Haïssaguerre M, Jaïs P, Shah D C, Gencel L, Pradeau V, Garrigues S, Chouairi S, Hocini M, Le Métayer P, Roudaut R, Clémenty J
Service de Cardiologie, Hôpital Cardiologique, Bordeaux, France.
J Cardiovasc Electrophysiol. 1996 Dec;7(12):1132-44. doi: 10.1111/j.1540-8167.1996.tb00492.x.
Atrial fibrillation (AF), the most common arrhythmia, is due to multiple simultaneous wavelets of reentry in the atria. The only available curative treatment is surgical, using atriotomies to compartmentalize the atria. Therefore, we investigated a staged anatomical approach using radiofrequency catheter ablation lines to prevent paroxysmal AF.
Forty-five patients with frequent symptomatic drug-refractory episodes of paroxysmal AF were studied. Progressively complex linear lesions were created by sequential applications of radiofrequency current in the right atrium and then in the left atrium if required. The outcome of the procedure was considered a success when the episodes of AF were either eliminated or recurred at a rate of no more than one episode (lasting < 6 hours) in 3 months. Patients who had no more than one episode per month were considered "improved." Right atrial ablation organized local electrical activity and led to stable sinus rhythm during the procedure in 18 (40%) of the 45 patients. However, sustained AF remained inducible in 40 of 45 patients, and the lesions failed to produce evidence of a significant linear conduction block/delay in all but four patients. There were no significant complications except for two transient sinus node dysfunctions. The procedure duration and fluoroscopic time were 248 +/- 79 and 53 +/- 22 min, respectively. Additional sessions were required in 19 patients to treat sustained right atrial flutter or arrhythmias linked to ectopic right or left atrial foci. During a mean follow-up of 11 +/- 4 months, right atrial ablation was successful in 15 (33%) patients, 6 without medication and 9 with a previously ineffective drug. Nine (20%) additional patients were improved. Ten patients with an unsuccessful outcome then underwent linear ablation in the left atrium. The procedure duration and fluoroscopy time were 292 +/- 94 and 66 +/- 24 min. A hemopericardium occurred in one patient. Two patients required reablation to treat ectopic atrial foci. Left atrial ablation terminated AF during the procedure in 8 patients, and sustained AF could not be induced in 5. Subsequent success was achieved in 6 (60%) patients, including 4 without medication, and 1 additional patient was improved.
Successful radiofrequency catheter ablation of drug-refractory daily paroxysmal AF is feasible using linear atrial lesions complemented by focal ablation targeted at arrhythmogenic foci. Ablation only in the right atrium is a safe technique providing limited success, whereas linear lesions in the left atrium significantly increase the incidence of stable restoration of sinus rhythm, the inability to induce sustained AF, and the final success rate. The described technique is promising but must be considered preliminary because significant improvements are required to optimize lesion characteristics and shorten total procedure duration.
心房颤动（AF）是最常见的心律失常，由心房内多个同时存在的折返小波引起。唯一可用的根治性治疗方法是手术，通过心房切开术将心房分隔开。因此，我们研究了一种分阶段的解剖学方法，使用射频导管消融线来预防阵发性AF。
对45例有频繁症状性药物难治性阵发性AF发作的患者进行了研究。通过在右心房依次施加射频电流，必要时再在左心房施加，形成逐渐复杂的线性病变。当AF发作被消除或复发率不超过每3个月1次发作（持续时间<6小时）时，该手术结果被认为是成功的。每月发作不超过1次的患者被认为“有所改善”。右心房消融使局部电活动有序，并使45例患者中的18例（40%）在手术过程中维持稳定的窦性心律。然而，45例患者中有40例仍可诱发持续性AF，除4例患者外，其余患者的病变均未产生明显线性传导阻滞/延迟的证据。除2例短暂性窦房结功能障碍外，无明显并发症。手术时间和透视时间分别为248±79分钟和53±22分钟。19例患者需要额外的手术来治疗持续性右心房扑动或与右或左心房异位灶相关的心律失常。在平均11±4个月的随访中，右心房消融在15例（33%）患者中成功，6例无需药物治疗，9例使用先前无效的药物。另外9例（20%）患者有所改善。10例手术结果未成功的患者随后进行了左心房线性消融。手术时间和透视时间分别为292±94分钟和66±24分钟。1例患者发生心包积血。2例患者需要再次消融以治疗心房异位灶。左心房消融使8例患者在手术过程中终止AF，5例患者不能诱发持续性AF。随后6例（60%）患者取得成功，包括4例无需药物治疗，另外1例患者有所改善。
使用线性心房病变并辅以针对致心律失常灶的局灶性消融，成功进行射频导管消融治疗药物难治性每日阵发性AF是可行的。仅在右心房进行消融是一种安全的技术，但成功率有限，而左心房的线性病变显著提高了窦性心律稳定恢复、不能诱发持续性AF以及最终成功率的发生率。所描述的技术很有前景，但必须被视为初步的，因为需要显著改进以优化病变特征并缩短总手术时间。
