心脏团队联合治疗合并左心房扩大的持续性心房颤动：连续节律监测的附加价值。

Heart-team hybrid approach to persistent atrial fibrillation with dilated atria: the added value of continuous rhythm monitoring.

机构信息

Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San-Raffaele University, Milan, Italy.

Department of Cardiac-Electrophysiology and Arrhythmia, IRCCS San Raffaele Hospital, Vita-Salute San-Raffaele University, Milan, Italy.

出版信息

Eur J Cardiothorac Surg. 2021 Jul 30;60(2):222-230. doi: 10.1093/ejcts/ezab064.

DOI:10.1093/ejcts/ezab064

PMID:33760052

Abstract

OBJECTIVES

To assess by a continuous implantable rhythm monitoring (ILR) the mid-term outcomes of a staged-hybrid approach for patients with persistent/long-standing persistent atrial fibrillation (AF) and dilated atria.

METHODS

Fifty patients [age 57 (standard deviation, SD: 8.3), previous catheter ablation 66%, AF history 6.5 (2-12) years, left ventricular ejection fraction 56 (SD: 7.9)%, left atrial volume index 44 (38-56) ml/m2] with persistent (44%) or long-standing persistent (56%) AF, underwent a 2-staged hybrid ablation (thoracoscopic epicardial procedure with Cobra-Fusion system and transcatheter Rhythmia mapping with endocardial touch-up of gaps). All patients received an ILR.

RESULTS

No hospital deaths and no stroke occurred. Follow-up was 98% complete [median 22 (11-34) months]. The 2-year arrhythmia-free survival off class I-III antiarrhythmic drugs/electrical cardioversion/redo catheter ablation and the arrhythmia control (maintenance of sinus rhythm with or without antiarrhythmic drugs/electrical cardioversion) were 65 (SD: 7.1)% and 82 (SD: 5.8)%, respectively. The occurrence of AF in the blanking period was identified as an independent predictor of AF recurrence (odds ratio 26.6, 95% confidence interval 5.3, 132.3; P < 0.001). At longitudinal analysis, the predicted prevalence of sinus rhythm and sinus rhythm off class I-III antiarrhythmic drugs/electrical cardioversion/redo catheter ablation was 82% and 69% at 2 years, respectively. Among patients with recurrence, 50% had short-lasting asymptomatic episodes, identified only by ILR monitoring. The proportion of patients with AF burden ≤1% was 82% and 91% at 1 and 2 years, respectively, and in these cases, left atrial volume index decreased from 46 (SD: 12) ml/m2 to 41 (SD: 11) ml/m2 (P = 0.026).

CONCLUSIONS

A staged hybrid approach yields promising results in selected patients with persistent/long-standing persistent AF and dilated left atrium who are at very high risk of AF recurrence. The use of ILR in this setting should become a standard to optimize patient management.

摘要

目的

通过连续植入式心律监测（ILR）评估分期杂交策略治疗持续性/长期持续性心房颤动（AF）和左心房扩张患者的中期结果。

方法

50 名患者[年龄 57（标准差，SD：8.3），既往导管消融 66%，AF 病史 6.5（2-12）年，左心室射血分数 56（SD：7.9）%，左心房容积指数 44（38-56）ml/m2]，其中 44%为持续性 AF，56%为长期持续性 AF，行两阶段杂交消融（胸腔镜心外膜手术联合 Cobra-Fusion 系统和经导管 Rhythmia 标测，心内膜间隙补点消融）。所有患者均接受 ILR 监测。

结果

无院内死亡和卒中发生。随访率为 98%[中位数 22（11-34）个月]。2 年无抗心律失常药物/电复律/再次导管消融及心律失常控制（维持窦性心律伴或不伴抗心律失常药物/电复律）的心律失常无复发率分别为 65（SD：7.1）%和 82（SD：5.8）%。空白期 AF 的发生是 AF 复发的独立预测因子（比值比 26.6，95%置信区间 5.3，132.3；P<0.001）。纵向分析显示，2 年时窦性心律和无抗心律失常药物/电复律/再次导管消融的窦性心律预测患病率分别为 82%和 69%。在复发患者中，50%有短暂无症状发作，仅通过 ILR 监测识别。AF 负荷≤1%的患者比例分别为 82%和 91%，在这些情况下，左心房容积指数从 46（SD：12）ml/m2降至 41（SD：11）ml/m2（P=0.026）。