Oraii Alireza, Chaumont Corentin, Rodriguez-Queralto Oriol, Wasiak Michal, Thind Munveer, Peters Carli J, Zado Erica, Hanumanthu Balaram Krishna J, Markman Timothy M, Hyman Matthew C, Tschabrunn Cory M, Guandalini Gustavo, Enriquez Andres, Shivamurthy Poojita, Kumareswaran Ramanan, Riley Michael P, Lin David, Schaller Robert D, Nazarian Saman, Callans David J, Supple Gregory E, Garcia Fermin C, Frankel David S, Dixit Sanjay, Marchlinski Francis E
Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
Circ Arrhythm Electrophysiol. 2025 Jan;18(1):e013351. doi: 10.1161/CIRCEP.124.013351. Epub 2024 Dec 20.
Patients undergoing first-time atrial fibrillation (AF) ablation can benefit from targeting non-pulmonary vein (PV) triggers. Preprocedural identification of high-risk individuals can guide planning of ablation strategy. This study aimed to create a preprocedural screening tool to identify patients at risk of non-PV triggers during first-time AF ablation.
All patients who underwent first-time AF ablation at the Hospital of the University of Pennsylvania between 2018 and 2022 were identified. Those who underwent non-PV trigger provocative maneuvers or had spontaneous non-PV trigger firing were included. Non-PV triggers were defined as non-PV ectopic beats triggering AF or sustained focal atrial tachycardia that occurred spontaneously, after AF cardioversion, or after standard provocative maneuvers. The provocative maneuvers included incremental isoproterenol infusion (3, 6, 12, and 20-30 µg/min) and an atrial burst pacing protocol. Risk factors associated with non-PV triggers in a stepwise multivariable logistic regression model with backward elimination were used to create a risk score.
A total of 163 (8.0%) of 2038 patients had non-PV triggers during first-time AF ablation. Based on the multivariable model, we created a risk score using female sex (1 point; odds ratio [OR], 1.90 [95% CI, 1.36-2.67]), sinus node dysfunction (1 point; OR, 1.84 [95% CI, 1.04-3.24]), prior cardiac surgery (1 point; OR, 2.26 [95% CI, 1.45-3.53]), moderate to severe left atrial enlargement (2 points; OR, 3.43 [95% CI, 2.46-4.79]), and cardiac sarcoidosis/amyloidosis (4 points; OR, 7.24 [95% CI, 3.03-17.33]). Internal validation using bootstrap resampling showed an optimism-adjusted C statistic of 0.715 (95% CI, 0.678-0.751). Among all first-time AF ablations, 68.1% of procedures were low-risk for non-PV triggers (scores 0-1, 4.3% risk), 17.8% were intermediate-risk (score 2, 10.5% risk), and 14.1% were high-risk (score ≥3, 22.6% risk).
A preprocedural screening tool can classify patients based on their risk of non-PV triggers during first-time AF ablation. This risk score can guide operators to identify patients who would benefit most from adjunctive non-PV trigger testing. However, further validation is needed to confirm these findings.
首次进行心房颤动（AF）消融的患者可从针对非肺静脉（PV）触发灶的治疗中获益。术前识别高危个体有助于指导消融策略的规划。本研究旨在创建一种术前筛查工具，以识别首次AF消融期间存在非PV触发灶风险的患者。
确定2018年至2022年在宾夕法尼亚大学医院接受首次AF消融的所有患者。纳入那些接受了非PV触发灶激发操作或有自发性非PV触发灶放电的患者。非PV触发灶定义为触发AF或持续性局灶性房性心动过速的非PV异位搏动，这些异位搏动可自发出现、在AF复律后出现或在标准激发操作后出现。激发操作包括递增异丙肾上腺素输注（3、6、12和20 - 30μg/min）以及心房猝发起搏方案。在采用向后排除法的逐步多变量逻辑回归模型中，将与非PV触发灶相关的危险因素用于创建风险评分。
2038例患者中，共有163例（8.0%）在首次AF消融期间存在非PV触发灶。基于多变量模型，我们使用以下因素创建了风险评分：女性（1分；比值比[OR]，1.90[95%CI，1.36 - 2.67]）、窦房结功能障碍（1分；OR，1.84[95%CI，1.04 - 3.24]）、既往心脏手术史（1分；OR，2.26[95%CI，1.45 - 3.53]）、中度至重度左心房扩大（2分；OR，3.43[95%CI，2.46 - 4.79]）以及心脏结节病/淀粉样变性（4分；OR，7.24[95%CI，3.03 - 17.33]）。使用自抽样法进行的内部验证显示，乐观调整后的C统计量为0.715（95%CI, 0.678 - 0.751）。在所有首次AF消融中，68.1%的手术对于非PV触发灶为低风险（评分0 - 1，风险4.3%），17.8%为中度风险（评分2，风险10.5%），14.1%为高风险（评分≥3，风险22.6%）。
一种术前筛查工具可根据首次AF消融期间患者发生非PV触发灶的风险对其进行分类。该风险评分可指导术者识别那些将从辅助性非PV触发灶检测中获益最大的患者。然而，需要进一步验证以证实这些发现。
