Kalman Jonathan M, Kistler Peter M, Hindricks Gerhard, Sanders Prashanthan
Department of Cardiology, Royal Melbourne Hospital, Grattan St., Parkville, Melbourne 3050, Australia.
Department of Medicine, University of Melbourne, Parkville, Melbourne 3052, Australia.
Eur Heart J. 2025 Mar 3;46(9):805-813. doi: 10.1093/eurheartj/ehae892.
Convincing evidence for the efficacy of ablation as first-line therapy in paroxysmal AF (PAF) and its clear superiority to medical therapy for rhythm control in both PAF and persistent AF (PsAF) has generated considerable interest in the optimal timing of ablation. Based on this data, there is a widespread view that the principle of 'the earlier the better' should be generally applied. However, the natural history of AF is highly variable and non-linear, and for this reason, it is difficult to be emphatic that all patients are best served by ablation early after their initial AF episodes. Sufficient evidence exists to indicate a conservative approach is reasonable in patients with infrequent and non-progressive episodes (i.e. absence of progressive increase in burden culminating in PsAF) in whom symptoms remain mild and well-controlled. A conservative management phase should be marked by assiduous attention to risk factor modification, changes in frequency and duration of AF episodes, and patient preferences. If and when AF does begin to progress, accumulating evidence indicates that early ablation accompanied by ongoing attention to risk factors provides the best outcomes.
有令人信服的证据表明，消融作为阵发性房颤（PAF）的一线治疗方法具有疗效，并且在PAF和持续性房颤（PsAF）的节律控制方面明显优于药物治疗，这引发了人们对消融最佳时机的极大兴趣。基于这些数据，普遍认为应普遍应用“越早越好”的原则。然而，房颤的自然病程高度可变且呈非线性，因此，很难强调所有患者在首次房颤发作后尽早进行消融就是最佳选择。有充分证据表明，对于发作不频繁且无进展（即不存在发作负担逐渐加重最终发展为PsAF）、症状仍轻微且得到良好控制的患者，采取保守方法是合理的。保守管理阶段应以密切关注危险因素的改变、房颤发作频率和持续时间的变化以及患者偏好为特征。如果房颤确实开始进展，越来越多的证据表明，早期消融并持续关注危险因素可带来最佳结果。
