Hartl Stefan, Makimoto Hisaki, Gerguri Shqipe, Clasen Lukas, Kluge Sophia, Brinkmeyer Christoph, Schmidt Jan, Rana Obaida, Kelm Malte, Bejinariu Alexandru
Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, 40225 Düsseldorf, Germany.
Department of Electrophysiology, Alfried Krupp Hospital, 45131 Essen, Germany.
J Clin Med. 2023 Jul 28;12(15):4982. doi: 10.3390/jcm12154982.
Performing repeated pulmonary vein isolation (re-PVI) after recurrent atrial fibrillation (AF) following prior PVI is a standard procedure. However, no consensus exists regarding the most effective approach in redo procedures. We assessed the efficacy of re-PVI using wide antral circumferential re-ablation (WACA) supported by high-density electroanatomical mapping (HDM) as compared to conventional re-PVI. Consecutive patients with AF recurrences showing true PV reconnection (residual intra-PV and PV antral electrical potentials within the initial ablation line) or exclusive PV antral potentials (without intra-PV potentials) in the redo procedure were prospectively enrolled and received HDM-guided WACA (Re-WACA group). Conventional re-PVI patients treated using pure ostial gap ablation guided by a circular mapping catheter served as a historical control (Re-PVI group). Patients with durable PVI and no antral PV potentials were excluded. Arrhythmia recurrences ≥30 s were calculated as recurrences. In total, 114 patients were investigated (Re-WACA: = 56, 68 ± 10 years, Re-PVI: = 58, 65 ± 10 years). There were no significant differences in clinical characteristics including the AF type or the number of previous PVIs. In the Re-WACA group, 11% of patients showed electrical potentials only in the antrum but not inside any PV. At 402 ± 71 days of follow-up, the estimated freedom from arrhythmia was 89% in the Re-WACA group and 69% in the Re-PVI group ( = 0.01). Re-WACA independently predicted arrhythmia-free survival (HR = 0.39, 95% CI 0.16-0.93, = 0.03), whereas two previous PVI procedures predicted recurrences (HR = 2.35, 95% CI 1.20-4.46, = 0.01). The Re-WACA strategy guided by HDM significantly improved arrhythmia-free survival as compared to conventional ostial re-PVI. Residual PV antral potentials after prior PVI are frequent and can be easily visualized by HDM.
在先前进行肺静脉隔离（PVI）后出现复发性心房颤动（AF）时，进行重复肺静脉隔离（re-PVI）是一种标准操作。然而，对于再次手术中最有效的方法尚无共识。我们评估了在高密度电解剖标测（HDM）支持下使用宽环周窦部再次消融（WACA）进行re-PVI与传统re-PVI相比的疗效。前瞻性纳入在再次手术中显示真正肺静脉重新连接（初始消融线内存在残余肺静脉内和肺静脉窦部电位）或仅存在肺静脉窦部电位（无肺静脉内电位）的AF复发连续患者，并接受HDM引导的WACA（Re-WACA组）。使用环形标测导管引导进行单纯开口间隙消融治疗的传统re-PVI患者作为历史对照（Re-PVI组）。排除肺静脉隔离持久且无窦部肺静脉电位的患者。心律失常复发≥30秒计算为复发。总共研究了114例患者（Re-WACA组：n = 56，68±10岁，Re-PVI组：n = 58，65±10岁）。包括房颤类型或先前PVI次数在内的临床特征无显著差异。在Re-WACA组中，11%的患者仅在窦部显示电位，但在任何肺静脉内均未显示。在402±71天的随访中，Re-WACA组的无心律失常估计自由度为89%，Re-PVI组为69%（P = 0.01）。Re-WACA独立预测无心律失常生存（HR = 0.39，95%CI 0.16 - 0.93，P = 0.03），而先前的两次PVI手术预测复发（HR = 2.35，95%CI 1.20 - 4.46，P = 0.01）。与传统开口再次PVI相比，HDM引导的Re-WACA策略显著提高了无心律失常生存。先前PVI后残留的肺静脉窦部电位很常见，并且可以通过HDM轻松可视化。
