Ivanovski Maja, Mrak Miha, Zupan Mežnar Anja, Žižek David
Department of Cardiology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia.
Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia.
Rev Cardiovasc Med. 2023 Nov 24;24(11):333. doi: 10.31083/j.rcm2411333. eCollection 2023 Nov.
"Ablate and pace" strategy is a reasonable treatment option in refractory atrial fibrillation (AF) when sinus rhythm (SR) cannot be achieved with catheter ablation or pharmacological therapy. Atrioventricular node ablation (AVNA) combined with conduction system pacing (CSP), with left bundle branch pacing (LBBP) or His bundle pacing (HBP), is gaining recognition since it offers the most physiological activation of the left ventricle. However, the incidence of conversion to SR after AVNA with CSP is not known. The purpose of the investigation was to determine the incidence of spontaneous conversion to SR and its predicting factors in patients undergoing CSP and AVNA.
Consecutive refractory symptomatic AF patients undergoing AVNA with CSP at our institution between June 2018 and December 2022 were retrospectively analyzed. Twelve lead electrocardiogram (ECG) recordings were analyzed at each outpatient follow-up visit. Echocardiographic and clinical parameters were assessed at baseline and six months after the implantation.
Sixty-eight patients (male 42.6%, age 71 8 years, left ventricular ejection fraction 40 15%) were included. Thirty-seven patients (54.4%) received HBP and 31 (45.6%) LBBP. During follow-up, spontaneous conversion to SR was registered in 6 patients (8.8%); 3 in the HBP group and 3 in the LBBP group. Baseline characteristics of patients who converted to SR did not differ from non-sinus rhythm (NSR) patients except for left atrial volume index (LAVI), which was significantly smaller in the SR group (45 mL/ (41-51) vs. 60 mL/ (52-75); = 0.002). Multiple regression model confirmed an inverse association between LAVI and conversion to SR even after considering other clinically relevant covariates (odds ratio 1.273, = 0.028). At follow-up, LAVI did not change in any group (SR: = 0.345; NSR: = 0.508). Improvement in New York Heart Association (NYHA) class was comparable in both groups.
Spontaneous conversion to SR after AVNA combined with CSP is not uncommon, especially in patients with smaller left atria. Further studies are warranted to clarify which patients should be considered for initial dual-chamber device implantation to provide atrio-ventricular synchrony in case of SR restoration.
当导管消融或药物治疗无法实现窦性心律（SR）时，“消融并起搏”策略是难治性心房颤动（AF）的一种合理治疗选择。房室结消融（AVNA）联合传导系统起搏（CSP），采用左束支起搏（LBBP）或希氏束起搏（HBP），因其能提供最生理性的左心室激动而逐渐得到认可。然而，AVNA联合CSP后转为SR的发生率尚不清楚。本研究的目的是确定接受CSP和AVNA的患者自发转为SR的发生率及其预测因素。
回顾性分析2018年6月至2022年12月在我院接受AVNA联合CSP的连续性难治性有症状AF患者。每次门诊随访时分析12导联心电图（ECG）记录。在基线和植入后6个月评估超声心动图和临床参数。
纳入68例患者（男性42.6%，年龄71±8岁，左心室射血分数40±15%）。37例患者（54.4%）接受HBP，31例（45.6%）接受LBBP。随访期间，6例患者（8.8%）自发转为SR；HBP组3例，LBBP组3例。转为SR的患者的基线特征与非窦性心律（NSR）患者无差异，除了左心房容积指数（LAVI），SR组显著更小（45 mL/（41 - 51）vs. 60 mL/（52 - 75）；P = 0.002）。多因素回归模型证实，即使在考虑其他临床相关协变量后，LAVI与转为SR之间仍呈负相关（优势比1.273，P = 0.028）。随访时，任何组别的LAVI均无变化（SR组：P = 0.345；NSR组：P = 0.508）。两组纽约心脏协会（NYHA）心功能分级的改善情况相当。
AVNA联合CSP后自发转为SR并不罕见，尤其是左心房较小的患者。有必要进一步研究以明确哪些患者应考虑初始植入双腔装置，以便在SR恢复时提供房室同步。
