Huang Wenchao, Luo Yan, Sun Huaxin, Yang Guoshu, Luo Duan, Xiong Shiqiang, Long Yu, Liu Hanxiong
Department of Cardiology, The Third People's Hospital of Chengdu, College of Medicine, Southwest Jiaotong University, Chengdu, China.
Cardiovasc Diagn Ther. 2023 Dec 15;13(6):1056-1067. doi: 10.21037/cdt-23-273. Epub 2023 Nov 2.
The long-term success rate of nonparoxysmal atrial fibrillation (AF) treated with pulmonary vein isolation (PVI) alone is not ideal. This may indicate atrial fibrosis as a major cause of recurrence. Therefore, the aim of this study is to investigate the efficacy of left atrial substrate modification (LASM) by targeting low-voltage area.
A total of 157 consecutive patients with drug-refractory nonparoxysmal AF who underwent radiofrequency ablation during hospitalization in the Third People's Hospital of Chengdu from April 2017 to August 2021 were prospectively included. Stepwise ablation was performed in two different orders: LASM first (n=53) and PVI first (n=104) group. All patients underwent ablation during AF, and the procedural endpoint was AF termination during ablation. In the LASM first group, LASM was performed first and if AF was terminated, PVI was not performed. Similarly, in the PVI first groups, LASM was performed if AF was not terminated. The primary outcome were AF termination and freedom from AF. The secondary outcome was adverse events. Cox regression analysis was used to define predictors of AF termination, and Kaplan-Meier analysis was used to assess differences between groups in AF freedom.
The baseline characteristics of the two groups were similar. At a median follow-up of 16 months, the 112 patients (39 in LASM first group and 73 in PVI first group) with AF termination had a higher success rate than the 45 patients who had no AF termination (78.6% 57.8%; P<0.01). The AF termination rate (24/53, 45.3% 12/104, 11.5%; P<0.01) and AF freedom (20/24, 83.3% 7/12, 58.3%; P=0.13) by LASM alone was higher than PVI alone. There were 3 cases of heart failure and 1 case of stroke (4/53) in the LASM first group, and 1 case of pericardial tamponade, 5 cases of heart failure and 1 case of stroke (7/104) in the LASM first group (7.5% 6.7%; P>0.05).
LASM provides higher immediate success and a slightly better long-term success rate compared to PVI. Patients who terminated AF were more likely to have AF freedom than those who did not. AF termination during procedure may improve symptoms and reduce hospitalization.
单独采用肺静脉隔离术（PVI）治疗非阵发性心房颤动（AF）的长期成功率并不理想。这可能表明心房纤维化是复发的主要原因。因此，本研究旨在探讨通过靶向低电压区域进行左心房基质改良（LASM）的疗效。
前瞻性纳入2017年4月至2021年8月在成都市第三人民医院住院期间接受射频消融的157例药物难治性非阵发性AF连续患者。以两种不同顺序进行逐步消融：先进行LASM（n = 53）和先进行PVI（n = 104）组。所有患者在房颤期间进行消融，手术终点为消融期间房颤终止。在先进行LASM组中，先进行LASM，如果房颤终止，则不进行PVI。同样，在先进行PVI组中，如果房颤未终止，则进行LASM。主要结局为房颤终止和无房颤。次要结局为不良事件。采用Cox回归分析确定房颤终止的预测因素，采用Kaplan-Meier分析评估两组在无房颤方面的差异。
两组的基线特征相似。在中位随访16个月时，房颤终止的112例患者（先进行LASM组39例，先进行PVI组73例）的成功率高于未终止房颤的45例患者（78.6%对57.8%；P<0.01）。单独采用LASM的房颤终止率（24/53，45.3%对12/104，11.5%；P<0.01）和无房颤率（20/24，83.3%对7/12，58.3%；P = 0.13）高于单独采用PVI。先进行LASM组有3例心力衰竭和1例卒中（4/53），先进行PVI组有1例心包填塞、5例心力衰竭和1例卒中（7/104）（7.5%对6.7%；P>0.05）。
与PVI相比，LASM提供了更高的即刻成功率和略好的长期成功率。房颤终止的患者比未终止的患者更有可能无房颤。手术期间房颤终止可能改善症状并减少住院。
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