Cardiology Department, University Hospital Antwerp, Wilrijkstraat 10, Edegem, Antwerp 2650, Belgium.
Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel,1090 Brussels, Belgium.
Europace. 2023 Nov 2;25(11). doi: 10.1093/europace/euad299.
Little is known about dynamic changes of the left atrial (LA) substrate over time in patients with atrial fibrillation (AF). This study aims to evaluate substrate changes following pulmonary vein isolation (PVI).
In our prospective observational study, consecutive patients undergoing first PVI-only and redo ablation were included. High-density maps of the two procedures were compared. Progression or regression was diagnosed if a significant concordant decrease or increase in bipolar voltages in ≥2 segments was observed, respectively. In 28 patients (61.2 ± 9.5 years, 39% female, 53.5% persistent AF), 111.013 voltage points from 56 high-density LA maps (1.982 points/patient) were analysed. Comparing the high-density maps of the first and second procedures, in the progression group (17 patients, 61%), there was a decrease in global (-35%, P < 0.001) and all regional voltages. In the regression group (11 patients, 39%), there was an increase in global (+43%, P < 0.001) and regional voltages. Comparing the progression with the regression group, the area of low-voltage zone (LVZ) increased (+3.5 vs. -4.5 cm2, P < 0.001) and LA activation time prolonged (+8.0 vs. -9.1 ms, P = 0.005). Baseline clinical parameters did not predict progression or regression. In patients with substrate progression, pulmonary veins (PVs) were more frequently isolated (P = 0.02) and the AF pattern at recurrence was more frequently persistent (P = 0.005).
Our study describes bidirectional dynamic properties of the LA substrate with concordant either progressive or regressive changes. Regression occurs with reduced AF burden after the first procedure, while progression is associated with persistent AF recurrence despite durable PV isolation. The dynamic nature of LA substrate poses questions about LVZ-based ablation strategies.
关于持续性心房颤动（AF）患者左心房（LA）基质随时间的动态变化知之甚少。本研究旨在评估肺静脉隔离（PVI）后的基质变化。
在我们的前瞻性观察研究中，纳入了首次仅行 PVI 及再次消融的连续患者。比较了这两种手术的高密度图。如果观察到≥2 个节段的双极电压显著一致减少或增加，则诊断为进展或消退。在 28 名患者（61.2±9.5 岁，39%为女性，53.5%为持续性 AF）中，分析了 56 个 LA 高密度图的 111.013 个电压点（每个患者 1.982 个点）。比较两次手术的高密度图，在进展组（17 例，61%）中，全球（-35%，P<0.001）和所有区域电压均降低。在消退组（11 例，39%）中，全球（+43%，P<0.001）和区域电压增加。比较进展组与消退组，低电压区（LVZ）面积增大（+3.5 比-4.5 cm2，P<0.001），LA 激活时间延长（+8.0 比-9.1 ms，P=0.005）。基线临床参数不能预测进展或消退。在基质进展的患者中，肺静脉（PVs）更常被隔离（P=0.02），复发时的 AF 模式更常为持续性（P=0.005）。
本研究描述了 LA 基质的双向动态特性，表现为一致的进展或消退变化。第一次手术后，随着 AF 负荷的降低，会出现消退，而尽管 PV 隔离持久，进展仍与持续性 AF 复发相关。LA 基质的动态性质引发了对 LVZ 为基础的消融策略的质疑。
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