Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
J Cardiovasc Electrophysiol. 2020 Jul;31(7):1616-1627. doi: 10.1111/jce.14544. Epub 2020 May 22.
During pulmonary vein isolation (PVI), nonisolation after initial encircling of the pulmonary veins (PVs) may be due to gaps in the initial ablation line, or alternatively, earliest PV activation may occur on the intervenous carina and ablation within the wide-area circumferential ablation (WACA) circle is needed to eliminate residual conduction. This study investigated prognostic implications and predictors of gap-related persistent conduction (gap-RPC) and carina-related persistent conduction (carina-RPC) during PVI.
Two hundred fourteen atrial fibrillation (AF) patients (57% paroxysmal, 61% male, mean age 62 ± 9 years) undergoing first contact force-guided radiofrequency PVI were studied. Preprocedural cardiac computed tomography imaging was used to assess left atrial and PV anatomy. PVI was assessed directly after initial WACA circle creation, after a minimum waiting period of 30 minutes, and after adenosine infusion. Persistent conduction was targeted for additional ablation and classified as gap-RPC or carina-RPC, depending on the earliest activation site. The 1-year AF recurrence rate was higher in patients with gap-RPC (47%) compared to patients without gap-RPC (28%; P = .003). No significant difference in 1-year recurrence rate was found between patients with carina-RPC (37%) and patients without carina-RPC (31%; P = .379). Multivariate analyses identified paroxysmal AF and WACA circumference as independent predictors of gap-RPC, whereas carina width and WACA circumference correlated with carina-RPC.
Gap-RPC is associated with increased AF recurrence risk after PVI, whereas carina-RPC does not predict AF recurrence. Moreover, gap-RPC and carina-RPC have different correlates and may thus have different underlying mechanisms.
在肺静脉隔离（PVI）过程中，初始环绕肺静脉（PVs）后出现的非隔离可能是由于初始消融线存在间隙，或者最早的 PV 激活可能发生在静脉间嵴上，需要在大面积环形消融（WACA）圈内部进行消融以消除残留的传导。本研究旨在探讨 PVI 过程中与间隙相关的持续性传导（gap-RPC）和嵴相关持续性传导（carina-RPC）的预后意义和预测因素。
本研究纳入了 214 例接受首次接触力指导的射频 PVI 的房颤（AF）患者（57%为阵发性，61%为男性，平均年龄 62±9 岁）。术前心脏计算机断层扫描成像用于评估左心房和 PV 解剖结构。在初始 WACA 环创建后直接评估 PVI，在等待至少 30 分钟后，以及在腺苷输注后再次评估。根据最早激活部位，将持续性传导靶向进行额外消融，并分为 gap-RPC 或 carina-RPC。与无 gap-RPC 的患者（28%）相比，存在 gap-RPC 的患者（47%）的 1 年 AF 复发率更高（P=0.003）。carina-RPC 患者（37%）与无 carina-RPC 患者（31%）的 1 年复发率无显著差异（P=0.379）。多变量分析确定阵发性 AF 和 WACA 周长是 gap-RPC 的独立预测因素，而嵴宽度和 WACA 周长与 carina-RPC 相关。
gap-RPC 与 PVI 后 AF 复发风险增加相关，而 carina-RPC 与 AF 复发无关。此外，gap-RPC 和 carina-RPC 具有不同的相关性，因此可能具有不同的潜在机制。
