Jiang Ruhong, Chen Minglong, Yang Bing, Liu Qiang, Zhang Zuwen, Zhang Fengxiang, Ju Weizhu, Li Mingfang, Sheng Xia, Sun Yaxun, Zhang Pei, Yu Lu, Chen Shiquan, Zhu Jun, Cheng Hui, Fu Guosheng, Tung Roderick, Jiang Chenyang
Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China.
Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China.
Europace. 2020 Apr 1;22(4):567-575. doi: 10.1093/europace/euz301.
The optimal procedural endpoint to achieve permanent pulmonary vein isolation (PVI) during ablation of atrial fibrillation (AF) remains unknown. We aimed to compare the impact of prolonged waiting periods and adenosine triphosphate (ATP) testing after PVI on long-term freedom from AF.
In total, 538 patients (median age 61 years, 62% male) undergoing first-time radiofrequency ablation for paroxysmal AF were randomized into four groups: Group 1 [PVI (no testing), n = 121], Group 2 (PVI + 30min waiting phase, n = 151), Group 3 (PVI+ATP, n = 131), and Group 4 (PVI + 30min+ATP, n = 135). The primary endpoint was freedom from AF. Repeat mapping to assess for late pulmonary vein (PV) reconnection was performed in patients who remained AF-free for >3 years (n = 46) and in those who had repeat ablation for AF recurrence (n = 82). During initial procedure, acute PV reconnection was observed in 33%, 26%, and 42% of patients in Groups 2, 3, and 4, respectively. At 36 months, no significant differences in freedom from AF recurrence were observed among all four groups (55%, 61%, 50%, and 62% for Groups 1, 2, 3, and 4, respectively; P = 0.258). Late PV reconnection was commonly observed, with a similar incidence between patients with and without AF recurrence (74% vs. 83%; P = 0.224).
Although PVI remains the cornerstone for AF ablation, intraprocedural techniques to assess for PV reconnection did not improve long-term success. Patients without AF recurrence after 3 years exhibited similarly high rates of PV reconnection as those that underwent repeat ablation for AF recurrence. The therapeutic mechanisms of AF ablation may not be solely predicated upon durable PVI.
在心房颤动(AF)消融过程中实现永久性肺静脉隔离(PVI)的最佳手术终点仍不明确。我们旨在比较PVI后延长等待期和三磷酸腺苷(ATP)测试对长期无房颤的影响。
总共538例首次接受阵发性AF射频消融的患者(中位年龄61岁,62%为男性)被随机分为四组:第1组[PVI(无测试),n = 121],第2组(PVI + 30分钟等待期,n = 151),第3组(PVI + ATP,n = 131),第4组(PVI + 30分钟 + ATP,n = 135)。主要终点是无房颤。对无房颤超过3年的患者(n = 46)和因房颤复发接受再次消融的患者(n = 82)进行重复标测以评估晚期肺静脉(PV)重新连接情况。在初始手术过程中,第2组、第3组和第4组分别有33%、26%和42%的患者观察到急性PV重新连接。在36个月时,四组之间在无房颤复发方面未观察到显著差异(第1组、第2组、第3组和第4组分别为55%、61%、50%和62%;P = 0.258)。晚期PV重新连接很常见,房颤复发患者和未复发患者的发生率相似(74%对83%;P = 0.224)。
尽管PVI仍然是AF消融的基石,但术中评估PV重新连接的技术并未提高长期成功率。3年后无房颤复发的患者与因房颤复发接受再次消融的患者相比,PV重新连接率同样很高。AF消融的治疗机制可能不仅仅取决于持久的PVI。