Substrate modification by pulmonary vein isolation and left atrial linear ablation in patients with persistent atrial fibrillation: its impact on complex-fractionated atrial electrograms

PV and Linear Ablation for CFAEs . Introduction: Linear ablations in the left atrium (LA), in addition to pulmonary vein (PV) isolation, have been demonstrated to be an effective ablation strategy in patients with persistent atrial fibrillation (PsAF). This study investigated the impact of LA linear ablation on the complex‐fractionated atrial electrograms (CFAEs) of PsAF patients. Methods and Results: A total of 40 consecutive PsAF patients (age: 54 ± 10 years, 39 males) who underwent catheter ablation were enrolled in this study. Linear ablation of both roofline between the right and left superior PVs and the mitral isthmus line joining from the mitral annulus to the left inferior PV were performed following PV isolation during AF. High‐density automated CFAE mapping was performed using the NAVX, and maps were obtained 3 times during the procedure (prior to ablation, after PV isolation, and after linear ablations) and were compared. PsAF was terminated by ablation in 13 of 40 patients. The mean total LA surface area and baseline CFAEs area were 120.8 ± 23.6 and 88.0 ± 23.5 cm² (74.2%), respectively. After PV isolation and linear ablations in the LA, the area of CFAEs area was reduced to 71.6 ± 22.6 cm² (58.7%) (P < 0.001) and 44.9 ± 23.0 cm² (39.2%) (P < 0.001), respectively. The LA linear ablations resulted in a significant reduction of the CFAEs area percentage in the region remote from ablation sites (from 56.3 ± 20.6 cm² (59.6%) to 40.4 ± 16.5 cm² (42.9%), P < 0.0001). Conclusion: Both PV isolation and LA linear ablations diminished the CFAEs in PsAF patients, suggesting substrate modification by PV and linear ablations. (J Cardiovasc Electrophysiol, Vol. 23, pp. 962‐970, September 2012)     

一种新的简化方法验证左心房顶部线性阻滞

目的 评价一种新的简化方法验证左心房顶部线完全传导阻滞的可靠性.方法 对31例阵发性心房颤动（房颤）患者双侧肺静脉完全电隔离后进行预部线消融,在窦性心律下用一种新的简化方法评价顶部线是否完全阻滞.假定在窦性心律下,左心房后壁的激动顺序发生变化（变为自下而上）和/或沿顶部消融线记录到连续分布的双电位,顶部线完全传导阻滞即实现.检验结果将与经典的起搏方法进行比较.结果 用简化的方法对31例患者的左心房顶部线进行评价,初次消融后8例未实现传导阻滞,再次标测及消融后所有患者顶部线均实现完全传导阻滞.25例沿左心房顶部消融线可记录到双电位,电位间距为（60±13）ms.窦性心律下左心房顶部左右两端传导延迟（87±11）ms和（82±9）ms（从左心房最早激动算起）,左心耳起搏时左、右两端传导延迟（129±13）ms（P＜0.05）和（135±22）ms（P＜0.05）.该方法评价左心房顶部完全线性阻滞的敏感性、特异性、阳性预测值及阴性预测值分别为100%,88.9%,96.8%和100%.结论 窦性心律下左心房后壁激动顺序变为自下而上以及沿顶部消融线连续双电位分布,提示顶部线性阻滞实现.     

Characterization of conduction recovery across left atrial linear lesions in patients with paroxysmal and persistent atrial fibrillation

Background: Left atrial (LA) linear lesions are effective in substrate modification for atrial fibrillation (AF). However, achievement of complete conduction block remains challenging and conduction recovery is commonly observed. The aim of the study was to investigate the localization of gap sites of recovered LA linear lesions.
Methods and Results: Forty-eight patients with paroxysmal (n = 26) and persistent/permanent (n = 22) AF underwent repeat ablation after pulmonary vein (PV) isolation and LA linear ablation at the LA roof and/or mitral isthmus due to recurrences of AF or flutter. In 35 patients, conduction through the mitral isthmus line (ML) had recovered whereas roof-line recovery was observed in 30 patients. The gaps within the ML were distributed to the junction between left inferior PV and left atrial appendage in 66%, the middle part of the ML in 20%, and in 8% to the endocardial aspect of the ML while only 6% of lines showed an epicardial site of recovery. The RL predominantly recovered close to the right superior PV (54%) and less frequently in the mid roof or close to the left PV (both 23%). Reablation of lines required significantly shorter RF durations (ML: 7.24 ± 5.55 minutes vs 24.08 ± 9.38 minutes, RL: 4.24 ± 2.34 minutes vs 11.54 ± 6.49 minutes; P = 0.0001). Patients with persistent/permanent AF demonstrated a significantly longer conduction delay circumventing the complete lines than patients with paroxysmal AF (228 ± 77 ms vs 164 ± 36 ms, P = 0.001).
Conclusions: Gaps in recovered LA lines were predominantly located close to the PVs where catheter stability is often difficult to achieve. Shorter RF durations are required for reablation of recovered linear lesions. Conduction times around complete LA lines are significantly longer in patients with persistent/permanent AF as compared to patients with paroxysmal AF.     

窦房结病与房颤之间发病的关系

近年来关于窦房结病变 (SND)和心房颤动(房颤,AF)之间发病的离子和分子机制研究很受关注。大量临床和动物实验已经证明窦房结和心房的电-解剖重构与SND和AF相关。心房结构重构与RAS激活有关;窦房结自主节律超极化激活起搏电流I_f和Ca₂ 电流异常,认为是SND和AF的一种关联;Cx40、Cx43和Cx45缝隙链接改变,可能是SND和AF的另一种关联。Emerin、SCN5A和HCN4等基因突变也与SND和AF的发病有关。本文简要概述了这方面的进展。     

左房机械功能对持续性心房颤动电复律术后疗效的影响

目的探讨左房机械功能对持续性心房颤动(简称房颤)电复律术后疗效影响。方法选择30例持续性房颤成功电复律患者,应用超声心动图测定其电复律术后48 h静息时窦性心律(简称窦律)下最大二尖瓣口面积、A波速度峰值(PMA),E波速度峰值(PME),计算左房射血力,测量左房内径,随访2个月,分析左房机械功能指标与持续性房颤电复律术后复发的关系。结果有11例(36.7%)患者电复律术后2个月复发,复发组左房射血力较窦律维持组明显下降[(8.5±2.4)×10-5N vs(11.4±3.6)×10-5N,P=0.020〗;复发组6例左房机械功能低下,较窦律维持组(5例)显著升高(54.5%vs 26.3%,χ2=4.9,P=0.042)。而复发组左房内径有增大的趋势(37.3±4.1mm vs 34.4±4.2 mm,P=0.077)。结论左房机械功能低下是持续性房颤电复律术后近期复发的危险因素。     

心房起搏对病态窦房结综合征伴阵发性心房颤动的预防作用

心房颤动(房颤)是十分常见的心律失常,其发生随着年龄逐渐增加.近年来随着起搏器在临床上应用范围的日益扩大,伴随着起搏器功能的开发及适应证的扩展,起搏与房颤之间的关系受到人们的重视.     

The impact of left atrial pressure on filtered P-wave duration in patients with atrial fibrillation

The cause of prolonged filtered P-wave duration (FPD) remains unclear in atrial fibrillation (AF) patients with normal left atrial size. We investigated whether FPD is associated with left atrial pressure (LAP) in AF patients without prominent LA enlargement. This study included 80 patients (48 men, age 65 ± 9 years, 25 persistent AF) with non-valvular AF who underwent catheter ablation (CA) for AF. LAP was measured in sinus rhythm during CA and signal-averaged electrocardiogram was recorded after CA. We retrospectively assessed the clinical and echocardiographic variables. Prolonged FPD was defined as FPD > 120 ms. Prolonged FPD (FPD > 120 ms) was detected in 23/80 patients (29 %). According to univariate analysis, higher mean LAP (14.9 ± 4.4 vs. 10.8 ± 3.5 mmHg, p < 0.0001), higher prevalence of persistent arrhythmia, higher BNP, larger LAD, higher E wave, and lower LVEF were associated with Prolonged FPD. According to multivariate analysis, higher mean LAP was the only factor associated with Prolonged FPD (p = 0.0058, OR 1.256 for each 1 mmHg increase in mean LAP, 95 % CI 1.068–1.476). Moreover, a significant correlation was observed between FPD and mean LAP (r = 0.503, p < 0.0001). Prolonged FPD is associated with high LAP in AF patients without prominent left atrial enlargement. Pressure overload of the left atria might cause slowing of atrial electrical activation.     

Impact of sinus rhythm restoration and maintenance on left ventricular function and exercise tolerance in patients with persistent atrial fibrillation

BACKGROUND: Although early improvement of haemodynamic parameters following successful cardioversion of atrial fibrillation (AF) has been well documented, the long-term benefits of sinus rhythm (SR) restoration are less obvious, mainly due to a high rate of AF relapses. AIM: To determine the impact of SR restoration and maintenance on exercise tolerance and heart failure progression in patients with persistent non-valvular AF during a one year follow-up period. METHODS AND RESULTS: We studied 104 patients (33 females, 71 males, mean age 60.4+/-7.4 years) with mild to moderate stable heart failure and persistent AF with well-controlled ventricular rate who were scheduled for cardioversion. They underwent submaximal exercise testing 24 hours before cardioversion, as well as 1 and 12 months afterwards. Exercise capacity was determined during symptom-limited exercise testing, according to a modified Bruce protocol. Heart failure symptoms were assessed at the same time-points of follow-up. RESULTS: SR was presented in 66 (63.5%) patients one year after cardioversion. In patients with SR, a significant improvement in left ventricular (LV) performance, exercise capacity and heart failure symptoms was noted. There was an increase in LV fractional shortening (29.9+/-7.6% vs 35.6+/-9.3%; p<0.001), maximal workload (4.7+/-2.3 vs 8.5+/-3.0 MET; p<0.001), exercise duration (125.3+/-115.3 vs 294.7+/-216.7 sec.; p<0.001), and improvement in the NYHA functional class (p<0.001). No such changes were observed in patients who had AF relapse during follow-up or in those who had unsuccessful cardioversion. CONCLUSIONS: Successful cardioversion of persistent AF resulted in a significant improvement of exercise capacity and a decrease in heart failure symptoms during one year follow-up period only in patients who maintained SR.     

持续性房颤患者左房球形指数与左房自发显影的相关性

目的 探讨持续性房颤患者发生左房自发显影的临床特征,分析其与反映左房球形化的左房球形指数之间的相关性。方法 回顾性分析首都医科大学附属北京同仁医院2021年8月至2022年12月收治的96例非瓣膜性持续性房颤患者的临床资料。根据经食道心脏超声有无左房自发显影表现,将患者分为左房自发显影组(54例)及对照组(42例)。对2组患者合并症、实验室检查结果、心脏超声参数及左房球形指数进行比较。采用SPSS 22.0统计软件进行数据分析。根据数据类型,分别采用t检验、Mann-Whitney U检验或χ²检验进行组间比较。应用Pearson相关分析左房球形指数与合并症及心脏超声参数的相关性。采用logistic回归分析左房自发显影的危险因素。结果 左房自发显影组患者女性患者比例、CHA2DS2-VASc评分、D-二聚体水平、氨基末端B型钠尿肽前体(NT-proBNP)水平、左房前后径与横径、左房球形指数均高于对照组,差异有统计学意义(P<0.05)。左房球形指数与体质量指数(BMI)、心力衰竭、左室舒张末内径(r=0.236,0.272,0.212;P<0.05...     

射频导管消融后窦性心律维持对持续性心房颤动患者左心收缩和舒张功能的影响

目的探讨持续性心房颤动(房颤)患者射频消融后窦性心律维持对左心收缩和舒张功能的影响。方法入选2015年12月至2016年12月在江苏省人民医院心内科接受射频消融的持续性房颤患者。前瞻性观察术后第3天、1、2、3、6及12个月患者左心收缩功能[左心房内径(LAD)、左心室收缩末期内径(LVESD)、左心室舒张末期内径(LVEDD)、左心室射血分数(LVEF)]和左心舒张功能[舒张早期经二尖瓣血液流速峰值与舒张晚期流速峰值的比值(E/A)、舒张早期经二尖瓣血液流速峰值与二尖瓣环运动速度比值(E/e′)]的变化。术后相应随访时间点行24 h动态心电图检查以判断房颤是否复发。结果本研究共纳入持续性房颤患者34例,其中男27例、女7例,年龄(59.7±9.1)岁。术后第1、2、3、6和12个月LAD分别为(42.5±4.2)mm、(41.4±4.2)mm、(40.7±3.8)mm、(40.0±3.6)mm及(40.2±3.8)mm,较术后第3天(46.7±4.1)mm明显降低,差异有统计学意义(P<0.001)。术后第12个月LVESD较术前明显降低[(29.8±2.5)mm对(32.4±4.8)mm,P=0.02],但术后第1、2、3、6和12个月的LVEDD与术前相比差异无统计学意义(P=0.93、P=0.83、P=0.90、P=0.54、P=0.76)。术后第2、3、6和12个月时LVEF(66.3%±5.0%,66.7%±5.9%,66.6%±5.9%、68.7%±4.5%)与术前(62.2%±7.0%)相比明显提高,差异有统计学意义(P=0.05、P=0.01、P=0.02、P=0.001);术后第2、3、6和12个月LVEF与术后第1个月相比差异无统计学意义(P=0.73、P=0.54、P=0.57、P=0.10)。术后第1、2、3、6及12个月E/A(1.2±0.6、1.3±1.0、1.1±0.6、1.1±0.3、1.1±0.4)与术后第3天(2.4±1.0)相比差异有统计学意义(P<0.001)。同样,术后第1、2、3、6及12个月的E/e′(11.7±3.5、11.1±3.9、10.9±3.0、11.6±3.2、12.0±3.3)与术后第3天(14.7±4.6)相比差异具有统计学意义(P=0.002、P=0.001、P=0.001、P=0.002、P=0.01)。2例患者分别于术后第6个月和术后1年复发,再次消融均成功。1例患者术后12个月时失访。结论射频导管消融可改善持续性房颤患者的左心收缩和舒张功能,术后第1个月患者的收缩和舒张功能基本恢复。     

A low fibrillatory wave amplitude predicts sinus node dysfunction after catheter ablation in patients with persistent atrial fibrillation

Journal of Interventional Cardiac Electrophysiology - Concealed sinus node dysfunction (SND) may become manifest after restoration of sinus rhythm by ablation in patients with persistent atrial...     

持续性心房颤动患者左心房结构和炎性因子变化分析

目的 研究持续性心房颤动患者炎性因子与心房结构重构的关联性.方法 研究对象为45例持续性心房颤动组和45例对照组.研究对象行超声心动图检测左心房直径,行超声背向散射测定技术检测房间隔和左心房后壁背向散射积分值（integrated backscatter,IBS）和背向散射积分周期变化值（cyclic variation of integrated backscatter,CVIB）.行免疫比浊法和酶联免疫吸附法检测患者血清高敏C-反应蛋白（high-sensitivity C-reactionprotein,hs-CRP）,白细胞介素（interleukin,IL）-6和肿瘤坏死因子（tumor necrosis factor,TNF-α）浓度.结果 持续性心房颤动组左心房直径和血清Hs-CRP、IL-6、TNF-α浓度均高于对照组,差异有统计学意义（P＜0.05）.心房颤动患者左心房直径与各血清炎性因子浓度（hs-CRP、IL-6和TNF-α）呈正相关（r=0.825,P＜0.01;r=0.432,P＜0.01;r=0.357,P＜0.01）.左心房直径＞40 mm亚组血清hs-CRP、IL-6和TNF-α浓度均高于左心房直径≤40 mm亚组,差异有统计学意义（P＜0.05）.结论 炎性因素参与了心房颤动的发病过程,血清hs-CRP、IL-6和TNF-α浓度与心房颤动的持续状态有关,心房纤维化和心肌重构也参与了心房颤动的发生和维持.     

Dissociation between coronary sinus and left atrial conduction in patients with atrial fibrillation and flutter

INTRODUCTION: Coronary sinus (CS) recordings are routinely used during electrophysiologic studies for various supraventricular and ventricular arrhythmias with the understanding that they represent left atrial (LA) activity. However, the behavior of CS electrical activity during atrial arrhythmias has not drawn any special attention beyond standard considerations. METHODS AND RESULTS: The study population consisted of 9 patients (3 women; mean age 59 +/- 11 years) with atrial fibrillation (AF) and atrial flutter (AFL) who developed dissociation of conduction between the CS and posterior LA during spontaneous AF and AFL. In all patients, the LA and the CS were mapped using a 64-electrode basket catheter and a multipolar electrode catheter, respectively. The right atrium (RA) was mapped simultaneously using a 24-polar electrode catheter (7 patients) or a 64-electrode basket catheter (2 patients). Eight patients showed stable double potentials in CS recordings during AF (9 episodes) and AFL (3 episodes). During ongoing arrhythmias, the first row of potentials maintained a constant relationship with the RA activity, whereas the second row of potentials was discordant with the posterior wall of the LA in 7 patients and concordant in 2 patients. In 1 patient with counterclockwise AFL, CS activation was isolated from the posterior wall of the RA until it reached the distal portion of the CS, after which it entered the lateral region of the LA. In 1 patient, a macroreentrant LA tachycardia involving CS muscle was observed. Rapid atrial pacing from the proximal CS and extrastimuli produced longitudinal dissociation of CS activation in all patients. CONCLUSION: Conduction between the CS and posterior LA can be dissociated during spontaneous atrial arrhythmias and provocative proximal CS pacing.