Ramirez F Daniel, Birnie David H, Nair Girish M, Szczotka Agnieszka, Redpath Calum J, Sadek Mouhannad M, Nery Pablo B
Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada.
J Cardiovasc Electrophysiol. 2017 Dec;28(12):1371-1378. doi: 10.1111/jce.13313. Epub 2017 Sep 5.
Targeting localized drivers (electrical rotors or focal impulses) during catheter ablation for atrial fibrillation (AF) has been proposed as a strategy to improve procedural success. However, the strength and quality of the evidence to support this approach is unclear.
Clinical studies reporting efficacy or safety outcomes of driver-guided ablation for AF were identified in Medline, Embase, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, Pubmed, and conference abstracts from major scientific meetings. Random-effects meta-analysis of efficacy outcomes from controlled studies was performed. Thirty-one reports from 30 studies were included: two randomized controlled trials, five nonrandomized controlled studies, and 23 uncontrolled studies. In controlled studies, driver-guided ablation has been associated with higher rates of acute AF termination (RR 2.08, 95% CI 1.43-3.05; P < 0.001) and increased freedom from AF/atrial tachycardia (AT) at ≥1 year (RR 1.34, 95% CI 1.05-1.70; P = 0.02). Similar rates of procedural complications have been reported between ablation strategies. Overall, current data on driver-guided ablation are predominantly from nonrandomized studies with considerable heterogeneity in mapping and ablation strategies used and in clinical outcomes reported.
Pooled data on the efficacy of AF driver-guided catheter ablation suggest increased freedom from AF/AT relative to conventional strategies. However, most studies are nonrandomized and of moderate quality. Though promising data exist, there remains no conclusive evidence for the efficacy of AF driver ablation. Robust data from randomized trials are needed.
在心房颤动（AF）导管消融术中靶向局部驱动因素（电转子或局灶性冲动）已被提议作为提高手术成功率的一种策略。然而，支持这种方法的证据的强度和质量尚不清楚。
在Medline、Embase、Cochrane对照试验中央注册库、Cochrane系统评价数据库、Pubmed以及主要科学会议的会议摘要中，识别报告驱动因素引导的房颤消融术疗效或安全性结果的临床研究。对对照研究的疗效结果进行随机效应荟萃分析。纳入了30项研究的31份报告：两项随机对照试验、五项非随机对照研究和23项非对照研究。在对照研究中，驱动因素引导的消融术与更高的急性房颤终止率相关（RR 2.08，95%CI 1.43 - 3.05；P < 0.001），并且在≥1年时房颤/房性心动过速（AT）复发率降低（RR 1.34，95%CI 1.05 - 1.70；P = 0.02）。两种消融策略报告的手术并发症发生率相似。总体而言，目前关于驱动因素引导消融术的数据主要来自非随机研究，在使用的标测和消融策略以及报告的临床结果方面存在相当大的异质性。
关于房颤驱动因素引导导管消融术疗效的汇总数据表明，与传统策略相比，房颤/房性心动过速复发率降低。然而，大多数研究是非随机的且质量中等。尽管存在有前景的数据，但仍然没有确凿的证据证明房颤驱动因素消融术的疗效。需要来自随机试验的有力数据。
