心房颤动导管消融治疗:未来走向平坦之路?

长久以来,心房颤动(房颤)的治疗一直困扰着我们,过去10年开展的导管射频消融术为房颤治疗带来了革命性的变化,同期,新型抗凝药物及抗心律失常药物的不断涌现也为房颤治疗增添了不少亮点.今天当我们再次从改善症状和预后的角度考虑房颤的治疗策略时,是否会有新的启示与发现?

Catheter ablation of atrial fibrillation:is or not a bright road in the future?

Catheter ablation of atrial fibrillation (AF) has opened a new door to cure AF and is fundamental-ly changing our clinical practice. The emergence of novel anticoagulation drugs and antiarrhythmic agents also bring us great hope and enriches our therapeutic options. When we reconsider the strategy of AF with regards to symptom relief and prognosis improvement, perhaps we will achieve new understanding and judgment. The newly issued study by Forleo1] evaluated the safety and efficacy of ablation therapy in type 2 diabetes mellitus patients with drug refractory AF. The results showed that patients who received a single ablation procedure but without medications were more free of AF than patients in the antiarrhythmic drugs (AADs) group(20% vs 57.1% ,P =0.001). In the ablation group, a significant improvement in quality-of-life (QoL) scores as compared with AADs group was also observed. Another A4 clinical trial was a randomized multicenter clinical study that compared the relative merits between pharmacology and catheter ablation of AF2]. At the 1-year follow-up, patients in ablation group experienced lower re-currence than patients in AADs group (11% vs 77%, P <0.0001). Symptom score, exercise capacity, and QoL were significantly higher in the ablation group. The results of another trial PABA-CHF3] identified pulmonary-vein isolation was superior to atrioventricular-node ablation with biventricular pacing in patients with heart failure on questionnaire score of QoL, 6-minute-walk distance and ejection fraction improvement. The observation of Nademanee4] revealed that sinus rhythm was the most important independent favorable parameter for survival for high-risk patients with AF that un-dergo substrate ablation. For patients with sinus rhythm post-ablation the 5-year stroke rate was less than those who re-mained in AF and continued warfarin treatment (3% vs 23%, P =0.004). All of the above studies were consistent with the results of prior studies by Pappone, Oral and other investigators that catheter ablation of AF can not only effectively reduce AF recurrence but also improve the QoL and prognosis of patients with AF.With regard to anticoagulation therapy of AF, there remains lots of practical issues. The actual usage of warfarin is far below the demands of stroke prevention due to inconvenient monitoring and underlying risk of hemorrhage. Although novel anticoagnlation agents emerge endlessly, their actual clinical indications are still underevaluated until large scale randomized clinical trials are completed. As the new generation of AADs, Dronedarone had been expected to completely replace warfarin due to relative higher security. But the results of the ANDROMEDA trial5] and ATHENA trial indicated that Dronedarone increases adverse reactions and worsens mortality in AF patients with heart dysfunction. By far, nearly all clinical studies referring to AADs on AF demonstrated limited effcacies and disappointing prognostic results. On the contrary, the researches on catheter ablation of AF consistently showed the clinical ad-vantage of catheter ablation on symptom control, recurrence prevention and prognosis improvement. Catheter abla-tion of AF is merging into the main stream of AF management.Although catheter ablation of AF in China has recently experienced fast development and is approaching an ad-vanced level similar to other countries, the actual numbers of ablation eases are still insufficient when considering the huge population of AF in China. Thus, when we strengthen the regularization of stoke prevention for AF pa-tients, we should simultaneously promote the development of AF ablation.