Bengel Philipp, Sossalla Samuel, Dinov Borislav
Department of Internal Medicine I, Cardiology and Angiology, Justus-Liebig-University Giessen, Klinikstr. 33, 35392 Giessen, Germany.
Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany.
Eur Heart J Case Rep. 2024 Jul 23;8(8):ytae358. doi: 10.1093/ehjcr/ytae358. eCollection 2024 Aug.
Pulmonary vein isolation (PVI) has emerged as a safe and effective treatment for patients with paroxysmal and persistent atrial fibrillation. Nevertheless, in some patients, a relapse of atrial fibrillation occurs although pulmonary veins are durably isolated. For those patients, the underlying mechanisms of atrial fibrillation perpetuation are manifold and optimal treatment options are not yet defined.
We describe a case of a 55-year-old man with a history of atrial fibrillation and previous PVI presenting with persistent AF and arrhythmia induced cardiomyopathy. During the redo procedure, electro-anatomical mapping revealed durably isolated PV. Bipolar mapping showed large low-voltage areas at the posterior wall and the septum. As the patient was refractory to electrical cardioversion, it was decided to modify the large low-voltage areas as potential arrhythmic substrate. After performing additional ablation with isolation of the posterior wall and two anterior/septal lines, the patient spontaneously converted to sinus rhythm.
Ablation in patients with persistent AF despite durable PVI remains a challenge for the treating team. Individualized ablation approaches addressing additional arrhythmic substrates or extra-PV triggers can be considered to treat patients with persistent AF and durable PVI.
肺静脉隔离（PVI）已成为阵发性和持续性心房颤动患者的一种安全有效的治疗方法。然而，在一些患者中，尽管肺静脉已被持久隔离，但仍会出现心房颤动复发。对于这些患者，心房颤动持续存在的潜在机制是多方面的，最佳治疗方案尚未确定。
我们描述了一例55岁男性患者，有房颤病史且曾接受过PVI，现表现为持续性房颤和心律失常性心肌病。在再次手术过程中，电解剖标测显示肺静脉已持久隔离。双极标测显示后壁和间隔有大片低电压区。由于患者对电复律无效，决定将大片低电压区作为潜在的心律失常基质进行改良。在进行了后壁隔离及两条前壁/间隔线的额外消融后，患者自发转为窦性心律。
对于尽管肺静脉已持久隔离但仍有持续性房颤的患者，消融治疗对治疗团队来说仍然是一个挑战。可以考虑采用个体化消融方法，针对额外的心律失常基质或肺静脉外触发因素，来治疗持续性房颤且肺静脉已持久隔离的患者。
