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。     

经导管射频消融治疗乙灶性心房颤动

报道１９例局灶性心房颤动（简称房颤）射频消融治疗的结果,其中药物治疗无效且发作频繁（〉１次／日）的阵发性房颤１７例、慢性房颤２例。１７例患者尚同时合并有频发房性早搏（简称房早）（动态心电图显示〉７００个／日）。同步记录高位右房、冠状静脉窦及左、右上肺静脉电图。根据房早或房颤开始发作时的心房激动顺序确定异位兴奋灶部位,以局部双极科较体表心电图Ｐ波起点最提前处为消融靶点。成功标准为消融后６０ｍｉｎ内房     

特发性心房颤动的电生理标测和射频线性消融治疗

研究电生理标测指导下 ,选择不同射频消融线治疗心房颤动 (简称房颤 )的可行性和有效性。 18例迷走神经介导型房颤患者经常规途径放置心内标测电极于冠状窦 (CS)、右房小梁部 (TRA)和右房平滑部 (SRA)。自发或诱发房颤后 ,连续多导同步记录CS、TRA和SRA心内双极电图 90s ,即刻回放分析上述三个部位有序房内激动波和无序房内激动波时程占所记录时间的百分比。若SRA无序激动时程 >60 %,TRA <4 0 %,作下腔静脉口至三尖瓣环后部的峡部消融线和从上腔静脉口经卵园窝及冠状窦口至下腔静脉口的间隔部消融线 (第一组 ) ;若SRA无序激动时程 <4 0 %,TRA >60 %,作峡部消融线和从上腔静脉口经右房前侧壁至下腔静脉口的游离壁消融线 (第二组 ) ;不符合上述标准者同时作峡部、游离壁及间隔部消融线 (第三组 )。消融成功标准定义为在未用或使用以前无效的抗心律失常药情况下 ,无房颤发作或每月发作少于一次且持续不超过 1min。第一组 11例 ,占总例数的 61%,术后随访7± 4个月 ,成功 8例 ,成功率 73 %。第二组 3例 ,占总例数 17%,分别随访 8,4和 11个月 ,2例成功。第三组 4例 ,占 2 2 %,术后随访 3～ 8个月 ,无一例有效。本研究结果表明 ,不同患者维系房颤的关键部位不尽相同 ,按心房内标测电图特征筛选消融部位有一定有     

心房内膜射频消融治疗心房颤动的实验研究

为探索心房内膜标测指导射频消融治疗心房颤动 (AF)的可行性 ,选实验犬 16只 ,对右心房行心内膜标测并在其指导下消融 (右房和双房消融组各 8只 )。与术前相比 ,在同等条件下 ,消融后不能诱发或仅可诱发短阵AF ,但无一次持续时间超过 1min者视为手术成功。右房消融组中 ,对标测出关键部位 (电激动最无序、ff间期最短、最早出现f波及导管刺激易诱发AF的部位 )的 5只犬 ,行纵向跨间隔的单径线消融 ,成功 3例、失败 2例 ;对关键部位不典型的 3只犬行双径线消融 ,成功 1例、失败 2例。双房消融组中 ,关键部位位于房间隔的 4只犬行单径线消融 +左房肺静脉口局灶性消融全部成功 ;关键部位位于右心房侧壁上部的 1只犬行双径线消融 +左房肺静脉口局灶性消融后也获成功 ;关键部位不典型的 3只犬行双径线消融 +左房肺静脉口局灶性消融 ,1例成功、2例失败。消融前后基础电生理参数无明显变化 (P <0 .0 5 )。结果初步表明经导管心房内膜射频消融治疗AF是可行的 ,且心内膜标测对消融方案的选择具有指导性     

经导管射频消融治疗老年持续性心房颤动的疗效

目的探讨老年持续性心房颤动(房颤)患者接受经导管射频消融的有效性与安全性。方法回顾性分析该院2007年8月至2012年8月收治入院的≥65岁持续性房颤患者100例的临床资料。依据病人自愿原则随机分为射频消融组50例与服药组50例。射频消融组均行导管射频消融术。服药组采用常规服胺碘酮、华法林。观察两组患者恢复窦性心律成功率、1～5年生存率及脑梗死、心肌梗死发生率。分析患者治疗前后心电图P波离散度(Pdis)及P波最大时限(Pmax)的变化。结果射频消融组治疗后9、12月窦性心律维持率明显优于服药组(P<0.05);两组患者治疗后Pdis及Pmax变化较治疗前有显著差异(P<0.05);射频消融组患者治疗后Pdis及Pmax优于服药组(P<0.05);射频消融组总有效率88%,服药组总有效率68%,两组总有效率比较差异显著(P<0.05);射频消融组1年生存率为96%(48/50),5年生存率为88%(44/50);服药组1年生存率为82%(41/50),5年生存率为68%(34/50),两组比较差异显著(P<0.05)。结论老年持续性房颤患者经导管环肺静脉线性消融安全、有效。     

对心房颤动射频导管消融治疗的再认识

自1998年起,心房颤动(房颤)的导管消融治疗就成为临床心电生理学研究的持续热点,目前在国外部分医疗中心,单中心房颤导管消融的治疗例数已逾千例。近2年多来,随着治疗主要技术的日臻完善,不仅其成功率再创新高,适应证扩展至几乎整个房颤临床谱,而且临床研究的结果还对房颤机制的研究产生了重要影响(即所谓“learningbyburning”)。因此可以说,晚近有关房颤导管消融的临床实践已经从一定程度上更新了对这项治疗本身乃至房颤机制的若干认识,并很可能成为未来房颤治疗的主要方法。肺静脉电隔离术　　肺静脉电隔离术是现阶段房颤导管消融治疗的…     

以终止持续性心房颤动为手术终点的递进式消融200例总结

目的总结递进式消融术式治疗持续性心房颤动(简称房颤)的手术过程及临床转归。方法采用递进式消融策略治疗连续200例持续性房颤患者,手术终点为通过单纯消融终止房颤。按以下顺序进行消融:环肺静脉前庭消融达肺静脉电学隔离;心房碎裂电位消融;左房顶部和二尖瓣环峡部线性消融;针对房颤转变而成的房性心动过速(简称房速)行激动标测结合拖带技术明确其机制,并进一步消融终止。经术后3个月空白期,对复发房性心律失常(房颤/房速)的患者进行再次消融。结果 136例患者(68%)术中房颤被消融终止,消融终止房颤组首次术后房性心律失常复发率显著低于未终止组[19.9%(27/136)vs 51.6%(33/64),P<0.01],复发患者经再次消融后,平均随访12.8±7.2个月,本组病例总体手术成功率78.5%(157/200)。消融终止房颤组手术总体成功率高于未终止组[(86.8%(118/136)vs 60.9%(39/64),P<0.01)]。结论递进式消融可能是治疗持续性房颤的一种有效术式。     

递进式消融法治疗持续性心房颤动的初步体会

目的评价一种递进式消融法治疗持续性心房颤动（房颤）的疗效。方法34例持续性房颤患者,年龄（54．8±11．4）岁,病程（36．5±9．8）个月。按以下顺序进行递进式消融：环肺静脉前庭消融达肺静脉电学隔离,左心房顶部和二尖瓣环峡部线性消融,心房碎裂电位消融,针对房颤转变的心房扑动（房扑）／房性心动过速（房速）行Carto激动标测结合拖带技术以明确其机制,并力求通过消融终止。结果递进式消融法使88．2％患者房颤节律发生变化（直接终止或转变为房扑／房速）,61．8％直接通过消融恢复窦性心律。随访（12．6±6．2）个月,82．4％患者维持窦性心律（其中42．9％服用胺碘酮）。结论递进式消融是治疗持续性房颤的一种有效方案。     

肥厚型心肌病合并心房颤动的射频导管消融治疗

目的评价肥厚型心肌病合并心房颤动（房颤）射频导管消融的安全性和疗效。方法入选2005年至2012年共57例肥厚型心肌病合并房颤患者,采用Carto三维标测系统引导环肺静脉消融电隔离术,附加二尖瓣、三尖瓣峡部线性消融及左心房碎裂电位消融以改良基质。结果57例患者均顺利完成导管消融术,平均手术时间（192±36）min,X线曝光时间（28±8）min,随访时间（3．1±2．0）年,单次消融成功率42．1％,多次消融成功率61．4％,其中梗阻性肥厚型心肌病患者消融成功率36．4％,非梗阻性患者成功率67．4％（P=0．031）。结论环肺静脉消融结合基质改良治疗肥厚型心肌病合并房颤在有经验的治疗中心安全有效。     

递进式消融法治疗持续性心房颤动的初步体会

Objective To evaluate the effect of catheter ablation on persistent atrial fibrillation (AF) using step-wise approach. Methods Thirty-four patients [mean age (54.8 ± 11.4) years] with persistent AF [mean (36.5 ± 9.8) months] underwent catheter ablation were enrolled. Ablation was performed in following sequence. Circumferential ablation of pulmonary veins to achieve isolation, linear ablation of left atrium roof and mitral isthmus, ablation at sites possessing complex fractionated atrial electrograms. Using activation Carto mapping system, if AF converted to atrial flutter (AFL) or atrial tachycardia (AT), then catheter ablation was applied to terminate tachycardia. Results The step-wise ablation approach was successful in rhythm changes (AF converted to AFL/AT) in 88.2% of patients, 61.8% of patients conversion to sinus rhythm directly via ablation. At 12.6 ±6.2 months of follow-up, 82.4% of patients were maintained in sinus rhythm (42.9% of those patients taking oral amiedarone). Conclusion Catheter ablation using step-wise approach is effective in persistent AF treatment.     

长程持续性房颤消融术中规整房速的处理

目的探索慢性房颤导管消融中规则房速的发生机制与处理方法。方法选择2009年1月至2013年5月在厦门心脏中心确诊并接受导管消融治疗的慢性房颤患者102例,采用递进式导管消融策略,分析慢性房颤患者在消融中发生规则房速的可能机制并进行相应处理。结果102例患者中,4例（4．9％）在肺静脉电隔离过程中转为窦律,3例（2．9％）在行碎裂电位消融时转为窦律,46例经碎裂电位消融及心房线性消融过程中转为规则房速（45．1％）,47例（46．1％）仍维持房颤。规则房速的发生机制为局灶自律性（17．6％）、折返性（77．8％）、其它（4．6％）,消融成功率为81．6％。结论慢性房颤递进式导管消融中,规则房速的发生机制多为大折返性,导管消融此类房速成功率较高。     

Atypical left atrial flutter after intraoperative radiofrequency ablation of chronic atrial fibrillation: successful ablation using three-dimensional electroanatomic mapping

Curative treatment of chronic atrial fibrillation (AF) remains a challenging task for electrophysiologists. Eliminating the initiating triggers by focal radiofrequency ablation in a subset of patients with paroxysmal AF and modifying the maintaining substrate by performing linear lesions within the left atrium in patients with prolonged episodes of AF are among the alternative approaches for management of these patients. Recently, a new intraoperative treatment procedure aimed at eliminating left atrial anatomic "anchor" reentrant circuits by induction of contiguous lesions using radiofrequency energy under direct vision was introduced. However, atypical left atrial flutter may occur during follow-up after intraoperative ablation of AF. These arrhythmias most likely are due to discontinuities in linear lesions; therefore, they can be successfully mapped and ablated in a subsequent percutaneous catheter ablation procedure. We report and discuss the case of a patient who underwent successful intraoperative ablation of chronic AF, but who developed atypical left atrial flutter postoperatively. Three-dimensional nonfluoroscopic electroanatomic mapping revealed a gap in the linear lesion line connecting the left upper and right upper pulmonary vein orifices. Ablation at the exit site of the breakthrough was successful.     

Clinical outcome of very late recurrence of atrial fibrillation after catheter ablation of paroxysmal atrial fibrillation

INTRODUCTION: High recurrence rate is still a major problem associated with ablation of paroxysmal atrial fibrillation (AF). Most of the recurrences occur within 6 months after ablation. The characteristics of very late recurrent AF (>12 months after ablation) have not been reported. METHODS AND RESULTS: Two hundred seven patients with drug-refractory AF underwent successful focal ablation or isolation of AF foci. After the first ablation procedure, Holter monitoring and event recorders were used to evaluate symptomatic recurrent AF. A second ablation procedure was recommended if the antiarrhythmic drugs could not control recurrent AF. During long-term follow-up (mean 30 +/- 11 months, up to 51 months), 70 patients had recurrent AF, including 13 patients (6%) with very late (>12 months) recurrent AF (group 1) and 57 patients (28%) with late (within 12 months after ablation) recurrent AF (group 2). Group 1 patients had a significantly lower incidence of multiple (> or = 2) AF foci (23% vs 63%, P = 0.02) than group 2 patients. In addition, the incidence of antiarrhythmic drugs use (38% vs 84%, P = 0.001) to maintain sinus rhythm after the first episode of recurrent AF was significantly lower in group 1 than group 2 patients, and the incidence of a second intervention procedure (8% vs 35%, P = 0.051) tended to be lower in group 1 than group 2 patients. CONCLUSION: The incidence of very late recurrent AF after ablation of paroxysmal AF is very low, and the clinical outcome of patients with very late recurrent AF is benign.     

Catheter ablation is preferred over surgery for persistent atrial fibrillation

There are important limitations that can hinder outcomes of surgical ablation in nonparoxysmal patients with atrial fibrillation (AF), which is the typical AF population undergoing concomitant cardiac surgery for valve or ischemic heart disease. Incomplete lesions with recovered conduction or gaps as well as arrhythmias originating from areas not targeted by surgical ablation are commonly seen at the time of recurrence. Therefore, while it might be reasonable to perform AF surgery in this cohort, it is important to know these limitations and establish adequate postoperative rhythm monitoring to detect recurrences, which can be effectively addressed by catheter ablation.     

Long-term follow-up of right atrial ablation in patients with atrial fibrillation:

INTRODUCTION: The aim of this study was to evaluate the efficacy and the impact on quality of life of a new ablative approach to the right atrium in patients with atrial fibrillation (AF). METHODS AND RESULTS: Seventy-four symptomatic patients with paroxysmal (n = 49) or permanent (n = 25) refractory AF underwent radiofrequency ablation. A nonfluoroscopic electroanatomic mapping system was used to perform the following lesions: (1) an isthmus line between the tricuspid annulus and the inferior vena cava; (2) a posterior intercaval line from the superior vena cava and the inferior vena cava; (3) a septal line from the superior vena cava to the fossa ovalis, proceeding to the coronary sinus ostium where a circumferential line around the ostium was performed, and then on to the inferior vena cava; and (4) a transversal lesion connecting the posterior intercaval and the septal lesions. In addition, electrical disconnection of the superior vena cava was performed. There were no complications. Postablation remapping showed the absence of discrete electrical activity inside and just around the ablation lines. Electrical disconnection of the superior vena cava was obtained in all patients. After 21 +/- 6 months, 49 patients (66%) had stable sinus rhythm with continuation of the previous antiarrhythmic drug therapy, 13 patients (18%) were considered improved, and 12 (16%) received no benefit (unsuccessful procedure). After ablation, quality of life was significantly improved, reaching the levels of the general Italian population. Ejection fraction and the extent of the low-voltage area were found by multivariate analysis to be independent predictors of AF recurrence. CONCLUSION: The results of the present study suggest that this ablative approach in combination with antiarrhythmic drugs is safe and effective in treating AF, leading to a marked increase in quality of life in patients with refractory AF.     

Midterm results of left atrial bipolar radiofrequency ablation combined with a mitral valve procedure in persistent atrial fibrillation

Introduction

The aim of the study was to assess the midterm results of left atrial bipolar radiofrequency ablation combined with a mitral valve procedure in patients with mitral valve disease and persistent atrial fibrillation.

Methods

Between October 2006 and July 2009, 95 patients with mitral valve disease and persistent atrial fibrillation underwent a mitral valve procedure and left atrial bipolar radiofrequency ablation. The postoperative data of the combined procedure were collected at the time of discharge and at one, three, six and 12 months after the operation.

Results

Hospital mortality rate was 6.3% (six patients). Normal sinus rhythm was achieved in 77.2% of patients during the early postoperative period in hospital, and in 73.3, 72.0 and 75% of patients at three, six and 12 months postoperatively, respectively. Patients were followed up for a mean duration of 14.02 ± 5.71 months (range: 6–19 months). During this midterm follow-up period, nine patients had late recurrence of atrial fibrillation. No risk factor was identified for late recurrence of atrial fibrillation.

Conclusion

Our midterm follow-up results suggest that the addition of left atrial bipolar radiofrequency ablation to mitral valve surgery is an effective and safe procedure to restore sinus rhythm in patients with chronic atrial fibrillation.     

导管射频消融治疗房颤时肺静脉电位振幅变化趋势的分析

目的 探讨肺静脉电位（PVP）指导的心房颤动（AF）射频消融治疗中PVP振幅（PVPA）与消融时间之间的关系以及不同类型AF在PVPA和消融时间之间是否存在差异。方法 连续选取2014年1月至2015年6月解放军总医院心内科住院且行肺静脉隔离（PVI）治疗的AF患者43例,按房颤类型分为阵发性AF组（n＝34）和持续性AF组（n＝9）,比较两组患者PVPA、消融时间以及术后12个月AF的复发率。结果 PVPA与消融时间之间存在线性相关,PVPA越大消融时间越长。两组患者在PVPA和消融时间上无显著性差异（P＞0.05）。持续性AF组复发率显著高于阵发性AF组（55.6% vs 17.6%,P＜0.05）。结论 在PVI治疗中,PVPA是指导消融的一个重要指标,但对于持续性AF患者除传统PVI外还应采取其他辅助消融策略,以提高其远期成功率。     

Effect of catheter ablation on progression of paroxysmal atrial fibrillation

Ablation and Progression of Atrial Fibrillation. Objective: The objective was to determine the effect of radiofrequency catheter ablation (RFA) on progression of paroxysmal atrial fibrillation (AF). Background: Progression to persistent AF may occur in up to 50% of patients with paroxysmal AF receiving pharmacological therapy. Hypertension, age, prior transient ischemic event, chronic obstructive pulmonary disease, and heart failure (HATCH score) have been identified as independent risk factors for progression of AF. Methods: RFA was performed in 504 patients (mean age: 58 ± 10 years) to eliminate paroxysmal AF. A repeat RFA procedure was performed in 193 patients (38%). Clinical variables predictive of outcome and their relation to progression of AF after RFA were assessed using multivariate analysis. Results: At a mean follow‐up of 27 ± 12 months after RFA, 434/504 patients (86%) were in sinus rhythm; 49/504 patients (9.5%) continued to have paroxysmal AF; and 14 (3%) were in atrial flutter. Among the 504 patients, 7 (1.5%) progressed to persistent AF. In patients with recurrent AF after RFA, paroxysmal AF progressed to persistent AF in 7/56 (13%, P < 0.001). The progression rate of AF was 0.6% per year after RFA (P < 0.001 compared to 9% per year reported in pharmacologically treated patients). Age >75 years, duration of AF >10 years and diabetes were independent predictors of progression to persistent AF. The HATCH score was not significantly different between patients with paroxysmal AF who did and did not progress to persistent AF (0.7 ± 0.8 vs 1.0 ± 0.5, P = 0.3). Conclusions: Compared to a historical control group of pharmacologically treated patients with paroxysmal AF, RFA appears to reduce the rate of progression of paroxysmal AF to persistent AF. Age, duration of AF, and diabetes are independent risk factors for progression to persistent AF after RFA. (J Cardiovasc Electrophysiol, Vol. 23, pp. 9‐14, January 2012)     

Tachycardia transition during ablation of persistent atrial fibrillation

Tachycardia Transition . Background: The “sequential ablation” strategy for persistent AF is aimed at progressive organization of AF until the rhythm converts to sinus rhythm or atrial tachycardia (AT). During ablation of an AT, apparently seamless transitions from one organized AT to another occur. The purpose of our study was to quantify the occurrence and the mechanism of this transition. Methods and Results: Twenty‐nine of 90 patients undergoing ablation for persistent AF had multiple AT during the procedure and constitute the study group. Thirty‐nine direct transitions from one AT to another during ablation were observed classified in four types: type I (79.4%), i.e., a direct transition of a faster to a slower tachycardia without significant intervening pause; type II (7.69%)—transition after intervening ectopy or longer pause; type III (10.26%)—A slower AT accelerated; type IV (2.56%)—alteration of activation sequence but with no change on CL. Conclusions: Transition to a second AT occurs frequently in the midst of ablation of AT in persistent AF patients. This transition occurs most commonly abruptly within the range of a single cycle length of the original AT. This is best explained by a continuation of AT that was “present” simultaneously with the pretransition tachycardia, being “entrained” (for a reentrant tachycardia) or “overdriven” for an automatic focal tachycardia. The presence of multiple tachycardia mechanisms active simultaneously would be consistent with the eclectic pathophysiology of persistent AF. (J Cardiovasc Electrophysiol, Vol. 22, pp. 506‐512 May 2011)     

Catheter ablation of atrial fibrillation

Following the advent of the surgical maze procedure, several catheter techniques have been developed to provide permanent prophylaxis against atrial fibrillation. These noninvasive techniques work by compartmentalizing the atria, by ablating the arrhythmogenic foci, or by isolating the atria from these foci. Although still at an early stage of development, preliminary results using focal ablation and circumferential ablation show extreme promise.