肺静脉隔离对典型心房扑动患者房性心律失常的影响：随机临床试验的系统评价和荟萃分析
Impact of pulmonary vein isolation on atrial arrhythmias in patients with typical atrial flutter: systematic review and meta-analysis of randomized clinical trials.
作者信息
Gomes Daniel A, Reis Santos Rita, Ferreira Jorge, Anselme Frédéric, Calvert Peter, Schmidt Amand Floriaan, Gupta Dhiraj, Boveda Serge, Adragão Pedro, Providência Rui
机构信息
Department of Cardiology, Hospital de Santa Cruz, Unidade Local de Saúde de Lisboa Ocidental, 2790-134 Carnaxide, Portugal.
Service de Cardiologie CHU de Rouen, 76000 Rouen, France.
出版信息
Eur Heart J Open. 2024 Dec 12;5(1):oeae102. doi: 10.1093/ehjopen/oeae102. eCollection 2025 Jan.
AIMS
Cavotricuspid isthmus (CTI) ablation is the current ablation treatment for typical atrial flutter (AFL). However, post-ablation atrial tachyarrhythmias, mostly in the form of atrial fibrillation (AF), are frequently observed after CTI ablation. We aimed to evaluate the effectiveness and safety of concomitant or isolated pulmonary vein isolation (PVI) in patients with typical AFL scheduled for ablation.
METHODS AND RESULTS
Electronic databases (PubMED, EMBASE, Clinicaltrials.gov) were searched through July, 2024. Randomized controlled trials (RCTs) were eligible if comparing PVI ± CTI ablation vs. CTI alone. The primary outcomes were any sustained atrial arrhythmia, typical AFL relapse, and AF. Secondary outcomes were need for redo-ablation or antiarrhythmic drugs. Random-effects and fixed-effects meta-analyses were undertaken for each individual outcome. Seven RCTs, with a total of 902 patients, were included. Comparing to CTI ablation alone, PVI ± CTI was more effective in preventing atrial tachyarrhythmias [risk ratio (RR) = 0.57, 95% CI: 0.41-0.79, = 0.0007, = 50%, number needed to treat (NNT) = 4.1]. The results were driven mainly by a reduction of new onset/recurrent AF (RR = 0.41, 95% CI: 0.27-0.61, < 0.0001, = 0%, NNT = 3.3), whereas there were no differences in typical AFL relapse (RR = 1.52, 95% CI: 0.63-3.66, = 0.35, = 9%). Major complication rate was low and comparable across groups, although uncomplicated pericardial effusion was higher in PVI ± CTI (1.8% vs. 0.0%, = 0.04). Results were comparable for the sub-analysis of PVI alone vs. CTI ablation.
CONCLUSION
In patients with typical AFL, PVI ± CTI ablation is more effective than CTI alone in reducing the atrial tachyarrhythmias and subsequent AF during follow-up, without affecting major complications rate. These results set the rationale for a well-designed, larger-scale RCT comparing both strategies.
目的
三尖瓣峡部（CTI）消融是目前治疗典型心房扑动（AFL）的消融方法。然而，CTI消融后常出现消融后房性快速性心律失常，大多表现为心房颤动（AF）。我们旨在评估在计划进行消融的典型AFL患者中，联合或单独进行肺静脉隔离（PVI）的有效性和安全性。
方法与结果
检索截至2024年7月的电子数据库（PubMED、EMBASE、Clinicaltrials.gov）。如果比较PVI±CTI消融与单纯CTI消融，则随机对照试验（RCT）符合纳入标准。主要结局为任何持续性房性心律失常、典型AFL复发和AF。次要结局为再次消融或抗心律失常药物的需求。对每个个体结局进行随机效应和固定效应荟萃分析。纳入了7项RCT，共902例患者。与单纯CTI消融相比，PVI±CTI在预防房性快速性心律失常方面更有效[风险比（RR）=0.57，95%可信区间（CI）：0.41 - 0.79，P = 0.0007，I² = 50%，需治疗人数（NNT）=4.1]。结果主要由新发/复发AF的减少所驱动（RR = 0.41，95%CI：0.27 - 0.61，P < 0.0001，I² = 0%，NNT = 3.3），而典型AFL复发无差异（RR = 1.52，95%CI：0.63 - 3.66，P = 0.35，I² = 9%）。主要并发症发生率较低且各组间相当，尽管PVI±CTI组无并发症的心包积液发生率较高（1.8%对0.0%，P = 0.04）。单独PVI与CTI消融的亚组分析结果相似。
结论
在典型AFL患者中，PVI±CTI消融在随访期间减少房性快速性心律失常及随后的AF方面比单纯CTI消融更有效，且不影响主要并发症发生率。这些结果为比较两种策略的精心设计的大规模RCT奠定了理论基础。
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