Bordignon Stefano, Perrotta Laura, Dugo Daniela, Bologna Fabrizio, Nagase Takahiko, Fuernkranz Alexander, Chun K R Julian, Schmidt Boris
Cardioangiologisches Centrum Bethanien, Agaplesion Markus-Krankenhaus, Wilhelm-Epstein Frankfurt/M, Germany.
J Cardiovasc Electrophysiol. 2017 Sep;28(9):1006-1014. doi: 10.1111/jce.13276. Epub 2017 Jul 26.
The ablation strategy for atrial fibrillation (AF) despite pulmonary vein isolation (PVI) is controversial. Left atrial appendage isolation (LAAI) may contribute to improve outcome. We describe an ablation approach ("Maze-like"-LAAI) that (1) modifies the underlying LA substrate by linear ablation (2) eliminates the LAA as a putative AF trigger site and (3) incorporates an unambiguous procedural endpoint. The role of LAA closure (LAAC) after LAAI was investigated.
Patients with atrial tachyarrhythmias nonresponsive to PVI underwent a LAAI ablation procedure. LAAI was achieved by combining (a) an anterior line, (b) a LA roof line and (c) a mitral isthmus line. Patients continued oral anticoagulation (OAC) therapy or underwent LAAC ≥6 weeks after LAAI.
Maze-like LAAI was attempted in our center in 107 of 3,611 AF ablation procedures (2.9%) and achieved in 88 of 107 patients (82%). In 8 of 107 (7%) patients cardiac tamponade occurred, all managed conservatively. During follow-up sinus rhythm was established in 65% at 1 year. After LAAI, 45 patients remained on OAC and 40 underwent LAAC. In both groups 1 patient experienced a bleeding complication. Thromboembolism exclusively occurred in the OAC group in 3 (7%) patients.
LAA isolation by Maze-like substrate modification may be considered a viable option for PVI non-responders. It offers a reproducible approach with an unambiguous procedural endpoint and leads to a favorable clinical outcome. However, extensive LA ablation increased the risk of tamponade. Consecutive LAA occlusion may offer a nonpharmacologic strategy to overcome the high thromboembolic risk associated with absent mechanical LAA contraction.
尽管进行了肺静脉隔离（PVI），房颤（AF）的消融策略仍存在争议。左心耳隔离（LAAI）可能有助于改善治疗结果。我们描述了一种消融方法（“迷宫样”-LAAI），该方法（1）通过线性消融改变潜在的左心房基质，（2）消除左心耳作为假定的房颤触发位点，（3）纳入明确的手术终点。研究了LAAI后左心耳封堵（LAAC）的作用。
对PVI无反应的房性快速心律失常患者进行LAAI消融手术。通过联合（a）前壁线、（b）左心房顶部线和（c）二尖瓣峡部线实现LAAI。患者在LAAI后继续口服抗凝（OAC）治疗或在≥6周后接受LAAC。
在我们中心，3611例房颤消融手术中有107例（2.9%）尝试了迷宫样LAAI，其中107例患者中有88例（82%）成功。107例患者中有8例（7%）发生心脏压塞，均经保守治疗。随访期间，1年时65%的患者恢复窦性心律。LAAI后，45例患者继续接受OAC治疗，40例患者接受LAAC。两组均有1例患者发生出血并发症。血栓栓塞仅发生在OAC组的3例（7%）患者中。
对于PVI无反应者，通过迷宫样基质改良进行LAA隔离可能是一种可行的选择。它提供了一种可重复的方法，具有明确的手术终点，并导致良好的临床结果。然而，广泛的左心房消融增加了心脏压塞的风险。连续的LAA封堵可能提供一种非药物策略，以克服与机械性LAA收缩缺失相关的高血栓栓塞风险。
