Emory University School of Medicine, Atlanta, Georgia.
Cardiology Division, Section of Cardiac Electrophysiology, Emory University School of Medicine, Atlanta, Georgia.
J Cardiovasc Electrophysiol. 2020 Jun;31(6):1270-1276. doi: 10.1111/jce.14454. Epub 2020 Apr 6.
Outcomes of catheter ablation for persistent atrial fibrillation (PeAF) are suboptimal. The convergent procedure (CP) may offer improved efficacy by combining endocardial and epicardial ablation.
We reviewed 113 consecutive patients undergoing the CP at our institution. The cohort was divided into two groups based on the presence (n = 92) or absence (n = 21) of continuous rhythm monitoring (CM) following the CP. Outcomes were reported in two ways. First, using a conventional definition of any atrial fibrillation/atrial tachycardia (AF/AT) recurrence lasting >30 seconds, after a 90 day blanking period. Second, by determining AF/AT burden at relevant time points in the group with CM.
Across the entire cohort, 88% had either persistent or long-standing persistent AF, mean duration of AF diagnosis before the CP was 5.1 ± 4.6 years, 45% had undergone at least one prior AF ablation, 31% had impaired left ventricle ejection fraction and 62% met criteria for moderate or severe left atrial enlargement. Mean duration of follow-up after the CP was 501 ± 355 days. In the entire cohort, survival free from any AF/AT episode >30 seconds at 12 months after the blanking period was 53%. However, among those in the CM group who experienced recurrences, mean burden of AF/AT was generally very low (<5%) and remained stable over the duration of follow-up. Ten patients (9%) required elective cardioversion outside the 90 day blanking period, 11 patients (9.7%) underwent repeat ablation at a mean of 229 ± 178 days post-CP and 64% were off AADs at the last follow-up. Procedural complications decreased significantly following the transition from transdiaphragmatic to sub-xiphoid surgical access: 23% versus 3.8% (P = .005) CONCLUSIONS: In a large, consecutive series of patients with predominantly PeAF, the CP was capable of reducing AF burden to very low levels (generally <5%), which appeared durable over time. Complication rates associated with the CP decreased significantly with the transition from transdiaphragmatic to sub-xiphoid surgical access. Future trials will be necessary to determine which patients are most likely to benefit from the convergent approach.
导管消融治疗持续性心房颤动（PeAF）的效果并不理想。汇聚程序（CP）通过结合心内膜和心外膜消融可能会提高疗效。
我们回顾了在我院接受 CP 的 113 例连续患者。根据 CP 后是否存在（n=92）或不存在（n=21）连续节律监测（CM），将队列分为两组。结果以两种方式报告。首先，使用传统定义，即在 90 天空白期后，任何持续时间超过 30 秒的心房颤动/房性心动过速（AF/AT）复发。其次，通过确定 CM 组中相关时间点的 AF/AT 负担。
整个队列中，88%的患者为持续性或长程持续性 AF，CP 前 AF 诊断的平均持续时间为 5.1±4.6 年，45%的患者至少接受过一次 AF 消融，31%的患者左心室射血分数受损，62%符合中度或重度左心房扩大标准。CP 后平均随访时间为 501±355 天。在整个队列中，空白期后 12 个月无任何 AF/AT 发作>30 秒的生存率为 53%。然而，在 CM 组中经历复发的患者中，AF/AT 的平均负担通常非常低（<5%），并且在随访期间保持稳定。10 名患者（9%）在 90 天空白期外需要择期电复律，11 名患者（9.7%）在 CP 后平均 229±178 天再次消融，64%的患者在最后一次随访时停用 AAD。从经膈到剑突下手术入路的转变显著降低了手术并发症发生率：23%对 3.8%（P=0.005）。
在一个由患有主要持续性 AF 的大量连续患者组成的系列中，CP 能够将 AF 负担降低到非常低的水平（通常<5%），并且随着时间的推移似乎是持久的。CP 相关并发症发生率随着从经膈到剑突下手术入路的转变显著降低。未来的试验将有必要确定哪些患者最有可能从汇聚方法中受益。
