Schreiber Doreen, Rieger Andreas, Moser Fabian, Kottkamp Hans
Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland.
J Cardiovasc Electrophysiol. 2017 Sep;28(9):971-983. doi: 10.1111/jce.13278. Epub 2017 Jul 5.
The BIFA concept (box isolation of fibrotic areas) supplementing pulmonary vein isolation (PVI) was implemented in atrial fibrillation (AF) patients with fibrotic atrial cardiomyopathy (FACM) to improve catheter ablation outcomes.
Ninety-two patients with FACM underwent PVI + BIFA. We investigated patient characteristics (58 persistent/34 paroxysmal, 68 ± 8 years, LA 44 ± 7 mm, CHA DS -VASc 2.6 ± 1.3, FACM I: 15.2%, II: 53.3%, III: 26.1%, IV: 5.4%), periprocedural data concerning fibrosis extent/distribution, and their impact on outcome. Based on severe fibrosis areas (SFAs) of 13.5 ± 13.9 cm detected by voltage mapping, 1.4 ± 0.5 boxes (n = 1-3, 2.2-35.3 cm ) were applied in the left atrium. With higher grade FACM, SFAs increased and maximum voltage decreased (I/IV: 6.29/3.18 mV). Anterior (ant.) SFAs were found to be more common and larger than posterior (post.) SFAs (58.3% vs. 42.6%, ant. 8.0 ± 8.0 vs. post. 4.7 ± 6.8 cm ). In 40 of 92 (43%) patients, both atrial walls were affected with rare cases of solely post. fibrosis (6 of 92, 6.6%). Women (39 of 92, 42%) showed FACM III+IV more often than men (P = 0.022) and can still present paroxysmal while persistent males are more likely to have FACM I-II. Single and multiple procedure (1.2/patient) success was 69% and 83% after 16 ± 8 months with an unfavorable impact of large SFA size, both-sided fibrosis and reduced maximum voltage, independently of patient characteristics and AF type.
FACM patients are a challenging AF subgroup for catheter ablation. Women seem to show FACM III+IV more often than men. The distribution of left atrial fibrosis is variable but more pronounced anteriorly. Atrial disease is characterized by SFA size but also maximum voltage reduction, both with implications on ablation outcome. Using BIFA, success rates of patients without fibrosis can be approached but are limited in FACM III+IV.
在患有纤维化心房心肌病（FACM）的心房颤动（AF）患者中实施了补充肺静脉隔离（PVI）的BIFA概念（纤维化区域盒式隔离），以改善导管消融效果。
92例FACM患者接受了PVI + BIFA。我们调查了患者特征（58例持续性/34例阵发性，68±8岁，左心房44±7mm，CHA₂DS -VASc 2.6±1.3，FACM I：15.2%，II：53.3%，III：26.1%，IV：5.4%）、关于纤维化程度/分布的围手术期数据及其对结果的影响。根据通过电压标测检测到的13.5±13.9cm²的严重纤维化区域（SFA），在左心房应用了1.4±0.5个盒式区域（n = 1 - 3，2.2 - 35.3cm²）。随着FACM分级升高，SFA增加且最大电压降低（I/IV：6.29/3.18mV）。发现前壁SFA比后壁SFA更常见且更大（58.3%对42.6%，前壁8.0±8.0对后壁4.7±6.8cm²）。92例患者中有40例（43%）双侧心房壁均受累，仅后壁纤维化的情况罕见（92例中有6例，6.6%）。女性（92例中有39例，42%）比男性更常出现FACM III + IV（P = 0.022），且仍可表现为阵发性，而持续性房颤的男性更可能患有FACM I - II。单次和多次手术（每位患者1.2次）在16±8个月后的成功率分别为69%和83%，大尺寸SFA、双侧纤维化和最大电压降低对结果有不利影响，且与患者特征和房颤类型无关。
FACM患者是导管消融具有挑战性的房颤亚组。女性似乎比男性更常出现FACM III + IV。左心房纤维化的分布是可变的，但在前壁更明显。心房疾病的特征在于SFA大小以及最大电压降低，两者均对消融结果有影响。使用BIFA，可以接近无纤维化患者的成功率，但在FACM III + IV中有限。
