Electrical isolation of the superior vena cava: an adjunctive strategy to pulmonary vein antrum isolation improving the outcome of AF ablation

PV isolation at the antrum (PVAI) has improved safety and efficacy of ablation procedures for atrial fibrillation (AF). AF triggers from the superior vena cava (SVC) may compromise the outcome of PVAI.
Purpose: We evaluated the (1) incidence of SVC triggers, (2) feasibility of empiric SVC electrical isolation (SVCI) as an adjunct to PVAI, and (3) SVCI safety.
Methods and Results: Of 190  patients (group I), 24 (12%) showed SVC triggers. Following PVAI, seven patients had AT originating from the SVC and three had AF. After SVCI, all 24  patients were arrhythmia-free 450 ± 180  days post procedure. In the subsequent 217  patients (group II), empirical SVCI was performed following PVAI. Sixty-six of all 407  patients (16%) experienced recurrence of AF.  A repeat procedure in 25 of the 66  patients showed that five (20%) had AF recurrence initiated by SVC triggers, of whom four were among group I patients (4/190; 2%) and one was from group II (1/217; 0.4%), (P < 0.05). Transient diaphragmatic paralysis can be avoided by pacing at the lateral aspect of the SVC using high output (30  mA). There was no SVC stenosis on CT scans before or 3 months after the procedure. There was no sinus node injury.
Conclusions: The SVC harbors the majority of non-PV triggers of AF. SVCI is feasible, safe, and may be considered as an adjunctive strategy to PVAI for ablation of AF. The long-term favorable outcome of this hybrid approach remains to be evaluated in a larger series of patients.     

Pulmonary vein isolation combined with superior vena cava isolation for atrial fibrillation ablation: a prospective randomized study

Aims: Circumferential pulmonary vein isolation (CPVI) is an establishedstrategy for atrial fibrillation (AF) ablation. Superior venacava (SVC), by harbouring the majority of non-pulmonary vein(PV) foci, is the most common non-PV origin for AF. However,it is unknown whether CPVI combined with SVC isolation (SVCI)could improve clinical results and whether SVCI is technicallysafe and feasible. Methods and results: A total of 106 cases (58 males, average age 66.0 ± 8.8years) with paroxysmal AF were included for ablation. They wereallocated randomly to two groups: CPVI group (n = 54) and CPVI+ SVCI group (n = 52). All cases underwent the procedure successfully.Pulmonary vein isolation was achieved in all cases. The proceduraltime and fluoroscopic time were comparable between the two groups.The mean ablation time for SVC was 7.8 ± 2.7 min. Superiorvena cava isolation was obtained in 50/52 cases. In the remainingtwo cases, SVCI was not achieved because of obviating diaphragmaticnerve injury. During a mean follow-up of 4 ± 2 months,12 (22.2%) cases in the CPVI group and 10 (19.2%) cases in theCPVI + SVCI group had atrial tachyarrhythmias (ATa) recurrence(P = 0.70). Nine of 12 cases in the CPVI group and 8/10 casesin the CPVI + SVCI group underwent reablation (P = 0.86), andPV reconnection occurred in 7/9 cases in the CPVI group andin 8/8 cases in the CPVI + SVCI group. All PV reconnection wasreisolated by gaps ablation. There was no SVC reconnection inthe CPVI + SVCI group. In two cases without PV reconnectionfrom the CPVI group, SVC-originated short run of atrial tachycardiawas identified and eliminated by the SVCI. At the end of 12months of follow-up, 50 cases (92.6%) in the CPVI group and49 (94.2%) in the CPVI + SVC group were free of ATa recurrence(P = 0.73). Conclusion: In our series of paroxysmal AF patients, empirically addingSVCI to CPVI did not significantly reduce the AF recurrenceafter ablation. Superior vena cava isolation may be useful,however, in selected patients in whom the SVC is identifiedas a trigger for AF. However, because of the preliminary propertyof the study and its relatively small sample size, the impactof SVCI on clinical results should be evaluated in a large seriesof patients.     

Characteristics and outcome in patients receiving multiple (more than two) catheter ablation procedures for paroxysmal atrial fibrillation

Background: The features of multiple catheter ablation procedures for paroxysmal atrial fibrillation (AF) are unknown. We aimed to investigate the electrophysiologic characteristics and the clinical outcomes in the patients with AF who received more than two ablation procedures.
Methods: The study consisted of 15 consecutive patients (age 48 ± 14 years, 10 males) who had undergone three to five (3.3 ± 0.6) catheter ablation procedures for recurrent paroxysmal AF.
Results: Ten patients had pulmonary vein (PV)-AF and one had AF originating from both PVs and the superior vena cava (SVC) in the first ablation procedure. All of them exhibited PV reconnection during the recurrent episodes. Four of the 15 patients had AF originating from non-PV foci (three from the SVC, one from the crista terminalis) in the first procedure, and two had AF recurrences due to recovered conduction from the SVC. In all patients with PV-AF recurrences, repeated PV isolation procedures could effectively eliminate the AF. The incidence of the need for additional LA linear ablation lesions was higher comparing between the first procedure and in the following ablation procedures (18% vs. 71%, P = 0.02). During a follow-up of 1.7 ± 1.1 years, 73% of the patients remained in sinus rhythm without any antiarrhythmic drugs after the final procedure.
Conclusions: Recovered PV connection was the major cause of the AF recurrences despite undergoing multiple catheter ablation procedures. It is advisable to inspect all PVs during the AF recurrence. Repeated PV isolation plus left atrial linear ablations could effectively eliminate the AF with satisfactory outcomes.     

Electrophysiological characteristics and catheter ablation in patients with paroxysmal supraventricular tachycardia and paroxysmal atrial fibrillation

Introduction: Paroxysmal supraventricular tachycardia (PSVT) is often associated with paroxysmal atrial fibrillation (AF). However, the relationship between PSVT and AF is still unclear. The aim of this study was to investigate the clinical and electrophysiological characteristics in patients with PSVT and AF, and to demonstrate the origin of the AF before the radiofrequency (RF) ablation of AF.
Methods and Results: Four hundred and two consecutive patients with paroxysmal AF (338 had a pure PV foci and 64 had a non-PV foci) that underwent RF ablation were included. Twenty-one patients (10 females; mean age 47 ± 18 years) with both PSVT and AF were divided into two groups. Group 1 consisted of 14 patients with inducible atrioventricular nodal reentrant tachycardia (AVNRT) and AF. Group 2 consisted of seven patients with Wolff-Parkinson-White (WPW) syndrome and AF. Patients with non-PV foci of AF had a higher incidence of AVNRT than those with PV foci (11% vs. 2%, P = 0.003). Patients with AF and atypical AVNRT had a higher incidence of AF ectopy from the superior vena cava (SVC) than those with AF and typical AVNRT (86% vs. 14%, P = 0.03). Group 1 patients had smaller left atrial (LA) diameter (36 ± 3 vs. 41 ± 3 mm, P = 0.004) and higher incidence of an SVC origin of AF (50% vs. 0%, P = 0.047) than did those in Group 2.
Conclusion: The SVC AF has a close relationship with AVNRT. The effect of atrial vulnerability and remodeling may differ between AVNRT and WPW syndrome.     

心房颤动上腔静脉节段性电隔离方法及安全性评估

目的:分析心房颤动(房颤)上腔静脉节段性电隔离的具体手术方法,并评估其安全性.方法:入选2017年11月至2018年9月期间我院阵发性房颤患者50例,患者常规进行肺静脉隔离后,继续行上腔静脉隔离.消融前进行上腔静脉造影,显示上腔静脉与右心房解剖关系,并在CARTO系统运用PentaRay电极导管进行上腔静脉及右心房三维...     

Long-term outcome of catheter ablation in patients with atrial fibrillation originating from the superior vena cava

Long‐Term Outcome of SVC AF Ablation. Introduction: Data of the long‐term clinical outcome after superior vena cava (SVC) isolation are limited. We aimed to evaluate the long‐term outcome in patients with atrial fibrillation (AF) who had triggers originating from the SVC and received catheter ablation of AF. Methods and Results: The study consisted of 68 patients (age 56 ± 12 years old, 32 males) who underwent the ablation procedure for drug‐refractory, symptomatic paroxysmal AF originating from the SVC since 1999. Group 1 consisted of 37 patients with AF initiated from the SVC only, and group 2 consisted of 31 patients with both SVC and pulmonary vein (PV) triggers. During a follow‐up period of 88 ± 50 months, the AF recurrence rate was 35.3% after a single procedure. The freedom‐from‐AF rates were 85.3% at 1 year and 73.3% at 5 years. In the baseline study, group 2 had larger left atrium (38 ± 4 mm vs 36 ± 5 mm, P = 0.04), left ventricle (50 ± 5 mm vs 46 ± 5 mm, P = 0.003), and PV diameters. Kaplan–Meier survival analysis showed a higher AF recurrence rate in group 2 compared to that in group 1 (P = 0.012). The independent predictor of an AF recurrence was a larger SVC diameter (P = 0.02, HR 1.4, 95% CI 1.1–1.8). Conclusion: Among the patients with paroxysmal AF originating from the SVC, 73% remained free of AF for 5 years after a single catheter ablation procedure. Superior vena cava isolation without PV isolation is an acceptable therapeutic strategy in those patients with AF originating from the SVC only. The SVC diameter was an independent predictor of AF recurrence. (J Cardiovasc Electrophysiol, Vol. 23, pp. 955‐961, September 2012)     

Efficacy of adjuvant anterior left atrial ablation during intracardiac echocardiography-guided pulmonary vein antrum isolation for atrial fibrillation

Background: Recent data have shown that the septum and anterior left atrial (LA) wall may contain “rotor” sites required for AF maintenance. However, whether adding ablation of such sites to standard ICE‐guided PVAI improves outcome is not well known. Objective: To determine if adjuvant anterior LA ablation during PVAI improves the cure rate of paroxysmal and permanent AF. Methods: One hundred AF patients (60 paroxysmal, 40 persistent/permanent) undergoing first‐time PVAI were enrolled over three months to receive adjuvant anterior LA ablation (Group I). These patients were compared with 100 randomly selected, matched first‐time PVAI controls from the preceding three months who did not receive adjuvant ablation (Group II). All 200 patients underwent ICE‐guided PVAI during which all four PV antra and SVC were isolated. In group I, a decapolar lasso catheter was used to map the septum and anterior LA wall during AF (induced or spontaneous) for continuous high‐frequency, fractionated electrograms (CFAE). Sites where CFAE were identified were ablated until the local EGM was eliminated. A complete anterior line of block was not a requisite endpoint. Patients were followed up for 12 months. Recurrence was assessed post‐PVAI by symptoms, clinic visits, and Holter at 3, 6, and 12 months. Patients also wore rhythm transmitters for the first 3 months. Recurrence was any AF/AFL >1 min occurring >2 months post‐PVAI. Results: Patients (age 56 ± 11 years, 37% female, EF 53%± 11%) did not differ in baseline characteristics between group I and II by design. Group I patients had longer procedure time (188 ± 45 min vs 162 ± 37 min) and RF duration (57 ± 12 min vs 44 ± 20 min) than group II (P < 0.05 for both). Overall recurrence occurred in 15/100 (15%) in group I and 20/100 (20%) in group II (P = 0.054). Success rates did not differ for paroxysmal patients between group I and II (87% vs 85%, respectively). However, for persistent/permanent patients, group I had a higher success rate compared with group II (82% vs 72%, P = 0.047). Conclusions: Adjuvant anterior LA ablation does not appear to impact procedural outcome in patients with paroxysmal AF but may offer benefit to patients with persistent/permanent AF.     

2014年第1期中文目录

目的：分析阵发性心房颤动（房颤）患者左心房低电压与肺静脉电隔离术后复发的关系。方法连续168例阵发性房颤患者[女性76例,年龄（62±11岁）],窦性心律下行左心房高密度（≥100点）标测,之后行肺静脉电隔离术治疗,在肺静脉隔离20min后给予异丙肾上腺素＋腺苷三磷酸（0.2mg/kg）,观察肺静脉传导恢复与否以及是否存在肺静脉外局灶触发的房颤,并对传导恢复的肺静脉以及肺静脉外局灶再次消融,直至激发试验阴性。本组患者均不进行基质改良。低电压的定义为CARTO消融导管记录的心肌局部双极电图振幅＜0.5mV。结果42例（25.0%）患者的左心房存在低电压区,主要位于左心房前壁（22例,52.4%）,与女性和左房直径增大相关。所有患者均完成肺静脉电隔离。随访（23±12）个月,35例患者复发房性快速心律失常,其中左房低电压者14例（14/42,33.3%）,非低电压者21例（21/126,16.7%,P＝0.028）。结论阵发性房颤患者左心房存在低电压区增加肺静脉电隔离术后的复发率,其形成可能与性别和左房直径有关。     

盐水灌注导管电隔离心房-肺(或上腔)静脉治疗阵发性心房颤动的评价

目的评价盐水灌注导管电隔离心房-肺(或上腔)静脉的效果及安全性。方法69例阵发性心房颤动(房颤)患者,男48例,女21例,平均年龄(55±10)岁,平均病史(4.2±1.1)年。所有患者均采用盐水灌注电极进行肺静脉口部节段性消融,电隔离终点为环状标测电极标测的肺静脉电位全部消失。术后随访症状,心电图及24h动态心电图,以无临床症状及无房颤的心电图证据判定为成功。结果69例共电隔离肺静脉206根,上腔静脉11根,右上肺静脉口外点消融1例。即刻电隔离成功率100%,放电时间(2902.0±1326.3)s。随访时间(118.1±69.7)天,成功率71%。结论应用盐水灌注导管电隔离心房-肺(或上腔)静脉消融安全有效,未见严重并发症发生。     

二代冷冻球囊消融犬上腔静脉有效性和安全性研究

目的通过二代冷冻球囊消融隔离犬上腔静脉(SVC),探讨其有效性和安全性,为临床开展冷冻球囊消融SVC提供证据。方法本研究共选取14只犬,通过二代冷冻球囊消融SVC,根据冷冻球囊消融时间用随机数字表法随机分为2组:90 s组和120 s组。术前行SVC造影显示SVC-右心房交界处,将28 mm冷冻球囊放置于SVC-右心房交界处进行冷冻。术后观察40~60 d后再次行电生理检查,之后处死行组织学病理检查。比较术中冷冻参数、并发症及术后窦房结恢复时间等指标。结果2组犬均成功隔离SVC。90 s组与120 s组犬在SVC隔离时间[(24.3±8.1)s对(22.7±9.0)s,P=0.297]、隔离温度[(-23.4±12.5)℃对(-21.5±11.1)℃,P=0.370)]及最低温度[(-51.2±6.2)℃对(-53.3±7.0)℃,P=0.195]均差异无统计学意义。术中90 s组1只犬出现暂时性膈神经损伤,120 s组1只犬出现一过性窦性心动过缓。术后平均观察51 d,90 s组有1只犬出现SVC电位恢复,120 s组全部犬SVC电位均保持隔离(85.7%对100.0%,P=0.299)。术后组织病理显示所有隔离的SVC均达到环形冷冻透壁损伤,高倍镜下未发现窦房结及膈神经损伤。结论二代冷冻球囊可安全有效的消融SVC,且有效冷冻剂量为90 s。     

Catheter Ablation of Paroxysmal Atrial Fibrillation: Have We Achieved Cure with Pulmonary Vein Isolation?

Pulmonary vein isolation (PVI) is the cornerstone of current ablation techniques to eliminate atrial fibrillation (AF), with the greatest efficacy as a stand-alone procedure in patients with paroxysmal AF. Over the years, techniques for PVI have undergone a profound evolution, and current guidelines recommend PVI with confirmation of electrical isolation. Despite significant efforts, PV reconnection is still the rule in patients experiencing post-ablation arrhythmia recurrence. In recent years, use of general anesthesia with or without jet ventilation, open-irrigated ablation catheters, and steerable sheaths have been demonstrated to increase the safety and efficacy of PVI, reducing the rate of PV reconnection over follow-up. The widespread clinical availability of ablation catheters with real-time contact force information will likely further improve the effectiveness and safety of PVI. In a small but definite subset of patients, post-ablation recurrent arrhythmia is due to non-PV triggers, which should be eliminated in order to improve success. Typically, non-PV triggers cluster in specific regions such as the coronary sinus, the inferior mitral annulus, the interatrial septum, the left atrial appendage, the Eustachian ridge, the crista terminalis region, the superior vena cava, and the ligament of Marshall. Focal ablation targeting the origin of the trigger is recommended in most cases. Empirical non-PV ablation targeting the putative substrate responsible for AF maintenance with ablation lines and/or elimination of complex fractionated electrograms has not been shown to improve success compared to PVI alone. Similarly, the role of novel substrate-based ablation approaches targeting putative localized sources of AF (e.g., rotors) identified by computational mapping techniques is unclear, as they have never been compared to PVI and non-PV trigger ablation in an adequately designed randomized trial. This review highlights PVI techniques and outcomes in treating recurrent drug-refractory AF and discusses the potential role of additional non-PV ablation.     

阵发性心房颤动患者非肺静脉触发灶的诱发及消融

目的探讨环肺静脉电隔离（CPVI）术中静脉注射异丙肾上腺素（ISO）和三磷酸腺苷：ATP）,在检出阵发性心房颤动（房颤）非肺静脉触发灶中的价值。方法回顾性分析2010年4～12月色浙江邵逸夫医院心内科所有患者接受三维标测系统指导下CPVI术136例患者,其中87例消融前后分别应用ISO＋ATP诱发房颤,Lasso导管置于右上肺静脉口、消融导管置于左上肺静脉中,结合冠状静冰窦导管判断房颤的触发灶,然后通过消融验证。结果87例首次接受导管消融的阵发性房颤患者,吏用ISO＋ATP后16例证实有非肺静脉房颤触发灶。其中,消融前诱发8例房颤、1例房性心动过速（房塞）、1例频发房性早搏（房早）。2例消融前诱发的患者CPVI术后房性快速性心律失常（ATa）仍存在,余8例及5例消融前未被诱发者CPVI后再次诱发时又检出非肺静脉触发灶。其中,9例为房颤（起源上腔静脉5例、冠状静脉窦内靠近口部1例、左心房后壁2例、不明1例）,3例房性心动过速（均为冠状挣脉窦口起源）和1例频发房性早搏（上腔静脉起源）。14例患者在相应非肺静脉触发灶部位消融后心聿失常均终止,且不再被诱发。2例起源不明的房颤患者电复律后转为窦性心律。随访2年,单次手术或功率为87．5％（14／16）。结论静脉注射ISO＋ATP可简单有效地检出阵发性房颤非肺静脉触发灶。     

非肺静脉起源阵发性心房颤动导管消融效果的中长期随访

目的 肺静脉隔离足治疗阵发性心房颤动(房颤)的主要策略.但是部分阵发性房颤患者的房颤为非肺静脉起源.本文对非肺静脉起源阵发性房颤消融效果进行中长期随访研究.方法 入选256例阵发性房颤患者,其中女性62例,平均年龄(53±2)岁,行电生理检查,共发现27例(占10.5%)为非肺静脉起源(非肺静脉起源组),包括起源于上腔静脉(16例,占59.3%),左心房后壁(4例,占14.8%),界嵴(2例,占7.4%),冠状静脉窦(2例,占7.4%),卵圆窝(1例,占3.7%),左心耳(1例,占3.7%),左心房游离壁(1例,占3.7%).其余患者为肺静脉起源组.非肺静脉起源组中,所有病例的触发灶均在初次消融术中成功消融.4例(14.8%)需行2次消融术,其中3例为上腔静脉起源,1例为左心房后壁起源.肺静脉起源组52例(22.7%)需行2次消融术,6例需3次消融术.结果 非肺静脉起源组随访(40±12)个月,有25例(92.6%)无房颤复发,肺静脉起源组随访(44±12)个月,185例(80.8%)无房颤复发.结论 在房颤某些亚群的治疗中,标测并消融非肺静脉起源的触发灶非常重要.而且对于该类病人,中长期的随访证实中长期成功率较高,提示导管消融治疗房颤有较好的中长期治疗效果.     

导管射频消融经验性肺静脉电隔离治疗心房颤动的疗效评价

研究导管射频消融经验性肺静脉电隔离治疗心房颤动(简称房颤)的疗效,2001年8月到2003年12月连续收治的131例行射频消融治疗的房颤患者中,107例行经验性肺和/或上腔静脉电隔离。术中只要所标测静脉的肌袖电位明确且与心房之间存在传导关系,以及标测和消融电极导管到位不困难,则行环状电极指导下的节段性消融静脉电隔离。术后不用除β受体阻滞剂以外的抗心律失常药物,临床症状缓解且无房颤的心电图证据判定为手术成功。结果:107例房颤患者中105例即刻静脉电隔离成功(98%),平均每人行3.3±0.8根肺或上腔静脉电隔离,共隔离静脉352根。21例因房颤复发再次行射频消融心脏大静脉电隔离(20%),3例进行了第3次手术,平均每人共完成1.2±0.5次静脉电隔离术。82例(78%,82/105)手术成功的患者随访13±8个月,66例患者无临床症状及房颤复发的证据(80%)。结论:射频消融电隔离3根以上心脏大静脉可以预防约4/5患者房颤的复发,但是部分患者可能需要进行多次手术。     

Marshall vein as arrhythmogenic source in patients with atrial fibrillation: correlation between its anatomy and electrophysiological findings

Background: Atrial fibrillation (AF) may originate from catecholamine-sensitive vein of Marshall (VOM) or its ligament in addition to pulmonary veins (PVs). The anatomy of VOM and its relation to arrhythmogenic foci in the left atrium are unknown. We studied the anatomy of VOM and its relation to foci in patients with AF.
Methods: The study population consisted of 100 patients with AF (mean age, 62 years; chronic AF, n = 15). AF sources were determined at baseline and after isoproterenol administration without sedation. VOM was identified by balloon-occluded coronary sinus (CS) angiography. We determined its anatomy in relation to left PVs.
Results: VOM was visualized in 73 patients (73%). Ninety-seven patients had 269 arrhythmogenic foci (PV, n = 77; non-PV, n = 48). Non-PV foci included left atrial posterior wall (24, 9%), left lateral area (12, 4.5%), roof (6, 2.2%), superior vena cava (28, 10.4%), crista terminalis (8, 3.0%), CS (10, 3.7%), and others (10, 3.7%). The incidence of PV foci in the left superior PV (LSPV) was significantly higher in patients with well-developed VOM than in those without (66% vs 42%, P < 0.05). Twenty-eight patients had 30 non-PV foci around the LSPV ostium. We successfully ablated the non-PV foci at the distal end of VOM in 11 patients. The ends of the VOM branches were good markers to search for non-PV foci. Seven of 11 (64%) patients with successful ablation of non-PV foci were free from arrhythmia, whereas only 6 of 17 (35%) were free from arrhythmia in those with residual non-PV foci.
Conclusions: To determine VOM anatomy is important to identify non-PV foci around the ends of VOM.     

Incidence and predictors of very late recurrence of atrial fibrillation after ablation

Introduction: Radiofrequency catheter ablation can effectively treat patients with refractory atrial fibrillation (AF). Very late AF recurrence (≥12 months post-ablation) is uncommon and may represent a unique patient cohort.
Methods and Results: A nested case-control study was performed in the cohort who underwent AF ablation at the University of Pennsylvania to characterize patients who develop very late AF recurrence after ablation. The procedure consisted of isolation of pulmonary veins (PVs) demonstrating triggers and elimination of non-PV triggers initiating AF. Twenty-seven (7.9%) patients with very late recurrence were compared to 219 patients without recurrence and ≥12 months of follow-up. The mean age was 54.6 ± 11.3 years and 79% were men. Very late recurrence patients more likely weighed >200 lbs (70% vs 55%, P = 0.01); during initial ablation had fewer PVs isolated (2.8 ± 1.1 vs 3.3 ± 1.0, P = 0.03); and were less likely to have right inferior PV isolation (37% vs 61%, P = 0.02), less likely to have isolation of all PVs (30% vs 56%, P = 0.01), and more likely to have non-PV triggers (30% vs 11% OR 3.4(95% CI, 1.3–8.7), P = 0.01). PV reconnectivity and new triggers were found in the majority of patients with very late recurrence of AF who underwent repeat ablation.
Conclusion: Very late recurrence of AF more likely occurred in patients >200 lbs who demonstrated non-PV triggers and did not undergo right inferior PV isolation. The majority of patients undergoing repeat ablation for very late recurrence demonstrated PV reconnectivity and new non-PV and PV triggers not observed during the initial ablation.     

Mechanisms of recurrent atrial fibrillation: comparisons between segmental ostial versus circumferential pulmonary vein isolation

Background: Electrical isolation of pulmonary veins (PVs) is an effective therapy for atrial fibrillation (AF). Both segmental ostial PV ablation and circumferential ablation with PV–left atrial (LA) block have been implicated to eliminate AF. However, the mechanism of the recurrent AF after undergoing either strategy remains unclear.
Methods and Results: Of the 73 consecutive patients with symptomatic AF that underwent PV isolation and had recurrences of AF, Group 1 consisted of 46 patients (age 56 ± 13 years old, 35 males) who underwent PV isolation by segmental ostial PV ablation and Group 2 consisted of 27 patients (age 51 ± 11 years old, 24 males) who underwent circumferential ablation with PV–LA block. In Group 1, the earliest ectopic beat or ostial PV potentials were targeted. In Group 2, circumferential ablation with PV–LA block was performed by encircling the extraostial regions around the left and right PVs. During the first procedure, all patients had PV–AF. There was no difference in the non-PV ectopy between Group 1 and Group 2. During the second procedure, the incidence of an LA posterior wall ectopy initiating AF was significantly lower (20% vs. 0%, P = 0.01) in Group 2. There was no difference in the PV ectopy initiating AF during the second procedure.
Conclusion: Circumferential ablation of AF with PV–LA block may eliminate the LA posterior wall ectopy and decrease the incidence of LA posterior wall ectopy initiating AF during the second procedure.     

上腔静脉与界嵴起源心房颤动的电生理特点和导管消融

目的探讨上腔静脉与界嵴起源心房颤动(简称房颤)的电生理特点和导管消融。方法9例房颤患者,完成环肺静脉电隔离后根据电生理和ECG诊断房颤为上腔静脉与界嵴起源。上腔静脉起源进行上腔静脉电隔离,界嵴起源则局灶消融最早激动点。术后随访ECG和Holter。结果上腔静脉起源7例,其中仅2例可根据体表ECG诊断。腔内电生理均发现上腔静脉起源的快速激动触发或驱动房颤,均行上腔静脉电隔离治疗成功。界嵴上部起源2例,腔内电生理发现局灶激动触发房性早搏或房性心动过速,局灶消融均获成功。1例在隔离上腔静脉时出现一过性窦性停搏。结论少数房颤起源于上腔静脉与界嵴的异位灶,腔内电生理具有特征性,上腔静脉电隔离和局灶消融可以有效治疗此类房颤。     

Predictors of non-pulmonary vein ectopic beats initiating paroxysmal atrial fibrillation: implication for catheter ablation.

OBJECTIVES: The purpose of this study was to investigate the predictor of non-pulmonary vein (PV) ectopic beats initiating paroxysmal atrial fibrillation (PAF). BACKGROUND: Non-PV ectopic beats can initiate PAF in some patients and play an important role in the recurrence of PAF after PV isolation. Information on the predictors of non-PV ectopic beats initiating PAF is unknown. METHODS: This study included 293 patients (215 men and 78 women, age 60 +/- 14 years) with clinically documented drug-refractory PAF. Of the 94 patients with non-PV ectopic beats initiating PAF, 38 (40%) patients had superior vena cava (SVC) ectopic beats and 32 (34%) had left atrial posterior free wall (LAPFW) ectopic beats. RESULTS: In a univariate analysis, only female gender was related to the presence of non-PV (p = 0.016) and SVC ectopic beats (p = 0.012). Right atrial enlargement (p = 0.005) and left atrial enlargement (p < 0.001) were related to the presence of LAPFW ectopic beats. In a multivariate analysis, female gender (p = 0.043; odds ratio 2.00, 95% confidence interval [CI] 1.02 to 3.92) and left atrial enlargement (p = 0.007; odds ratio 2.34, 95% CI 1.27 to 4.32) could predict the presence of non-PV ectopic beats. Subgroup analysis showed that female gender could predict the presence of SVC ectopic beats (p = 0.039; odds ratio 2.14, 95% CI 1.04 to 4.43). In contrast, left atrial enlargement could predict the presence of LAPFW ectopic beats (p = 0.002; odds ratio 3.89, 95% CI 1.62 to 9.38). CONCLUSIONS: The location of non-PV ectopic beats initiating PAF can be predicted by both gender and left atrial enlargement.     

Impact of adenosine-provoked acute dormant pulmonary vein conduction on recurrence of atrial fibrillation

Impact of ATP Reconduction on AF Recurrence. Introduction: Adenosine can be associated with acute recovery of conduction to the pulmonary veins (PVs) immediately after isolation. The objective of this study was to evaluate whether the response to adenosine predicts atrial fibrillation (AF) recurrence after a single ablation procedure in patients with paroxysmal AF. Methods and Results: A total of 109 consecutive patients (61 ± 10 years; 91 males) with drug‐refractory paroxysmal AF who underwent AF ablation were analyzed. After PV antrum isolation (PVAI), dormant PV conduction was evaluated by an administration of adenosine in all patients. No acute reconnections were provoked by the adenosine in 70 (64.2%) patients (Group‐1), but they were provoked in at least one side of the ipsilateral PVs in 39 (35.8%) patients (Group‐2). All adenosine‐provoked dormant conductions were successfully eliminated by additional ablation applications. By 12 months after the initial procedure, 72 (66.1%) patients were free of AF recurrences without any antiarrhythmic drugs. A Cox regression multivariate analysis of the variables including the adenosine‐provoked reconductions, age, gender, duration of AF, presence of hypertension or structural heart disease, left atrial size, left ventricular ejection fraction, and body mass index demonstrated that adenosine‐provoked reconductions were an independent predictor of AF recurrence after a single ablation procedure (hazard ratio: 1.387; 95% confidence interval: 1.018–1.889, P = 0.038). At the repeat session for recurrent AF, conduction recovery was observed similarly in both groups (P = 0.27). Conclusion: Even after the elimination of any adenosine‐provoked dormant PV conduction, the appearance of acute adenosine‐provoked reconduction after the PVAI was an independent predictor of AF recurrence after a single AF ablation procedure. (J Cardiovasc Electrophysiol, Vol. 23 p. 256‐260, March 2012.)