导管消融治疗心房颤动中的病灶递送与瘢痕形成：DECAAF II试验
Lesion delivery and scar formation in catheter ablation for atrial fibrillation: The DECAAF II trial.
作者信息
Akoum Nazem, Mekhael Mario, Bisbal Felipe, Wazni Oussama, McGann Christopher, Lee Hyejung, Bardsley Tyler, Greene Tom, Dean J Michael, Dagher Lilas, Kholmovski Eugene, Mansour Moussa, Marchlinski Francis, Wilber David, Hindricks Gerhard, Mahnkopf Christian, Wells Darryl, Jaïs Pierre, Sanders Prashanthan, Brachmann Johannes, Bax Jeroen J, Morrison-de Boer Leonie, Deneke Thomas, Calkins Hugh, Sohns Christian, Marrouche Nassir
机构信息
Cardiology Department, University of Washington Medical Center, Seattle, Washington.
Cardiology Department, Tulane University School of Medicine, New Orleans, Louisiana.
出版信息
Heart Rhythm. 2025 Jun;22(6):1384-1393. doi: 10.1016/j.hrthm.2024.08.062. Epub 2024 Sep 6.
BACKGROUND
The Efficacy of Delayed Enhancement MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation of Atrial Fibrillation randomized trial showed no difference in atrial fibrillation (AF) recurrence with additional delayed enhancement magnetic resonance imaging (DE-MRI) fibrosis-targeted ablation to pulmonary vein isolation (PVI) in persistent AF.
OBJECTIVE
We evaluated the effect of lesion delivery on ablation-induced scarring and AF recurrence.
METHODS
Lesions delivered, targeting fibrotic and nonfibrotic areas identified from preablation DE-MRI, were studied in relation to ablation-induced scarring on 3-month DE-MRI, including their association with arrhythmia recurrence.
RESULTS
A total of 593 patients treated with radiofrequency were analyzed: 293 (49.4%) underwent PVI and 300 (50.6%) underwent additional fibrosis-guided ablation. Lesion analysis showed that 80.9% in the MRI fibrosis-guided group vs 16.5% in the PVI group (P < .001) had ≥40% of baseline fibrosis targeted. MRI assessment of ablation-induced scar showed that 44.8% of fibrosis-guided ablation and 15.5% of PVI had ≥40% of their fibrosis covered by scar (P < .001), demonstrating significant attenuation from lesions delivered to scar formed. In the overall population, fibrosis coverage with scar was not associated with recurrence (hazard ratio [HR] 0.90; 95% confidence interval [CI] 0.80-1.01; P = .08 per 20% increase). In patients with baseline fibrosis < 20%, fibrosis coverage with scar was associated with lower recurrence than PVI (HR 0.85; 95% CI 0.73-0.97; P = .03), whereas the association was not significant when baseline fibrosis ≥ 20% (HR 0.97; 95% CI 0.80-1.17; P = .77). Significant center variation was observed in fibrosis targeting and coverage with scarring.
CONCLUSION
Radiofrequency ablation lesions do not uniformly result in scar formation. A post hoc analysis suggests reduced arrhythmia recurrence when ablation-induced scarring covers fibrotic regions in patients with low baseline fibrosis.
背景
延迟强化磁共振成像引导下的纤维化消融与传统导管消融治疗心房颤动的随机试验表明，在持续性心房颤动患者中，在肺静脉隔离（PVI）基础上增加延迟强化磁共振成像（DE-MRI）纤维化靶向消融，心房颤动（AF）复发率并无差异。
目的
我们评估了消融靶点对消融所致瘢痕形成及房颤复发的影响。
方法
根据消融前DE-MRI确定纤维化和非纤维化区域作为消融靶点，研究这些靶点与3个月后DE-MRI上消融所致瘢痕形成的关系，包括它们与心律失常复发的关联。
结果
共分析了593例接受射频治疗的患者：293例（49.4%）接受了PVI，300例（50.6%）接受了额外的纤维化引导消融。病灶分析显示，MRI纤维化引导组中80.9%的患者与PVI组中16.5%的患者（P <.001）有≥40%的基线纤维化被作为靶点。MRI对消融所致瘢痕的评估显示，44.8%的纤维化引导消融和15.5%的PVI有≥40%的纤维化被瘢痕覆盖（P <.001），表明从消融靶点到形成的瘢痕有显著衰减。在总体人群中，瘢痕的纤维化覆盖率与复发无关（风险比[HR] 0.90；95%置信区间[CI] 0.80 - 1.01；每增加20%，P = 0.08）。在基线纤维化<20%的患者中，瘢痕的纤维化覆盖率与PVI相比复发率较低（HR 0.85；95% CI 0.73 - 0.97；P = 0.03），而当基线纤维化≥20%时，这种关联不显著（HR 0.97；95% CI 0.80 - 1.17；P = 0.77）。在纤维化靶点及瘢痕覆盖率方面观察到显著的中心差异。
结论
射频消融病灶并非均能导致瘢痕形成。一项事后分析表明，在基线纤维化程度较低的患者中，消融所致瘢痕覆盖纤维化区域时心律失常复发率降低。
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