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既往因心律失常接受“多次”消融术后出现的房性心动过速:采用抗心律失常药物治疗还是再次消融?

Atrial Tachycardias After "Multiple" Previous Ablations for Tachyarrhythmias: Treatment by Anti-arrhythmic Drugs or Additional Ablation?

作者信息

Kantharia Bharat K, Tun Zaw Win, Shah Arti N

机构信息

Cardiovascular and Heart Rhythm Consultants, New York, NY, USA.

Icahn School of Medicine at Mount Sinai, New York, NY, USA.

出版信息

J Innov Card Rhythm Manag. 2024 Mar 15;15(3):5795-5802. doi: 10.19102/icrm.2024.15037. eCollection 2024 Mar.

Abstract

Pulmonary vein (PV) isolation (PVI) ablation as the first-line therapy for atrial fibrillation (AF) and repeat PVIs for patients who had symptomatic improvement with the index PVI but who develop AF recurrence are directed by practice guidelines. How many catheter ablation (CA) procedures constitute the definition of "multiple" ablations is not known. Whether atrial tachyarrhythmias (AF, atrial tachycardia [AT], atrial flutter [AFL]) that occur post-ablation are due entirely to the proarrhythmic effects of CA or a continuum of the arrhythmia spectrum from the underlying atriopathy is debatable. Herein, we describe a case of a 65-year-old man with a CHADS-VASc score of 5 points who suffered from atrial tachyarrhythmias for which seven CA procedures were performed. Because of symptomatic and drug-refractory AT/AFL that failed cardioversions, he requested another ablation procedure. During the eighth procedure, high-density three-dimensional electroanatomic mapping, including Coherent and Ripple mapping (CARTO 3; Biosense Webster, Diamond Bar, CA, USA), of AT/AFL was performed. Small discrete areas of relatively viable tissue within an extensively scarred left atrium and a macro-re-entrant circuit with early-meets-late activation between the left atrial anterior wall and the right superior PV were found. Radiofrequency ablation performed at this site resulted in the termination of the tachycardia, and bidirectional conduction block across the line was achieved. On clinical follow-ups and rhythm monitoring by an implantable loop recorder, the patient remained in sinus rhythm with significant clinical improvement. Our case suggests that, in patients with prior multiple CAs, additional clinically indicated ablation should be performed using high-density mapping to accurately identify arrhythmia mechanisms, elucidate the disease substrate, and restore the sinus rhythm successfully.

摘要

肺静脉(PV)隔离(PVI)消融作为心房颤动(AF)的一线治疗方法,对于那些在首次PVI消融后症状有所改善但仍出现AF复发的患者进行重复PVI消融,这是由实践指南指导的。目前尚不清楚多少次导管消融(CA)手术构成“多次”消融的定义。消融后发生的房性快速心律失常(AF、房性心动过速[AT]、心房扑动[AFL])是否完全归因于CA的促心律失常作用,还是源于潜在心房病变的心律失常谱的延续,这一点存在争议。在此,我们描述了一名65岁男性患者,其CHADS-VASc评分为5分,患有房性快速心律失常,为此进行了7次CA手术。由于症状性且药物难治的AT/AFL经心脏复律失败,他要求进行另一次消融手术。在第八次手术期间,对AT/AFL进行了高密度三维电解剖标测,包括相干和波动标测(CARTO 3;美国加利福尼亚州钻石吧市百盛韦伯斯特公司)。在广泛瘢痕化的左心房内发现了相对存活组织的小离散区域,以及左心房前壁和右上肺静脉之间存在早期与晚期激动的大折返环。在此部位进行射频消融导致心动过速终止,并实现了跨线双向传导阻滞。在临床随访以及通过植入式环路记录仪进行的心律监测中,患者维持窦性心律,临床症状有显著改善。我们的病例表明,对于先前接受过多次CA手术的患者,应使用高密度标测进行额外的临床指征消融,以准确识别心律失常机制,阐明疾病基质,并成功恢复窦性心律。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/2867/10994163/ebd7690dfa6b/icrm-15-5795-g001.jpg

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