了抗心律失常药物。并发症发生率非常低，5例患者（0.6%）发生心脏压塞，5例CB2患者（占CB2患者的0.9%）发生持续性膈神经麻痹。空白期复发（风险比4.68，95% CI 1.70-12.9）是复发的唯一显著预测因素。
对于结构性心脏病患病率较低的PeAF患者，采用当代技术的仅PVI策略可产生与阵发性房颤消融相当的优异预后。
