Seitz Julien, Bars Clement, Ferracci Ange, Maluski Alexandre, Penaranda Guillaume, Theodore Guillaume, Faure Jacques, Bremondy Michel, Curel Laurence, Beurtheret Sylvain, Avula Uma M R, Kalifa Jerome, Pisapia Andre
Cardiology Rhythmology Department, Saint Joseph Hospital, Marseille, France.
Cardiology Rhythmology Department, Saint Joseph Hospital, Marseille, France; Cardiology Rhythmology Department, Private Hospital Institute Mutualiste Montsouris, Paris, France.
JACC Clin Electrophysiol. 2016 Nov;2(6):732-742. doi: 10.1016/j.jacep.2016.04.003. Epub 2016 Jun 1.
This study sought to evaluate the impact of a complex fractionated atrial electrogram (CFAE)-guided ablation strategy on atrial fibrillation (AF) dynamics in patients with persistent AF.
It is still unclear whether complete pulmonary vein isolation (PVI) is required or if the ablation of well-delineated pulmonary vein (PV) subregions could achieve similar outcomes in persistent AF.
CFAE-guided ablations were performed in 76 patients (65.2 ± 10 years of age) with persistent AF. In 47 patients, we measured mean PVs and left atrial appendage (LAA) cycle length (CL) values (PV-CL and LAA-CL), before ablation and before AF termination. We defined "active" PVs as PV-CL ≤ LAA-CL, "rapid fires" as PV-CL ≤80% of LAA-CL, and "PV-LAA CL gradient" as a significant CL difference between the 2 regions.
AF termination (sinus rhythm [SR] or atrial tachycardia [AT] conversion) occurred in 92% and SR conversion in 75%. The radiofrequency time for AF termination and total radiofrequency time were 26 ± 25 min and 61.1 ± 21.6 min, respectively. Thirty of 47 patients had active PV (with 19 PV "rapid fires"). Ablation significantly increased median CL, both at PVs and LAA from 188 ms (interquartile range [IQR]: 161 to 210 ms) to 227.5 ms (IQR: 200 to 256 ms) (p < 0.0001) and from 197 ms (IQR: 168 to 220 ms) to 224 ms (IQR: 193 to 250 ms) (p < 0001), respectively. After ablation, PV-LAA CL gradients were withdrawn and all PV "rapid fires" were extinguished (without PVI). After 17.2 ± 10 months of follow-up and 1.61 ± 0.75 procedures, 86.3% and 73% of the patients were free from AF and from any arrhythmia (AF/AT), respectively.
CFAE-guided ablation leads to a large decrease in PV frequency of activation, preceding AF termination. A PV modulation approach, rather than complete PVI, may be preferable for persistent AF.
本研究旨在评估复杂碎裂心房电图（CFAE）引导的消融策略对持续性房颤（AF）患者房颤动态变化的影响。
对于持续性房颤患者，是否需要完全肺静脉隔离（PVI），或者对明确界定的肺静脉（PV）子区域进行消融是否能取得相似的结果，目前仍不清楚。
对76例（年龄65.2±10岁）持续性房颤患者进行CFAE引导的消融。在47例患者中，我们在消融前和房颤终止前测量了平均肺静脉和左心耳（LAA）的周长（CL）值（PV-CL和LAA-CL）。我们将“活跃”肺静脉定义为PV-CL≤LAA-CL，“快速发放”定义为PV-CL≤LAA-CL的80%，“PV-LAA CL梯度”定义为这两个区域之间明显的CL差异。
房颤终止（转为窦性心律[SR]或房性心动过速[AT]）的发生率为92%，转为SR的发生率为75%。房颤终止的射频时间和总射频时间分别为26±25分钟和61.1±21.6分钟。47例患者中有30例存在活跃肺静脉（其中19例肺静脉有“快速发放”）。消融后，肺静脉和左心耳的中位数CL均显著增加，分别从188毫秒（四分位间距[IQR]：161至210毫秒）增至227.5毫秒（IQR：200至256毫秒）（p<0.0001），以及从197毫秒（IQR：168至220毫秒）增至224毫秒（IQR：193至250毫秒）（p<0.0001）。消融后，PV-LAA CL梯度消失，所有肺静脉“快速发放”均消失（未进行PVI）。经过17.2±10个月的随访和1.61±0.75次手术，分别有86.3%和73%的患者无房颤和无任何心律失常（AF/AT）。
CFAE引导的消融在房颤终止前可使肺静脉激活频率大幅降低。对于持续性房颤，采用肺静脉调制方法而非完全PVI可能更为可取。
