心房颤动肺静脉电隔离术后早期复发的临床意义

目的:总结分析心房颤动(房颤)肺静脉电隔离术后早期(2周内)房颤复发者的随访结果.方法:105例房颤患者[平均年龄(55±12)岁],采用导管进行环肺静脉电隔离治疗,其中阵发性房颤78例,持续性房颤27例.实施环肺静脉电隔离共358根.结果:在术后早期随访[平均(3.9±2.6)d]中,105例患者中38例(36%)复发房颤.阵发性房颤与持续性房颤者早期房颤复发的发生率相比,差异无统计学意义(35%∶41%,P>0.05).在后期随访[平均(208±125)d]中,67例早期未复发患者中58例(87%)、38例早期房颤复发患者中13例(34%)无房颤发生,二者成功率比较,P<0.01.结论:肺静脉电隔离术后2周内大约36%患者房颤复发,早期房颤复发患者较早期未复发者后期成功率低.     

环肺静脉大环消融和肺静脉节段电隔离治疗阵发性心房颤动结果对比

目的 环肺静脉大环消融(CPVA)和肺静脉节段电隔离(SPVI)是目前导管射频消融治疗阵发性心房颤动(房颤)的两大主流术式,本文研究目的 是验证"CPVA对阵发性房颤的有效率比SP-VI高"这一假设,同时对比两种消融术式的其他治疗结果.方法 2006年1月至2007年12月入选阵发性房颤病人129例,SPVI和CPVA两组分别为64例和65例.排除标准为,房颤持续时间＞72 h,接受过导管消融的复发病例.结果 SPVI和CPVA组病人成功率分别为78.1%、78.5%;并发症发生率分别为7.8%、10.6%,差异无统计学意义.严重并发症3.9%.X线曝光时间SPVI组多于CPVA组,消融术时间CPVA组长于SPVI组.SPVI组的射频放电时间少于CPVA组.CPVA组术后房性心动过速/心房扑动发生率明显高于SPVI组(12.3%vs 3.1%).结论 SPVI和CPVA两种消融术式均能够比较安全有效地控制阵发性房颤的发作,治疗效果类似.     

环肺静脉隔离术对阵发性心房颤动患者左心房大小和功能的影响

目的:探讨环肺静脉隔离术对阵发性心房颤动(Af)患者左心房大小和功能的影响。方法:28例阵发性Af患者择期行环肺静脉隔离术,根据Af复发与否分为复发组(5例)和未复发组(23例);同期选择窦性心律患者30例作为对照组。应用超声心动图对所有患者在窦性心律下于术前、术后24h、1个月和3个月时测量左心房最大容积(LAVmax)、左心房最小容积(LAVmin)、二尖瓣环晚期运动峰值速度(A峰)、肺静脉收缩期波(S峰)、舒张期波(D峰)、心房血流逆向波(PVa峰),并计算左心房射血分数(LAEF)。结果:①左心房大小:复发组和未复发组患者消融术前LAVmax和LAVmin均较对照组增加(均P<0.05),在术后24hLAVmin均增加(均P<0.01),LAVmax无明显变化;未复发组术后1个月时LAVmax、LAVmin均减小至正常(均P<0.05),术后3个月时未再进一步减小,而复发组术后1个月和3个月恢复至术前大小。②左心房功能:复发组和未复发组消融术前LAEF和A峰值均较对照组降低(均P<0.05),术后24h左心房功能指标均较术前明显降低(均P<0.05);术后1个月时复发组和未复发组左心房功能指标较术后24h均明显增加(均P<0.01),2组PVa峰、S峰和D峰值均恢复至术前正常水平(均P<0.05),LAEF和A峰在未复发组增加至正常水平(P<0.05),而在复发组仅恢复至术前水平;术后3个月时左心房功能指标较术后1个月时均未再有明显变化。结论:环肺静脉隔离术可以逆转阵发性Af造成的左心房大小和功能异常,而且长期对左心房大小和功能无负面影响。     

Percutaneous pulmonary vein isolation for treatment of atrial fibrillation

BACKGROUND: Transvenous catheter ablation for the treatment of atrial fibrillation is an evolving technique. AIM: The purpose of this study was to identify subgroups of patients most likely to benefit from pulmonary vein electrical isolation. METHODS: Patients with symptomatic atrial fibrillation resistant to pharmacological therapy were studied. Mapping-guided segmental application of radio-frequency energy was used to electrically isolate the pulmonary veins in 74 patients. Ischaemic or dilated cardiomyopathy was present in 34% of patients. Atrial fibrillation had been present for a mean time (+/- standard deviation) of 6.6 +/- 6.1 years. It was paroxysmal in 53 patients (72%). RESULTS: The mean number of procedures was 1.6/patient. After 6 +/- 6 months, 73% of patients (54/74) were in sinus rhythm. Thirteen of those in sinus rhythm were using anti-arrhythmic medications (25%). Recurrence of atrial fibrillation soon after pulmonary vein isolation occurred in 50%. Patients with persistent/permanent atrial fibrillation were less likely to be in sinus rhythm at follow up (11/21 (52%) vs 43/53 (81%); P = 0.01). However, the rate of early recurrence was similar in the intermittent and the persistent/permanent groups (26/53 (49%) vs 11/21(52%), respectively; P-value not significant). Patients with persistent atrial fibrillation were more likely to experience a recurrence of atrial fibril-lation (89%; P = 0.04). No other baseline factors predicted procedural success. Cardiac tamponade occurred in two patients and moderate pulmonary vein stenosis (>50% diameter narrowing) occurred in three patients. CONCLUSIONS: Pulmonary vein isolation is an effective curative treatment for a broad group of patients with atrial fibrillation. However, the procedure is only suitable for patients with problematic atrial fibrillation resistant to other therapies because of the small risk of serious complications.     

Efficacy and safety of segmental ostial versus circumferential extra-ostial pulmonary vein isolation for atrial fibrillation

INTRODUCTION: Pulmonary vein (PV) isolation for atrial fibrillation (AF) can be performed using a segmental ostial or a circumferential extra-ostial approach. The relative merits and potential limitations of each approach are currently debated. Here we report our early experience with each of these approaches, including their relative efficacy and safety. METHODS AND RESULTS: Forty patients with drug-refractory AF underwent segmental ostial PV isolation and were compared to 40 consecutive patients who underwent PV isolation using a circumferential extra-ostial approach. The latter approach described here is novel in two aspects: (1) the endpoint for ablation was PV isolation and not only delay in left atrial to PV conduction time, and (2) isolation of the right and left PVs was achieved by a single encirclement of ipsilateral veins. At follow-up, 60% of the patients in the segmental group were free of AF compared to 75% of the patients in the circumferential group. There was one thromboembolic cerebrovascular complication during the ablation procedure in each group. CONCLUSION: PV isolation using a circumferential extra-ostial approach, where the ipsilateral PVs are isolated together by one encircling line of block using electroanatomic mapping, is a technically feasible procedure. This approach is at least as effective and safe as the more established segmental ostial approach for AF ablation.     

Left atrial stiffness relates to left ventricular diastolic dysfunction and recurrence after pulmonary vein isolation for atrial fibrillation

Left Atrial Stiffness and Atrial Fibrillation . Introduction: An increased left atrial (LA) stiffness reflects the structural remodeling and deterioration of the LA function. This study was designed to estimate LA stiffness by measuring a combination of the strain and LA pressure in patients undergoing pulmonary vein isolation (PVI) of atrial fibrillation (AF) and to evaluate the influence of the LA stiffness on the cardiac function, serum markers, and recurrence of AF after PVI. Methods: In 155 consecutive patients with AF, the brain natriuretic peptide (BNP) and aminoterminal procollagen type III propeptide (PIIIP) plasma levels were measured before the PVI. The difference between the minimum and maximum LA systolic pressures was directly measured by a transseptal puncture. The ratio of the difference in the LA pressures to the peak systolic LA strain evaluated by speckle‐tracking echocardiography was used as an index of the LA stiffness. Results: The calculated LA stiffness index was related to the BNP level (r_s= 0.444, P < 0.001), E/E′ ratio (r_s= 0.444, P < 0.001), LA volume index (r_s= 0.370, P < 0.001), and PIIIP level (r_s= 0.305, P = 0.002). During a mean follow‐up period of 33.8 ± 12.2 months, 45 patients (29%) presented with AF recurrences. A Cox proportional hazard regression analysis showed the LA stiffness index was an independent predictor of recurrence of AF (HR 2.88; 95% CI 1.75 to 4.73, P < 0.001). Conclusions: In patients with AF, the LA stiffness index is related to left ventricular diastolic dysfunction, LA dilatation, and collagen synthesis and may predict AF recurrences after PVI. (J Cardiovasc Electrophysiol, Vol. 22, pp. 999‐1006, September 2011)     

Acquired pulmonary vein stenosis after radiofrequency catheter ablation of paroxysmal atrial fibrillation

INTRODUCTION: Elimination of the initiating focus within the pulmonary vein (PV) using radiofrequency (RF) catheter ablation is a new treatment modality for treatment of drug-refractory atrial fibrillation. However, information on the long-term safety of RF ablation within the PV is limited. METHODS AND RESULTS: In 102 patients with drug-refractory atrial fibrillation and at least one initiating focus from the PV, series transesophageal echocardiography was performed to monitor the effect of RF ablation on the PV. There were 66 foci in the right upper PV and 65 foci in the left upper PV. Within 3 days of ablation, 26 of the ablated right upper PVs (39%) had increased peak Doppler flow velocity (mean 130+/-28 cm/sec, range 106 to 220), and 15 of the ablated left upper PVs (23%) had increased peak Doppler flow velocity (mean 140+/-39 cm/sec, range 105 to 219). Seven patients had increased peak Doppler flow velocity in both upper PVs. No factor (including age, sex, site of ablation, number of RF pulses, pulse duration, and temperature) could predict PV stenosis after RF ablation. Three patients with stenosis of both upper PVs experienced mild dyspnea on exertion, but only one had mild increase of pulmonary pressure. There was no significant change of peak and mean flow velocity and of PV diameter in sequential follow-up studies up to 16 (209+/-94 days) months. CONCLUSION: Focal PV stenosis is observed frequently after RF catheter ablation applied within the vein, but usually is without clinical significance. However, ablation within multiple PVs might cause pulmonary hypertension and should be considered a limiting factor in this procedure.     

Pulmonary vein isolation for vagotonic, adrenergic, and random episodes of paroxysmal atrial fibrillation

INTRODUCTION: Based on the clinical history, paroxysmal atrial fibrillation (PAF) may be classified as vagotonic, adrenergic, or random. It is unclear whether pulmonary vein (PV) isolation is equally effective for these types of PAF. METHODS AND RESULTS: Segmental ostial ablation to isolate the PVs was performed in 188 consecutive patients (mean age 53 +/- 12 years) with PAF. Based on the clinical history, PAF was classified as random in 136 patients (72%), adrenergic in 30 (16%), and vagotonic in 22 (12%). Three or four PVs were targeted for isolation in all patients, and successful isolation was achieved in 96% of targeted PVs. At 1-year follow-up, 69% of patients with random AF, 83% of patients with adrenergic AF, and 50% of patients with vagotonic AF were free from recurrent episodes of AF in the absence of any antiarrhythmic drug therapy. Vagotonic AF was an independent clinical predictor of recurrent AF (P = 0.03). CONCLUSION: PV isolation has a lower efficacy in patients with vagotonic PAF than in patients with adrenergic or random episodes of PAF, suggesting that the PVs less often play an important role in vagotonic PAF.     

Preprocedural predictors of atrial fibrillation recurrence following pulmonary vein antrum isolation in patients with paroxysmal atrial fibrillation: long-term follow-up results

Predictors of Recurrence after AF Ablation. Introduction: The objective of this study was to identify the simple preprocedural parameters of atrial fibrillation (AF) recurrence following single ablation procedure in patients with paroxysmal AF during long‐term follow‐up period. Methods and Results: Consecutive 474 patients (61 ± 10 years; 364 males, left atrial (LA) diameter 37.6 ± 5.1 mm) with drug‐refractory paroxysmal AF who underwent AF ablation were analyzed. Pulmonary vein antrum isolation (PVAI), cavotricuspid isthmus line creation with bidirectional conduction block, and elimination of all non‐PV triggers of AF were performed in all patients. With a mean follow‐up of 30 ± 13 months after single procedure, 318 patients (67.1%) were in sinus rhythm without any antiarrhythmic drugs. Multivariate analysis using Cox's proportional hazards model, including the age, gender, duration of AF, body mass index, LA size, left ventricular ejection fraction, and presence of hypertension and structural heart disease as variables, demonstrated that LA size was an independent predictor of AF recurrences after PVAI with a 7.2% increase in the probability for every 1 mm increase in LA diameter (P = 0.0007). When the patients were categorized into 3 groups according to the LA diameter, the patients with moderate (40–50 mm) and severe dilatation (>50 mm) had a 1.30‐fold (P = 0.0131) and 2.14‐fold (P = 0.0057) increase, respectively, in the probability of recurrent AF as compared with the patients with normal LA diameter (≤40 mm). Conclusion : In the long‐term follow‐up period, LA size was the best preprocedural predictor of AF recurrence following single ablation procedure in the patients with paroxysmal AF, even in the patients with a relatively small LA. (J Cardiovasc Electrophysiol, Vol. 22, pp. 621‐625, June 2011)     

Discrimination of left atrial and pulmonary vein potentials in patients with paroxysmal atrial fibrillation

INTRODUCTION: Ablation of muscular fascicles around the ostium of pulmonary veins (PVs) resulting in electrical isolation of the veins may prove to be an effective treatment for atrial fibrillation (AF). Correctly discriminating atrial and PV potentials is necessary to effectively isolate PVs from the left atrium in patients with paroxysmal AF. METHODS AND RESULTS: A training set of 151 electrode recordings obtained from 10 patients with AF was used to develop an algorithm to discriminate atrial and PV potentials. Bipolar electrograms were collected from a multielectrode basket catheter placed sequentially into each PV. Amplitude, slope, and normalized slopes of both bipolar and quadripolar electrograms (difference between adjacent bipoles) were entered into a binary logistic regression model. A receiver operating characteristic curve was used to define a threshold able to effectively discriminate atrial and PV potentials. The normalized slopes of both domains, bipolar and quadripolar, produced a logistic function that discriminated atrial and PV potentials against a threshold (0.38) with 97.8% sensitivity and 94.9% specificity. The algorithm then was evaluated on a test set of 214 electrode recordings from four patients who also had paroxysmal AF. These patient electrograms also were evaluated by two independent electrophysiologists. The algorithm and electrophysiologists matched identification of activation origin in 84% of electrograms. CONCLUSION: Atrial and PV potentials acquired from a multielectrode basket catheter can be discriminated using the normalized slopes of bipolar and quadripolar electrograms. These additional parameters need to be included by physicians determining the preferential ablation site within PVs.     

Association of platelet activation markers with recurrence of atrial fibrillation after pulmonary vein isolation

Atrial fibrillation (AF) is known to cause platelet activation. AF and its degree of thrombogenesis could be associated with monocyte-platelet aggregates (MPAs). We investigated on whether the content of MPAs or other platelet activation markers is associated with the recurrence of AF after pulmonary vein isolation (PVI). A total of 73 patients with symptomatic AF underwent PVI. After 6 months, all patients were evaluated for episodes of AF recurrence. At the same time, flow-cytometric quantification analyses were performed to determine the content of MPAs. Further platelet activation parameters were detected by using either cytometric bead arrays or quantitative immunological determination. Patients with recurrent AF (n = 20) compared to individuals without AF relapse (n = 53) were associated with an increased content of MPAs (43 ± 3% vs. 33 ± 2%, p = 0.004), as well as an increased CD41 expression on monocytes (191 ± 20 vs. 113 ± 6, p = 0.001). The level of the soluble platelet activation markers such as D-dimer, sCD40L, and sP-selectin did not differ between these groups. The content of MPAs correlated weakly with the level of sCD40L (r = 0.26, p = 0.03), but not with sP-selectin and D-dimer, whereas sP-selectin and sCD40L correlated with each other (r = 0.38, p = 0.001). Only the cellular marker of platelet activation, the content of MPAs, was increased in patients with recurrent AF after PVI. In contrast, soluble markers remained unaltered. These data indicate a distinct mechanism and level of platelet activation in AF. The clinical relevance of MPAs in identifying AF recurrence or in guiding the therapy with anticoagulants remains to be elucidated.     

Our approach to persistent atrial fibrillation in the setting of pulmonary vein isolation

In patients with persistent atrial fibrillation (AF) despite durable pulmonary vein isolation, there are a variety of approaches to further ablation. Here we summarize our strategy in this population. In brief, our approach is to isolate the posterior wall, ablate the coronary sinus musculature and left lateral ridge, complete a lateral mitral line, and achieve cavotricuspid isthmus block. Subsequently, we target organized atrial flutters and if AF persists, we ablate areas of long, fractionated electrograms within scarred regions. We administer isuprel in patients with a presentation consistent with triggered atrial fibrillation (low scar burden, paroxysms of AF).     

应用重叠参考图像透视技术易化环肺静脉电隔离术操作治疗阵发性心房颤动

目的 探讨重叠参考图像透视技术(Overlay Ref)对环肺静脉电隔离术治疗阵发性心房颤动(房颤)的影响.方法 入选194例阵发性房颤患者,随机分为Overlay Ref组(97例)及对照组(97例).Overlay Ref组使用Overlay Ref技术(将参考图像以反白的形式叠加于透视屏上)辅助环肺静脉电隔离术的操作.对照组常规方法完成环肺静脉电隔离术.比较两组的总消融手术时间、消融时间、X线曝光量、肺静脉隔离率及随访1年的成功率.结果 两组患者的基线临床特征差异无统计学意义.所有患者均接受了环肺静脉电隔离术.Overlay Ref组的消融时间〔(89±13) min对(102±22) min,P＜0.01〕和总消融术时间[ (139±22) min对(162±31) min,P＜0.01]均明显比对照组短.Oveday Ref组的X线曝光量[( 13531±283) mGy对(13123±369)mGy]稍大,但差异无统计学意义(P＞0.05).两组的环肺静脉电隔离率(97.9％对96.9％,P=NS)及随访1年的成功率(84.5％对81.4％,P＞0.05)差异也无统计学意义.结论 Overlay Ref技术可以易化环肺静脉电隔离术的操作,缩短房颤导管消融术的学习曲线.     

Optimal observation time after completion of circumferential pulmonary vein isolation for atrial fibrillation to prevent chronic pulmonary vein reconnections

Purpose

To identify predictors of chronic pulmonary vein (PV) reconnection (CPVR) after successful circumferential PV isolation (CPVI) for atrial fibrillation (AF).

Materials and methods

A total of 718 PVs from 181 consecutive AF patients (141 males, median age 61 years, 92 paroxysmal AF) who underwent a second ablation procedure for recurrent AF were retrospectively analyzed.

Results

During the second procedure, a CPVR was observed in 477 PVs (66.4%) among 169 patients. In a multiple logistic regression analysis, the observation time after the final completion of the PVI (OT-final) was a significant negative predictor (odds ratio 0.980; P < 0.001). A receiver operating characteristic analysis demonstrated that the greatest area under the curve was for the OT-final (0.670). At an optimal cutoff of 35 min, the sensitivity and specificity for predicting a CPVR were 66.9% and 60.6%, respectively. By Kaplan Meier analysis, CPVR was more frequent in PVs with an OT-final of < 35 min than ≥ 35 min (log-rank test, P = 0.018). In a vessel-by-vessel analysis, the OT-final at all PV sites was a significant negative predictor, while male gender in the right PVs and left-inferior PV, number of RF applications for the ipsilateral CPVI in the right PVs and left-superior PV, and major PV diameter in the left-superior PV were significant positive predictors of a CPVR (all P < 0.05).

Conclusions

An optimal observation time (≥ 35 min in this study) to determine whether PVI is successfully completed during the initial CPVI for AF may be needed to prevent a CPVR and subsequent AF recurrence thereafter.