De Sisti A, Leclercq J F, Fiorello P, Palamara A, Attuel P
Divisione di Cardiologia, Ospedale Sandro Pertini, Roma.
G Ital Cardiol. 1998 Nov;28(11):1253-60.
Although the safety and effectiveness of radiofrequency (RF) transcatheter ablation in patients with atrial flutter (AFL) is well established, little attention is paid to previous history of associated paroxysmal atrial fibrillation (AF) and the recurrence of AFL after RF ablation. In addition, it is not known whether the elimination of AFL can modify the natural history of AF in patients who experience both of these arrhythmias. Accordingly, the aim of this study was to evaluate the effect of RF ablation of AFL in patients with or without a previous history of AF in terms of the incidence of both arrhythmias in the follow-up.
RF ablation of the atrial isthmus between tricuspid ring, coronary sinus os and inferior vena cava was performed in 27 patients (23 males, 4 females; mean age 61 +/- 9 years) according to the technique described by Cosio. Based on ECG pattern, twenty patients exhibited common or type 1 AFL (negative F waves in the inferior leads with a sawtooth morphology), while seven patients had both common and uncommon AFL (various surface F wave morphologies, generally positive F waves in the inferior leads). A history of association between AFL and paroxysmal AF was documented in 48% of patients, but AFL was the major arrhythmia. After ablation, the patients were followed up and the clinically documented occurrence of arrhythmias was determined.
Based on clinical history before ablation, we compared patients with an association between AFL and AF (Gr AFL + AF; n = 13) vs patients with only AFL (Gr AFL; n = 14). The characteristics of the two groups were similar regarding age, sex, duration of symptom, structural heart disease, left atrial size, P-wave duration, AFL interruption during RF procedure, antiarrhythmic treatment before and after RF procedure, and duration of follow-up. During a follow-up of 12 +/- 6 months, AFL recurred in 10 patients (37%), 4 from Gr AFL + AF, and 6 from Gr AFL (p = NS). Episodes of paroxysmal AF occurred in 6 patients (22%), 5 from Gr AFL + AF and 1 from Gr AFL (p < 0.05). In Gr AFL + AF, the incidence of AF after ablation was significantly lower (1.8 +/- 0.6 vs. 0.7 +/- 1 episodes/year; p < 0.02). Characteristics of patients with or without AFL recurrence in the follow-up were similar. The percentage of patients with the occurrence of AFL or AF, associated or unassociated in the follow-up, was 55%.
A history of paroxysmal AF before RF ablation of AFL is not predictive of long-term success or failure of the procedure when considering the recurrence of AFL alone. Nevertheless, the general results are disappointing because the majority of patients have arrhythmias, AFL or AF, associated or unassociated in the follow-up. A clinical history of AF before ablation is correlated with a higher incidence of AF in the follow-up. In any event, the incidence of AF episodes is lower in the follow-up, indicating a possible beneficial effect of AFL ablation on AF mechanisms.
尽管经导管射频（RF）消融治疗心房扑动（AFL）患者的安全性和有效性已得到充分证实，但对于既往阵发性心房颤动（AF）病史以及RF消融术后AFL复发情况关注较少。此外，尚不清楚消除AFL是否会改变同时患有这两种心律失常患者的AF自然病程。因此，本研究的目的是评估RF消融AFL对有或无AF病史患者两种心律失常在随访中的发生率的影响。
根据Cosio描述的技术，对27例患者（23例男性，4例女性；平均年龄61±9岁）进行了三尖瓣环、冠状窦口和下腔静脉之间心房峡部的RF消融。根据心电图模式，20例患者表现为常见或1型AFL（下壁导联F波为负向，呈锯齿状形态），而7例患者既有常见AFL又有不常见AFL（各种体表F波形态，下壁导联F波通常为正向）。48%的患者记录有AFL与阵发性AF相关病史，但AFL是主要心律失常。消融后，对患者进行随访并确定临床记录的心律失常发生情况。
根据消融前的临床病史，我们比较了AFL与AF相关患者组（AFL+AF组；n=13）和仅患有AFL患者组（AFL组；n=14）。两组在年龄、性别、症状持续时间、结构性心脏病、左心房大小、P波持续时间、RF手术期间AFL中断情况、RF手术前后的抗心律失常治疗以及随访持续时间方面特征相似。在12±6个月的随访期间，10例患者（37%）AFL复发，其中4例来自AFL+AF组，6例来自AFL组（p=无显著性差异）。6例患者（22%）发生阵发性AF，5例来自AFL+AF组，1例来自AFL组（p<0.05）。在AFL+AF组中，消融后AF的发生率显著较低（1.8±0.6次/年对0.7±1次发作/年；p<0.02）。随访中有无AFL复发患者的特征相似。随访中发生AFL或AF（相关或不相关）的患者百分比为55%。
在仅考虑AFL复发时，AFL射频消融术前的阵发性AF病史并不能预测该手术的长期成功或失败。然而，总体结果令人失望，因为大多数患者在随访中存在相关或不相关的心律失常，即AFL或AF。消融术前的AF临床病史与随访中较高的AF发生率相关。无论如何随访中AF发作的发生率较低，表明AFL消融对AF机制可能有有益作用。
