胸腔镜与导管消融治疗心房颤动：FAST 随机试验的长期随访。

Thoracoscopic vs. catheter ablation for atrial fibrillation: long-term follow-up of the FAST randomized trial.

机构信息

Department of Cardiovascular Surgery, Hospital Clínic, University of Barcelona, Villarroel 170, Barcelona, Spain.

Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.

出版信息

Europace. 2019 May 1;21(5):746-753. doi: 10.1093/europace/euy325.

AIMS

Our objectives were to compare effectiveness and long-term prognosis after epicardial thoracoscopic atrial fibrillation (AF) ablation vs. endocardial catheter ablation, in patients with prior failed catheter ablation or high risk of failure.

METHODS AND RESULTS

Patients were randomized to thoracoscopic or catheter ablation, consisting of pulmonary vein isolation with optional additional lines (2007-2010). Patients were reassessed in 2016/2017, and those without documented AF recurrence underwent 7-day ambulatory electrocardiography. The primary rhythm outcome was recurrence of any atrial arrhythmia lasting >30 s. The primary clinical endpoint was a composite of death, myocardial infarction, or cerebrovascular event, analysed with adjusted Cox proportional hazard ratios (HRs). One hundred and 24 patients were randomized with 34% persistent AF and mean age 56 years. Arrhythmia recurrence was common at mean follow-up of 7.0 years, but substantially lower with thoracoscopic ablation: 34/61 (56%) compared with 55/63 (87%) with catheter ablation [adjusted HR 0.40, 95% confidence interval (CI) 0.25-0.64; P < 0.001]. Additional ablation procedures were performed in 8 patients (13%) compared with 31 (49%), respectively (P < 0.001). Eleven patients (19%) were on anti-arrhythmic drugs at end of follow-up with thoracoscopy vs. 24 (39%) with catheter ablation (P = 0.012). There was no difference in the composite clinical outcome: 9 patients (15%) in the thoracoscopy arm vs. 10 patients (16%) with catheter ablation (HR 1.11, 95% CI 0.40-3.10; P = 0.84). Pacemaker implantation was required in 6 patients (10%) undergoing thoracoscopy and 3 (5%) in the catheter group (P = 0.27).

CONCLUSION

Thoracoscopic AF ablation demonstrated more consistent maintenance of sinus rhythm than catheter ablation, with similar long-term clinical event rates.

目的

我们的目的是比较经胸心外膜与心内导管消融治疗既往消融失败或消融失败高风险患者心房颤动（房颤）的有效性和长期预后。

方法和结果

患者被随机分为经胸心外膜或导管消融组，消融策略包括肺静脉隔离及（或）其他可选线路（2007-2010 年）。2016/2017 年对患者进行了重新评估，对于无记录的房颤复发患者，进行 7 天动态心电图检查。主要节律转归是任何持续 >30s 的房性心律失常的复发。主要临床终点是死亡、心肌梗死或脑血管事件的复合终点，采用校正 Cox 比例风险比（HR）进行分析。102 例患者随机分为经胸心外膜消融组（n=61）和心内导管消融组（n=63），两组分别有 34%的持续性房颤和平均年龄 56 岁。平均随访 7.0 年后，心律失常复发较为常见，但经胸心外膜消融组显著低于心内导管消融组：61 例患者中有 34 例（56%）复发，63 例患者中有 55 例（87%）复发[校正 HR 0.40，95%置信区间（CI）0.25-0.64；P<0.001]。分别有 8 例（13%）和 31 例（49%）患者进行了额外的消融治疗（P<0.001）。11 例（19%）患者在随访结束时服用抗心律失常药物，其中经胸心外膜消融组 9 例（15%），心内导管消融组 24 例（39%）（P=0.012）。复合临床结局无差异：心外膜消融组 9 例（15%），心内导管消融组 10 例（16%）（HR 1.11，95%CI 0.40-3.10；P=0.84）。需要植入起搏器的患者，心外膜消融组 6 例（10%），心内导管消融组 3 例（5%）（P=0.27）。