St Vincent Medical Group, St Vincent Hospital, Indianapolis, Indiana.
J Cardiovasc Electrophysiol. 2019 Apr;30(4):493-502. doi: 10.1111/jce.13832. Epub 2019 Jan 8.
Focal impulse and rotor modulation (FIRM)-guided ablation has had mixed results of published success, and most studies have had a follow-up for a year or less. We aimed to study a consecutive group of patients followed for at least 1.5 years, subgrouped into those with an initial FIRM ablation and those with a previous, failed ablation who now received a FIRM guided one, to evaluate for success in each group and factors that might affect success.
Of 181 patients, 167 were available for analysis. Group 1 (n = 122) had a first or primary ablation (paroxysmal atrial fibrillation [PAF] 51; persistent atrial fibrillation [PeAF] 71) and group 2 (n = 45) had a redo ablation (PAF 18; PeAF 27). All patients were done under general anesthesia. FIRM mapping was done in the right atrium first and then the left, and only rotors consistently seen on multiple epochs were ablated, using 15 to 30 W. Rotor ablation was discontinued when remapping showed elimination of rotational activity at the site. Wide area catheter ablation was done for pulmonary vein isolation (PVI). Routine follow-up was at 3, 6, and 12 months of the first year, with a Holter monitor at 6 months, and then every 6 months thereafter. Event recorders were given to patients with potential arrhythmic symptoms.
Mean follow-up was 16 months. Nearly 40% of patients had obstructive sleep apnea; mean body mass index was 32; and average left atrial size was 39.7 mm and 46.2 mm for PAF and PeAF patients, respectively. Freedom from atrial arrhythmia recurrence was: in group 1 patients, 82.4% for PAF and 67.6% for PeAF patients; in group 2 patients, 83.3% for PAF, but only 40.7% for PeAF patients. Comparing outcomes for the first 10 patients studied to the next 20 or more done by three operators showed no difference, suggesting no learning curve affecting the ablation results. Furthermore, the univariate analysis did not show any demographic factor to have an independent significance for ablation success or failure. Spontaneous termination during rotor ablation occurred in 76.8% of PAF and 27.6% of PeAF patients but did not affect the long-term outcomes for maintenance of sinus rhythm.
FIRM-guided atrial ablation plus PVI in our patient population resulted in good success from a recurrence of atrial arrhythmias in patients undergoing an initial ablation procedure. For those with persistent AF undergoing a second procedure now using FIRM guidance plus PVI, the results are lower. Further research is needed to define better the appropriate population for FIRM-guided ablation and the degree of ablation needed for success in these patients.
聚焦激动和转子调制（FIRM）引导消融的发表成功率参差不齐，大多数研究的随访时间都在一年或更短。我们旨在研究一组至少随访 1.5 年的连续患者，分为首次 FIRM 消融组和之前失败消融现接受 FIRM 引导消融组，以评估每组的成功率和可能影响成功率的因素。
在 181 名患者中，有 167 名患者可进行分析。第 1 组（n=122）进行了首次或原发性消融（阵发性心房颤动[PAF]51 例；持续性心房颤动[PeAF]71 例），第 2 组（n=45）进行了再次消融（PAF18 例；PeAF27 例）。所有患者均在全身麻醉下进行。首先在右心房进行 FIRM 映射，然后在左心房进行映射，只有在多个时间段内持续观察到的转子才会被消融，使用 15 至 30 瓦。当重新映射显示在该部位消除旋转活动时，转子消融会停止。为了进行肺静脉隔离（PVI），还进行了广泛的导管消融。在第一年的前 3、6 和 12 个月进行常规随访，在第 6 个月进行 Holter 监测，然后每 6 个月进行一次。对于有潜在心律失常症状的患者，会给予事件记录器。
平均随访时间为 16 个月。近 40%的患者患有阻塞性睡眠呼吸暂停；平均体重指数为 32；左心房大小分别为 39.7 毫米和 46.2 毫米，用于 PAF 和 PeAF 患者。第 1 组患者中无房性心律失常复发的比例为：PAF 患者为 82.4%，PeAF 患者为 67.6%；第 2 组患者中 PAF 患者为 83.3%，但 PeAF 患者仅为 40.7%。将前 10 名接受研究的患者与另外 20 名或更多名由三名操作者进行的患者的结果进行比较，结果没有差异，这表明消融结果没有学习曲线的影响。此外，单因素分析未发现任何人口统计学因素对消融成功或失败有独立意义。在 PAF 患者中，76.8%和 PeAF 患者中 27.6%的患者在转子消融过程中出现自发性终止，但这并未影响窦性节律维持的长期结果。
在我们的患者人群中，使用 FIRM 引导的心房消融加 PVI 对首次消融治疗的患者的房性心律失常复发有良好的效果。对于那些正在接受第二次手术且现在使用 FIRM 引导加 PVI 的持续性房颤患者，结果较低。需要进一步研究以更好地确定 FIRM 引导消融的合适人群以及这些患者成功所需的消融程度。
