O'Neill Louisa, De Becker Benjamin, Smet Maarten A J De, Francois Clara, Le Polain De Waroux Jean-Benoit, Tavernier Rene, Duytschaever Mattias, Knecht Sebastien
Department of Cardiology, AZ Sint-Jan Hospital, 8000 Bruges, Belgium.
Department of Cardiology, Blackrock Clinic, A94 E4X7 Dublin, Ireland.
Rev Cardiovasc Med. 2023 Nov 30;24(12):339. doi: 10.31083/j.rcm2412339. eCollection 2023 Dec.
Persistent atrial fibrillation (AF) is a diverse condition that includes various subtypes and underlying causes of arrhythmia. Progress made in catheter ablation technology in recent years has significantly enhanced the durability of ablation. Despite these advances however, the effectiveness of ablation in treating persistent AF is still relatively modest. Studies exploring the mechanisms behind persistent AF have identified substrate-driven focal and re-entrant sources within the atrial body as crucial in sustaining AF among individuals with persistent AF. Furthermore, the widespread adoption of atrial late gadolinium enhancement cardiac magnetic resonance (CMR) imaging and the ongoing refinement of invasive voltage mapping techniques have allowed for detailed assessment of fibrotic remodelling prior to or at the time of procedure. Translation into clinical practice, however, has yielded overall disappointing results. The clinical application of AF mapping in ablation procedures has not shown any substantial advantages beyond the use of pulmonary vein isolation (PVI) alone and adjunct ablation of fibrotic areas has yielded conflicting results in recent randomized trials. The emergence of pulsed field ablation represents a welcome development in the field and several studies have demonstrated an enhanced safety profile and increased procedural efficiency with this non-thermal energy modality. Pulsed field ablation also holds promise for safe and efficient substrate ablation beyond the pulmonary veins, but further trials are needed to assess its impact on longer term success rates. Continued advancements in our comprehension of AF mechanisms, alongside ongoing developments in catheter technology aimed at safe formation of transmural lesions, are essential for achieving better clinical outcomes for patients with persistent AF.
持续性心房颤动（AF）是一种复杂的病症，包括各种亚型以及心律失常的潜在病因。近年来导管消融技术取得的进展显著提高了消融的持久性。然而，尽管有这些进展，消融治疗持续性AF的有效性仍然相对有限。探索持续性AF背后机制的研究已经确定，心房内由基质驱动的局灶性和折返性起源对于持续性AF患者维持AF至关重要。此外，心房延迟钆增强心脏磁共振（CMR）成像的广泛应用以及侵入性电压标测技术的不断完善，使得在手术前或手术时能够详细评估纤维化重塑。然而，转化为临床实践的结果总体令人失望。AF标测在消融手术中的临床应用并未显示出比单独使用肺静脉隔离（PVI）有任何实质性优势，并且在最近的随机试验中，纤维化区域的辅助消融产生了相互矛盾的结果。脉冲场消融的出现是该领域一个令人欣喜的进展，多项研究表明这种非热能模式具有更高的安全性和更高的手术效率。脉冲场消融对于肺静脉以外的基质消融的安全和有效也具有前景，但需要进一步试验来评估其对长期成功率的影响。对AF机制理解的持续进步，以及旨在安全形成透壁损伤的导管技术的不断发展，对于为持续性AF患者实现更好的临床结果至关重要。
