环肺静脉电隔离对阵发性心房颤动患者左房功能的影响

目的应用超声心动图技术评价环肺静脉电隔离术(CPVA)对阵发性心房颤动(PAF)患者左房功能的影响。方法 PAF患者81例,择期行CPVA,据术后PAF有无复发分为成功组及复发组;应用超声心动图测定术前及术后3天、3个月、12个月时静息状态下左房主动排空容积(LAAEV)、左房主动排空分数(LAAEF)、左房最大容积(LAVmax)、左房总排空容积(LATEV)、左房总排空分数(LATEF)、二尖瓣血流频谱A峰峰值流速(VA)、A峰速度时间积分(A-VTI)及左房射血力(LAEF)。结果成功组,术后3个月与术前比较,反应左房辅助泵功能的指标LAAEV、VA、A-VTI及LAEF均减少(P0.05);术后12个月与术前比较,LAAEV、VA、A-VTI及LAEF均增加(P0.05),反映左房储存功能的指标LAVmax、LATEV及LATEF均增加(P0.05)。复发组,术后12个月与术前比较,LAAEV、VA、A-VTI及LAEF均减少(P0.05)。结论 CPVA对PAF患者术后近期左房功能有不利影响,而术后远期功能得到明显改善。     

Phased-array intracardiac echocardiography during pulmonary vein isolation and linear ablation for atrial fibrillation

INTRODUCTION: Fluoroscopic imaging provides limited anatomic guidance for left atrial structures. The aim of this study was to determine the utility of real-time, phased-array intracardiac echocardiography during radiofrequency ablation for atrial fibrillation. METHODS AND RESULTS: In 29 patients undergoing pulmonary vein isolation (n = 16) or linear (n = 13) left atrial radiofrequency ablation for atrial fibrillation, intracardiac phased-array echocardiography was used to visualize left atrial anatomy and the pulmonary veins, as well as ablation and mapping catheters during ablation procedures. In the 16 pulmonary vein isolation patients, the mean pulmonary vein ostial diameters measured by venography and intracardiac echocardiography were similar for all veins positions, except that left common pulmonary vein diameters were larger as measured by echocardiography (2.50 +/- 0.29 cm) than by venography (1.79 +/- 0.50 cm, P = 0.001). The ostial diameters measured by echocardiography and venography were not correlated, however (r = 0.23, P = 0.19). As directed by echocardiography, only 1 of 25 circular mapping catheters (4%) used in 16 patients was replaced due to inappropriate sizing of the pulmonary veins. Mean pulmonary vein Doppler flow velocities increased after ablation for left-sided veins but ostial diameters were unchanged. In the linear ablation patients, the entire extent of the linear electrode array could be visualized in only 3 of 52 of catheter positions (6%) in the 13 patients. A portion of the catheter could be seen in only 50% of all target catheter positions. CONCLUSION: Phased-array intracardiac echocardiography (1) allows sizing and positioning of pulmonary vein mapping catheters, (2) provides measures of pulmonary vein ostial diameters, (3) continuously monitors pulmonary vein Doppler flow velocities, and (4) has limited use in positioning linear ablation catheters in the left atrium.     

Bi-directional electrical pulmonary vein isolation as an endpoint for ablation of paroxysmal atrial fibrillation

Objective Various approaches to pulmonary vein (PV) isolation have shown variable efficacy in patients with paroxysmal atrial fibrillation (AF). The purpose of this study is to report the efficacy and safety of routine isolation of all PVs using an endpoint of bi-directional electrical block. Materials and methods This study included 85 consecutive patients who underwent PV isolation for symptomatic paroxysmal AF. Complete isolation of all PVs was confirmed by demonstration of bi-directional block: (a) loss of all PV potentials, and (b) failure to capture the left atrium by pacing 10–14 bipolar pairs of electrodes on a circumferential catheter placed at the entrance of the PV at 10 mA with 2 ms pulse width. Induction of AF by burst pacing was attempted after PV isolation. Results Freedom from symptomatic or asymptomatic AF (detected by event recorder or Holter monitor) was present in 85% and 76% of patients at 6 and 12 months. Additional mitral isthmus or posterior left atrial lines were performed in seven patients with inducible atrial arrhythmias after PV isolation. Atrial tachycardia occurred in three of these patients during long-term follow-up and in two of the 78 patients without additional ablation. Conclusion The use of bi-directional block circumferentially across all PV ostia as an electrophysiological endpoint may improve results of PV isolation for paroxysmal AF. Avoidance of routine additional left atrial ablation lines may decrease the risk of atrial tachycardia and esophageal fistula. Dr. Essebag is the recipient of a Clinician Scientist Award from the Canadian Institutes of Health Research (CIHR). Dr. Reynolds is the recipient of grant #1K23HL077171-01 from the National Heart, Lung, and Blood Institute (NHLBI).     

肺静脉电隔离治疗左心房线性消融后复发的心房颤动--肺静脉电隔离的必要性

自90年代后期射频导管消融治疗心房颤动(房颤)应用于临床以来，对房颤的发生机制的认识及治疗方法有了越来越多的研究与报道。目前尚无充分的证据支持以任何一种方法完全取代另外一种，在不同的中心采用的方法亦不统一。以下结合1例肺静脉电隔离成功治疗左心房线性消融后复发的阵发性房颤，以阐明肺静脉电隔离的必要性。     

Thoracoscopic epicardial pulmonary vein ablation for lone paroxysmal atrial fibrillation.

Surgical treatment of atrial fibrillation recently gained new popularity since the introduction of different energy sources for ablative therapy as an alternative to the original "cut-and-sew" techniques. However, most of the cases have been performed together with other cardiac surgical procedures and mainly through a standard median sternotomy approach. We report here the first European case of closed-chest thoracoscopic pulmonary vein isolation in a patient with lone paroxysmal atrial fibrillation.     

肺静脉节段性消融治疗阵发性心房颤动

肺静脉内的折返是促使心房颤动（房颤）发作的最可能机制，肺静脉在房颤的发生和维持机制中起重要作用。在实时左心房三维标测系统（Carto）指导下，肺静脉环状射频消融电隔离治疗阵发性房颤已成为可能。这里我们评价术前16排螺旋CT指导下肺静脉节段性消融治疗顽固性阵发性房颤的临床效果。     

实时三维超声结合斑点追踪超声评价阵发性房颤患者射频消融术后左室同步性及收缩功能

目的 探讨实时三维超声心动图（RT-3DE）联合斑点追踪超声（STE）无创评价阵发性房颤（PAF）患者射频消融手术前后左心室同步性及收缩功能变化。方法 40例接受环肺静脉射频消融治疗的PAF患者术前、术后3个月窦性心律下进行RT-3DE及STE检测。Qlab7.0脱机分析3D-Advanced软件得到左室17节段时间-容积曲线,将左室特定节段到达最小收缩容积（Tmsv）时间的标准差校正值和达到最小收缩容积（Tmsv）最大时间差的校正值（Tmsv 16-SD%、Tmsv 12-SD%、Tmsv 6-SD%、Tmsv 16-Dif%、Tmsv 12-Dif%、Tmsv 6-Dif%）作为评价左室收缩同步性的指标。Qlab7.0脱机分析TMQA软件得到左室整体纵向收缩期峰值应变（GlS）、径向收缩期峰值应变（GrS）和圆周收缩期峰值应变（GcS）。结果 40例PAF患者术后3个月有4例复发,36例患者维持窦性心律（PAF组）。PAF组左室整体射血分数（GLVEF）与正常对照组相比未见统计学差异（57.4±6.6 vs 59.3±7.7 P>0.05）。维持窦律者纳入术后研究,PAF组术前Tmsv 16-SD%、Tmsv 12-SD%、Tmsv 6-SD%、Tmsv 16-Dif%、Tmsv 12-Dif%、Tmsv 6-Dif%与对照组比较均显著延长（P均<0.05）。术后3个月上述指标较术前缩短,差异有统计学意义（P<0.05）。与正常对照组相比,PAF组GlS、GrS、GcS明显降低（-12.61±5.46 vs-23.42±7.59,-18.71±9.74 vs -33.22±8.67,-15.43±7.11 vs -25.49±9.63 P<0.05）;术后3个月与术前相比,上述指标明显增加（-16.40±6.55 vs-12.61±5.46,-25.37±8.36 vs -18.71±9.74,-18.74±7.56 vs -15.43±7.11 P<0.05）。结论 RT-3DE联合STE可评价PAF患者环肺静脉射频消融术后左室协调性及收缩功能。     

肺静脉电隔离对环肺静脉线性消融术效果的影响

目的:探讨肺静脉完全隔离与否对环肺静脉线性消融术治疗阵发性心房颤动(Af)效果的影响。方法:63例阵发性Af患者随机分为隔离肺静脉组(30例)和不隔离肺静脉组(33例)。所有患者均在三维电解剖系统指导下完成环左右肺静脉线性消融。在术前和术后均放置10极环状导管(Lasso)以标测各肺静脉电位情况,对隔离肺静脉组,如环肺静脉消融完成后仍残存肺静脉电位则补充进行节段性肺静脉隔离,而对不隔离肺静脉组环肺静脉消融完成后不作进一步处理。结果:环肺静脉消融完成后,不隔离肺静脉组33例患者中30例(90.9%)未达完全肺静脉隔离。隔离肺静脉组30例患者中26例(86.7%)未达完全肺静脉隔离,在行补充性节段消融后,隔离肺静脉组完全肺静脉电隔离率达96.7%(29/30)。平均随访(11±3)个月后,不隔离肺静脉组81.8%(27/33)的患者和隔离肺静脉组83.3%(25/30)的患者停用抗心律失常药物后无Af发作,2组间差异无统计学意义。结论:环肺静脉线性消融术用于治疗阵发性Af时,术中完全的肺静脉电隔离对于提高长期疗效并非必需。     

Randomized comparison between pulmonary vein antral isolation versus complex fractionated electrogram ablation for paroxysmal atrial fibrillation

Catheter Ablation of Paroxysmal AF. Introduction: Circumferential pulmonary vein antral isolation (PVAI) and atrial complex fractionated electrograms (CFEs) are both ablative techniques for the treatment of paroxysmal atrial fibrillation (PAF). However, data on the comparative value of these 2 ablation strategies are very limited. Methods and Results: We randomized 118 patients with drug‐refractory PAF to receive PVAI ablation (n = 60) or CFE ablation (n = 58). For CFE group, spontaneous/induced AF was mapped using validated, automated software to guide ablation until all CFE areas were eliminated. For PVAI group, all 4 pulmonary vein antra were electrically isolated as confirmed by circular mapping catheter. Patients with spontaneous/inducible AF after the initial ablation procedure were crossed over to the other arms. After initial ablation procedure, AF persisted/inducible in 24/59 patients (41%), and 34/58 patients (59%) assigned to PVAI and CFE ablation, respectively (P = 0.05). Then 58 patients underwent PVAI + CFE ablation. After 22.6 ± 6.4 months, PVAI ablation group was more likely than CFE ablation group to achieve control of any AF/atrial tachycardia (AT) off drugs (43/60, 72% vs 33/58, 57%, P = 0.075) and lower recurrence rate of AT (11.9% vs 34.5%, P = 0.004). Patients who received CFE ablation alone (38%) had significantly lower overall success rate to achieve control of AF/AT off drugs compared with patients who received PVAI ablation (77%, P = 0.002) alone or PVAI + CFE ablation (69%, P = 0.008) due to higher recurrence rate of AT (50% vs 6% vs 13%, P < 0.01). Conclusions: CFE ablation in PAF patients was associated with higher occurrence rate of postprocedure AT compared with PVAI ablation, whereby making it less likely to be a sole ablation strategy for PAF patients. (J Cardiovasc Electrophysiol, Vol. 22, pp. 973‐981, September 2011)     

阵发性心房颤动冷冻消融与射频消融早期复发及其预测因素对比

目的评价阵发性心房颤动(简称房颤)患者采取二代冷冻消融(CB)及射频消融(RF)早期复发的对比及其预测因素。方法入选拟行阵发性房颤消融术的患者160例。分为CB组和RF组,各组80例。比较两组患者临床资料,分别于术前及术后24 h测定炎症因子和心肌损伤标志物。明确两组术后房颤早期复发的危险因素。结果两组性别、年龄、发病时间及左房内径均无差异。CB组与RF组早期复发率无差异(33.8%vs 32.5%,P>0.05)。术前两组炎症因子和心肌损伤标志物无差异。术后CB组心肌损伤标志物肌钙蛋白、肌酸激酶、肌酸激酶同工酶及谷草转氨酶的升高明显高于RF组(P<0.05)。Logistic多因素回归分析示性别、左房内径、术前白介素-6(IL-6)值及术后IL-6值是RF组早期复发的独立危险因素,对于CB组,只有性别是房颤早期复发的独立危险因素(女性患者更高,P<0.05)。结论冷冻消融与射频消融早期复发率无明显差别,并且由于其心肌损伤方式不同,术后预测早期复发因素有所不同。     

经导管环肺静脉左房线性消融术对阵发性心房颤动患者左心房结构和功能的影响

目的: 评价环肺静脉左房线性消融术对阵发性心房颤动（房颤）患者左心房结构和功能的影响。方法: 阵发性房颤患者33例,Carto系统下行环肺静脉左房线性消融术,应用超声心动图测定其消融术前1～3 d、术后1、3、6、12个月静息时窦性心律下左心房内径、容积指标、二尖瓣口A波速度峰值(VA)及E波速度峰值(VE),并计算左心房排空分数,分析消融术前后左心房结构和功能的变化。结果: 33例阵发性房颤患者均成功施行环肺静脉左房线性消融术,1年治愈率82%。左房前后径消融术后1个月较术前显著增大［(44±4)mm vs. （41±3）mm,P<0.01］,术后3个月、6个月时与术前比较无显著差异,随访1年时左房前后径较术前有显著减小［（40±3）mm vs. (41±3)mm,P<0.05］。与左心房辅助泵功能相关的左心房最小容积,术后1个月显著增大,左心房主动排空分数、左心房总排空分数显著降低（P<0.05),术后3个月时恢复到术前水平。VA术后均低于术前（P<0.05,P<0.01）,而VE/VA术后1个月显著上升（P<0.05,P<0.01）,但在随后的随访中与术前无显著差异。 结论: 阵发性房颤患者左房环肺静脉线性消融术后近期左房前后径增大,辅助泵功能下降,术后3个月恢复至术前水平,术后1年左房结构可部分逆重构。