Brasca Francesco M, Curti Emanuele, Perego Giovanni B
Istituto Auxologico, IRCCS Ospedale S. Luca, 20149 Milan, Italy.
J Clin Med. 2025 Mar 18;14(6):2071. doi: 10.3390/jcm14062071.
The cornerstone of ablative therapy for atrial fibrillation (AF) is pulmonary vein isolation (PVI). Whether PVI should be added with additional lesions in persistent atrial fibrillation (PerAF) or for any post-ablative recurrent AF is a matter of debate. Whatever the ablative strategy, it must determine the choice of energy source to achieve the most durable lesion sets with the least likelihood of complications. Radiofrequency (RF) is the most studied thermal ablation technique. It can be combined with high-density electroanatomic mapping and can be used for both pulmonary and extrapulmonary atrial ablation. Cryoenergy is at least as effective as radiofrequency for PVI; it is rapid, relatively safe, and has a steep learning curve. Therefore, it has been proposed as a first-line approach for PVI-only procedures. More recently, a non-thermal technique based on the application of pulsed direct current (Pulsed Field Ablation-PFA) has been introduced. PFA causes cell death by opening cell membrane pores (electroporation) without a significant increase in tissue temperature. It is fast and does not alter the extracellular matrix as thermal techniques do, although it ends up causing long-lasting, transmural lesions. Most importantly, it is relatively selective on cardiac myocytes and therefore potentially safer than thermal techniques. Some PFA systems can be combined with electroanatomic mapping systems. However, as of now, it appears that these ablation technologies should be considered complementary rather than alternative for a number of practical and theoretical reasons.
心房颤动（AF）消融治疗的基石是肺静脉隔离（PVI）。对于持续性心房颤动（PerAF）或任何消融后复发性房颤，是否应在PVI基础上增加额外的消融灶仍存在争议。无论采用何种消融策略，都必须确定能量源的选择，以实现最持久的消融灶且并发症发生的可能性最小。射频（RF）是研究最多的热消融技术。它可与高密度电解剖标测相结合，可用于肺内和肺外心房消融。冷冻能量在PVI方面至少与射频一样有效；它操作迅速、相对安全且学习曲线较陡。因此，它已被提议作为仅进行PVI手术的一线方法。最近，一种基于脉冲直流电应用的非热技术（脉冲场消融 - PFA）被引入。PFA通过打开细胞膜孔（电穿孔）导致细胞死亡，而不会使组织温度显著升高。它速度快，不会像热技术那样改变细胞外基质，尽管最终会形成持久的透壁性损伤。最重要的是，它对心肌细胞具有相对选择性，因此可能比热技术更安全。一些PFA系统可与电解剖标测系统相结合。然而，截至目前，出于一些实际和理论原因，这些消融技术似乎应被视为互补而非替代。
