Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA.
J Cardiovasc Electrophysiol. 2022 Sep;33(9):1994-2000. doi: 10.1111/jce.15592. Epub 2022 Jun 15.
Pulmonary venous (PV) electrical recovery underlies most arrhythmia recurrences after atrial fibrillation (AF) ablation. Little is known about procedural profiles and outcomes of patients with electrically silent PVs upon redo ablation for AF.
In a prospectively maintained registry, we enrolled 838 consecutive patients (2013-2016) undergoing redo ablation procedures. Ablation procedures targeted the PVs, the PV antra, and non-PV sites at operators' discretion. Procedural profiles and clinical outcomes were assessed. The primary outcome was freedom from AF after a 3-month blanking period. The secondary outcome was improvement in quality of life.
Most patients undergoing redo AF ablation (n = 684, 82%) had PV reconnection while the remaining 154 (18%) had electrically silent PVs. Patients with recurrent AF and electrically silent PVs were older (66 vs. 64 years, p = .02), had more prior ablation procedures (median 2 IQR 1-3 vs 1 IQR 1-2 p = .001), were more likely to have non-paroxysmal AF (62% vs. 49%, p = .004) and atrial flutter (48% vs. 29%, p = .001) and had significantly larger left atrial volumes (89 vs. 81 ml, p = .003). Patients with silent PVs underwent a more extensive non-PV ablation strategies with antral extension of prior ablation sets in addition to ablation of the roof, appendage, inferior to the right PVs, peri-mitral flutter lines, cavotricuspid isthmus lines and ablation in the coronary sinus. Upon one year of follow-up, patients with electrically silent PVs were less likely to remain free from recurrent atrial arrhythmias (64% vs. 76%, p = .008). Regardless of PV reconnection status, redo ablation resulted in improvement in quality of life.
Rhythm control with extensive ablation allowed maintenance of sinus rhythm in about two thirds of patients with silent PVs during redo AF ablation procedures. Regardless of PV reconnection status, redo ablation resulted in improvement in quality of life. This remains a challenging group of patients, highlighting the need to better understand non-PV mediated AF.
在心房颤动（AF）消融后，肺静脉（PV）的电恢复是大多数心律失常复发的基础。对于因 AF 再次消融而 PV 电沉默的患者，其手术过程特征和结局知之甚少。
我们前瞻性地纳入了 838 例连续患者（2013-2016 年），这些患者接受了再消融治疗。消融程序可根据操作人员的判断靶向 PV、PV 窦和非-PV 部位。评估了手术过程特征和临床结局。主要结局是在 3 个月的空白期后无 AF 复发。次要结局是生活质量的改善。
大多数接受 AF 再消融的患者（n=684，82%）存在 PV 再连接，而其余 154 例（18%）存在电沉默的 PV。复发性 AF 伴电沉默 PV 的患者年龄更大（66 岁比 64 岁，p=0.02），消融次数更多（中位数 2 IQR 1-3 比 1 IQR 1-2，p=0.001），更有可能患有非阵发性 AF（62%比 49%，p=0.004）和房性扑动（48%比 29%，p=0.001），并且左心房容积明显更大（89 比 81ml，p=0.003）。电沉默 PV 患者接受了更广泛的非-PV 消融策略，包括以前消融集的窦延伸，以及右 PV 周围、心耳、下壁、二尖瓣环旁扑动线、三尖瓣峡部线和冠状窦内消融。随访 1 年后，电沉默 PV 患者无复发性房性心律失常的比例较低（64%比 76%，p=0.008）。无论 PV 再连接状态如何，再次消融均可改善生活质量。
在 AF 再次消融过程中，广泛的消融可以使大约三分之二的电沉默 PV 患者维持窦律。无论 PV 再连接状态如何，再次消融均可改善生活质量。这仍然是一组具有挑战性的患者，这突出表明需要更好地了解非-PV 介导的 AF。
