Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute: IHU LIRYC ANR-10-IAHU-04 and Equipex MUSIC ANR-11-EQPX-0030, Bordeaux, France.
London Cardiac Institute, London, Ontario, Canada.
J Cardiovasc Electrophysiol. 2018 Feb;29(2):274-283. doi: 10.1111/jce.13377. Epub 2017 Nov 22.
It is largely believed that atrial tachycardias (ATs) encountered during ablation of persistent atrial fibrillation (PsAF) are a byproduct of ablative lesions. We aimed to explore the alternative hypothesis that they may be a priori drivers of AF remaining masked until other AF sources are reduced or eliminated.
Radiofrequency ablation of fibrillatory drivers mapped by electrocardiographic imaging (ECGI; ECVUE™, Cardioinsight Technologies, Cleveland, OH, USA) terminated PsAF in 198 (73%) out of 270 patients (61 ± 10 years, 9 ± 9 m). Two hundred and six ATs in 158 patients were subsequently mapped. Their anatomic relationship to the fibrillatory drivers prospectively identified by ECGI was then established. There were 26 (13%), 52 (25%), and 128 (62%) focal, localized, and macrore-entrant ATs, respectively. In focal/localized re-entrant ATs, 64 (82%) were terminated within an AF-driver region, in which 26 (81%) among 32 focal/localized ATs analyzed with 3-D-mapping system merged to driver map occurred from AF-driver regions in 1.0 ± 1.0 cm distance from the driver core. Importantly, there was no attempt at ablation of the associated AF-driver region in 25 of 64 (39%) of focal/localized re-entrant ATs. The sites of ATs origin generally had low-voltage, fractionated, and long-duration electrograms in AF. All but two focal/localized re-entrant ATs were successfully ablated.
The majority of post-AF-ablation focal and localized re-entrant ATs originate from the region of prospectively established AF-driver regions. A third of these are localized to regions not subsequently submitted to ablation. These data suggest that many ATs exist, although not necessarily manifest independently, prior to ablation. They may have a role in the maintenance of PsAF in these individuals.
人们普遍认为，在持续性心房颤动（PsAF）消融过程中遇到的房性心动过速（ATs）是消融损伤的副产物。我们旨在探索另一种假设，即它们可能是 AF 潜在的驱动因素，在其他 AF 源减少或消除之前，这些因素一直被掩盖。
通过心电图成像（ECGI；ECVUE™，Cardioinsight Technologies，克利夫兰，俄亥俄州，美国）对电描记图驱动的心房颤动进行射频消融，198 例（73%）270 例患者（61±10 岁，9±9m）的 PsAF 得以终止。随后对 158 例患者中的 206 例 AT 进行了标测。然后确定了它们与 ECGI 前瞻性识别的电描记图驱动之间的解剖关系。分别有 26（13%）、52（25%）和 128（62%）局灶性、局限性和大折返性 AT。在局灶性/局限性折返性 AT 中，64（82%）在 AF 驱动区域内终止，其中 32 个局灶性/局限性 AT 中有 26 个（81%）用 3D 标测系统分析，与驱动图合并，发生于距离驱动核心 1.0±1.0cm 的驱动区域。重要的是，在 64 例（39%）局灶性/局限性折返性 AT 中，有 25 例未尝试消融相关的 AF 驱动区域。AT 起源部位在 AF 时通常具有低电压、碎裂和长持续时间的电图。除了两个局灶性/局限性折返性 AT 之外，所有的都被成功消融。
大多数房性心动过速（ATs）起源于前瞻性确定的 AF 驱动区域。其中三分之一局限于未随后接受消融的区域。这些数据表明，在消融之前，许多 ATs 存在，尽管不一定独立存在。它们可能在这些患者的 PsAF 维持中起作用。
