Comprehensive Arrhythmia Research and Management Center, University of Utah, Salt Lake City (F.F., T.Y., M.K., E.G.K., A.K.M., N.F.M.).
Clinic for Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt/Saale, Germany (F.F.).
Circ Arrhythm Electrophysiol. 2019 Aug;12(8):e007174. doi: 10.1161/CIRCEP.119.007174. Epub 2019 Aug 19.
Macroreentrant atrial tachycardia (AT) accounts for 40% to 60% of recurrent atrial arrhythmias after atrial fibrillation (AF) ablation. To describe late gadolinium enhancement magnetic resonance imaging (LGE-MRI)-detected scar-based dechanneling as new ablation strategy to treat ATs after AF ablation.
Data from 102 patients who underwent initial AF ablation and repeat ablation for recurrent atrial arrhythmia within 1-year follow-up were analyzed. All patients underwent LGE-MRI before initial and repeat ablation. Depending on the recurrent rhythm, patients with AF and AT recurrence were assigned to group 1 or 2, respectively. Group 1 underwent fibrosis homogenization as second procedure. Group 2 underwent LGE-MRI-detected scar-based dechanneling. Both groups underwent reisolation of pulmonary veins if necessary.
Forty-six patients (45%) presented with AF, and 56 patients (55%) presented with AT recurrence during follow-up after initial ablation. In the first 25 patients from group 2, the AT was electroanatomically mapped, and a critical isthmus was defined. It was found that those isthmi were located in the regions with nontransmural scarring detected by LGE-MRI. In the last 31 patients from group 2, an empirical LGE-MRI-based dechanneling was performed solely based on the LGE-MRI results. During 1-year follow-up after second ablation, 67% patients in group 1 and 64% patients in group 2 were free from recurrence (log-rank, P=1.000). In group 2, 64% in the electroanatomically guided and 65% in the LGE-MRI dechanneling group were free from recurrence (log-rank, P=0.900).
Anatomic targeting of LGE-MRI-detected gaps and superficial atrial scar is feasible and effective to treat recurrent arrhythmias post-AF ablation. Homogenization of existing scar is the appropriate treatment for recurrent AF, whereas dechanneling of existing isthmi seems the right approach for patients recurring with AT.
大折返性房性心动过速（AT）占房颤（AF）消融后复发性房性心律失常的 40%至 60%。描述基于晚期钆增强磁共振成像（LGE-MRI）检测到的瘢痕脱道化作为治疗 AF 消融后 AT 的新消融策略。
分析了 102 例在 1 年随访期间因复发性房性心律失常而接受初始 AF 消融和重复消融的患者的数据。所有患者在初始和重复消融前均行 LGE-MRI 检查。根据复发性节律，将 AF 和 AT 复发的患者分别归入组 1 或组 2。组 1 行纤维化均化作为第二术式。组 2 行 LGE-MRI 检测到的基于瘢痕的脱道化。如果有必要，两组均行肺静脉再隔离。
46 例（45%）患者表现为 AF，56 例（55%）患者在初始消融后随访期间表现为 AT 复发。在组 2 的前 25 例患者中，对 AT 进行了电解剖标测，并定义了一个关键峡部。结果发现，这些峡部位于 LGE-MRI 检测到的非透壁瘢痕区域。在组 2 的最后 31 例患者中，单纯根据 LGE-MRI 结果进行了经验性 LGE-MRI 脱道化。在第二次消融后 1 年的随访中，组 1 中 67%的患者和组 2 中 64%的患者无复发（对数秩检验，P=1.000）。在组 2 中，电解剖引导组中 64%的患者和 LGE-MRI 脱道化组中 65%的患者无复发（对数秩检验，P=0.900）。
基于 LGE-MRI 检测到的缝隙和表浅心房瘢痕的解剖靶点治疗 AF 消融后复发性心律失常是可行和有效的。现有瘢痕的均化是治疗复发性 AF 的适当方法，而现有峡部的脱道化似乎是治疗 AT 复发的正确方法。
