进一步推进我国导管消融治疗心房颤动的临床研究

目前,心房颤动（房颤）治疗的研究方向主要有两个,一是导管消融,电生理学家力图通过不断改进消融术式,获取更好的消融效果,以期达到最终根治房颤的目的;二是药物治疗,许多药理学家则希望研制出副作用小、见效快、能长期抑制房颤的抗心律失常药物（AAD）,部分对导管消融治疗房颤效果有疑虑的临床医师也对此抱有很大希望。     

心房颤动的治疗：前景光明

Great achievements have been made in management of atrial fibrillation （AF） , including drug therapy, catheter ablation and percutaneous closure of left atrial appendage in recent years. The development of new generation anticoagulation drugs will hopefully be a landmark in the management of AF. It was shown in RELY study that dabigatran, a direct competitive inhibitor of thrombin,was associated with lower rates of stroke and systemic embolism but similar rates of major hemorrhage as compared with warfarin. ATHENA study revealed that dronedarone reduced the incidence of stroke and hospitalization due to cardiovascular events or death in patients with AF. Dronedarone, a new antiarrhythmic drug, was approved by FDA for management of AF. Catheter ablation of AF has emerged as a mainstream therapy,it was shown in a recent study that the incidence of stroke in the patients underwent successful ablation was only 0.07%. This study estabolished the fact that successful catheter ablation of AF could improve the outcome of patients with AF. In the field of device therapy of AF, PROTECT-AF confirmed that percutaneous closure of left atrial appendage was not inferior to warfarin with regard to prevention of stroke in patients with AF.     

Emerging Energy Sources for Catheter Ablation of Atrial Fibrillation

Catheter-based ablation techniques have been increasingly used as a curative therapy for treating atrial fibrillation (AF). Currently, radiofrequency (RF) energy is the most widely accepted and used method for catheter ablation of AF. However, RF ablation has potential disadvantages, including endocardial disruption, charring, platelet activation, pulmonary vein stenosis, and thrombus formation, and has limited efficacy in performing atrial linear ablation. As a result, new alterative energy sources have been explored for AF ablation. These new technologies, including cryoablation, microwave, ultrasound, and laser have different potential advantages over RF, but all of them have limited clinical experiences. Furthermore, the emergence of these new ablation energy sources should be paralleled with development of new ablation catheters, mapping and imaging tools to improve the successful rate of AF ablation. In the future, conventional RF ablation will remain the standard approach for AF, but some of these energies may be used in combination at specific sites for safety reasons, such as the use of cryoablation inside PVs or the use of microwave to create long atrial linear ablation more effectively.     

Complications of Catheter Ablation of Atrial Fibrillation: Cause, Prevention and Management

It has been reported that curative catheter ablation for atrial fibrillation (AF) can significantly reduce AF recurrence, and improve the morbidity and mortality of the AF patients, compared with medical treatment. However, a variety of complications of catheter ablation of AF have been reported, and some of them are fatal in patients with structurally normal hearts. There remain unsolved safety issues concerning AF ablation, before the catheter ablation is established as first-line therapy, even for selected patients in experienced centers. In this article, a variety of complications are reviewed and their prevention and treatment are discussed.     

Technology insight: catheter ablation of the pulmonary veins in the treatment of atrial fibrillation

Over the past 5 years, catheter ablation of atrial fibrillation (AF) has evolved from being an experimental procedure to one that is performed in most large medical centers throughout the world. The rapid and widespread acceptance of this procedure reflects encouraging reports of the safety and efficacy of a pulmonary vein (PV) approach, which has 70-80% efficacy and around a 5% risk of major complications. Currently three PV-based ablation strategies are employed for catheter ablation of AF, termed segmental PV isolation, circumferential PV ablation and circumferential PV isolation. Three main research activities are ongoing in the field of catheter ablation of AF. One aim is to better define the safety and efficacy of AF ablation using the three approaches listed. The second research focus is to improve safety and efficacy by the development of new mapping and ablation tools. And the third major area of research is the development of new strategies for AF ablation. It is highly likely during the next 5 years that catheter ablation of AF will become a routine and well-accepted treatment strategy for this common arrhythmia condition.     

REVIEW: Nonpharmacological Therapies for Atrial Fibrillation

In recent years, nonpharmacological therapies for atrial fibrillation (AF) have emerged given the limitations of medical therapy. Advancements in particular have been made in the areas of radiofrequency catheter ablation and AF surgery, and have been accompanied by substantial technological improvements. This article will discuss several different modalities of nonpharmacological AF management including catheter ablation, AF surgery and device‐based therapy.     

心房颤动导管消融：更上一层楼

十余年来,心房颤动（房颤）导管消融已经从一项探索中的技术发展为广泛应用的房颤治疗方法,其进展日新月异.目前,房颤导管消融的技术更成熟,风险效益比更明确,普及更广泛,已然进入了快速发展的成熟时期.     

Cryoballoon in atrial fibrillation ablation

Encouraging results of ablation therapy in patients with paroxysmal atrial fibrillation (AF) have prompted changes in professional practice guidelines. The most recent European guidelines have suggested that ablation might be offered as first-line therapy in selected patients. Cryoballoon ablation is a promising technology in interventional AF therapy. Two different sizes of the cryoballoon are currently available: a smaller (23?mm) and a larger (28?mm) balloon relative to the ostial diameter of the pulmonary veins. New tools, the circular mapping catheter and the use of intracardiac echocardiography, provide important periprocedural information. A meta-analysis of previous studies revealed outcome data with an AF-free survival rate of 72.83% at the 1-year follow-up in paroxysmal AF patients undergoing cryoballoon ablation. The most frequent, but reversible complication is phrenic nerve palsy with reported incidences up to 10%. All efforts must be taken to overcome this limitation, since the overall major complication rate tends to be lower in cryoballoon compared to radiofrequency ablation. In persistent AF, reported results in cryoballoon ablation had a limited success rate below 50% after a single procedure. A double balloon approach using both cryoballoon sizes might overcome some of the limitations in persistent AF. Prospective data and randomized studies are required. This article outlines the current status of cryoballoon technology in AF ablation therapy.     

Health-related quality of life questionnaires: an important method to evaluate patient outcomes in atrial fibrillation ablation

Improvement of symptoms and health-related quality of life (HRQoL) are important treatment goals in the management of patients with atrial fibrillation (AF). For patients with symptomatic AF, catheter ablation is a commonly performed therapy for rhythm control. As a result, accurate documentation of the changes in HRQoL for these patients is necessary. This paper will review why HRQoL questionnaires are important in evaluating patient outcomes for AF ablation. First, we discuss how the results of these questionnaires can influence the cost-effectiveness of AF ablation. This may, in turn, affect healthcare resource allocation in favor of this therapy. Also, these questionnaires can provide additional information over traditional quantitative measures of AF burden in assessing post-ablation outcomes. By standardizing the way by which HRQoL is measured and reported, these questionnaires are valuable in evaluating this important patient-reported outcome in AF ablation trials.     

Our Approach to Maximizing the Durability of Pulmonary Vein Isolation During a Paroxysmal Atrial Fibrillation Ablation Procedure

Maximizing Lesion Durability in PVI. Recurrence of atrial fibrillation (AF) after a single ablation procedure has been reported in the range of 15–60% depending on patient selection. A major factor leading to AF recurrence after catheter ablation therapy is electrical reconnection of one or more pulmonary veins (PVs) due to recovery of excitability of atrial tissue within ablation lesions. Maximizing the durability of pulmonary vein isolation (PVI) is critical to reduce recurrence rates and improve outcome after catheter treatment for AF. Strategies to increase the durability of the lesions include optimization of catheter contact by use of steerable sheaths, direct visualization by intracardiac ultrasound, and observation of the decrease in impedance at the beginning of ablation. Furthermore, currently achievable endpoints in addition to electrical PVI may reduce AF recurrence, such as identification of dormant conduction with adenosine administration and rendering the ablation line unexcitable to pacing. Integration of all these strategies into routine catheter ablation procedures for AF has reduced our AF recurrence rates and can easily be incorporated into practice without additional technological advances. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1272–1276, November 2012)     

Frontier of catheter ablation for atrial fibrillation

The sudden evolution of catheter ablation (CA) therapy for atrial fibrillation (AF) was brought by the discovery of a new insight into the triggering mechanism of AF by Haïssaguerre et al. in 1998. This discovery opened a new era of evolution of ablation therapy of paroxysmal AF (PAF). At the frontier of AF ablation, technical development of CA for long-standing persistent AF (CAF) has been done enthusiastically, although the detailed electrophysiologic mechanism and anatomical substrate of persistent AF remain unknown. Stepwise ablation composed of multiple procedures, circumferential pulmonary vein isolation (PVI), biatrial defragmentation, and anatomical linear ablation with the endpoint of AF termination has been the most widely accepted method, because the efficacy of this method was reported to be surprisingly high during a relatively short duration of follow-up. Recently, they showed this strategy has a significant limitation in efficacy for CAF with long AF duration (>7 years), enlarged left atrium (>50 mm in left anterior descending artery), short AF cycle length (AFCL) (<130 ms) and impaired cardiac function. For cases associated with these clinical, anatomical, and electrophysiological parameters, AF termination as an endpoint might be abandoned if peak prolongation of AFCL, reduction of intra-/inter-atrial AFCL gradient, and low defibrillation threshold are attained after predetermined lesion set is completed. Prolonged procedure with massive tissue ablation to attain AF termination should be avoided, because it potentially increases adverse events during and immediately after the procedure and causes extensive scar-formation in both atria with atrial mechanical dysfunction.     

心房颤动导管消融治疗:未来走向平坦之路?

长久以来,心房颤动(房颤)的治疗一直困扰着我们,过去10年开展的导管射频消融术为房颤治疗带来了革命性的变化,同期,新型抗凝药物及抗心律失常药物的不断涌现也为房颤治疗增添了不少亮点.今天当我们再次从改善症状和预后的角度考虑房颤的治疗策略时,是否会有新的启示与发现?     

心房颤动导管消融治疗:未来走向平坦之路?

长久以来,心房颤动(房颤)的治疗一直困扰着我们,过去10年开展的导管射频消融术为房颤治疗带来了革命性的变化,同期,新型抗凝药物及抗心律失常药物的不断涌现也为房颤治疗增添了不少亮点.今天当我们再次从改善症状和预后的角度考虑房颤的治疗策略时,是否会有新的启示与发现?     

心房颤动导管消融治疗:未来走向平坦之路?

长久以来,心房颤动(房颤)的治疗一直困扰着我们,过去10年开展的导管射频消融术为房颤治疗带来了革命性的变化,同期,新型抗凝药物及抗心律失常药物的不断涌现也为房颤治疗增添了不少亮点.今天当我们再次从改善症状和预后的角度考虑房颤的治疗策略时,是否会有新的启示与发现?     

心房颤动导管消融治疗:未来走向平坦之路?

长久以来,心房颤动(房颤)的治疗一直困扰着我们,过去10年开展的导管射频消融术为房颤治疗带来了革命性的变化,同期,新型抗凝药物及抗心律失常药物的不断涌现也为房颤治疗增添了不少亮点.今天当我们再次从改善症状和预后的角度考虑房颤的治疗策略时,是否会有新的启示与发现?     

心房颤动导管消融治疗:未来走向平坦之路?

长久以来,心房颤动(房颤)的治疗一直困扰着我们,过去10年开展的导管射频消融术为房颤治疗带来了革命性的变化,同期,新型抗凝药物及抗心律失常药物的不断涌现也为房颤治疗增添了不少亮点.今天当我们再次从改善症状和预后的角度考虑房颤的治疗策略时,是否会有新的启示与发现?     

心房颤动导管消融治疗:未来走向平坦之路?

长久以来,心房颤动(房颤)的治疗一直困扰着我们,过去10年开展的导管射频消融术为房颤治疗带来了革命性的变化,同期,新型抗凝药物及抗心律失常药物的不断涌现也为房颤治疗增添了不少亮点.今天当我们再次从改善症状和预后的角度考虑房颤的治疗策略时,是否会有新的启示与发现?     

心房颤动导管消融治疗:未来走向平坦之路?

长久以来,心房颤动(房颤)的治疗一直困扰着我们,过去10年开展的导管射频消融术为房颤治疗带来了革命性的变化,同期,新型抗凝药物及抗心律失常药物的不断涌现也为房颤治疗增添了不少亮点.今天当我们再次从改善症状和预后的角度考虑房颤的治疗策略时,是否会有新的启示与发现?     

心房颤动导管消融治疗:未来走向平坦之路?

长久以来,心房颤动(房颤)的治疗一直困扰着我们,过去10年开展的导管射频消融术为房颤治疗带来了革命性的变化,同期,新型抗凝药物及抗心律失常药物的不断涌现也为房颤治疗增添了不少亮点.今天当我们再次从改善症状和预后的角度考虑房颤的治疗策略时,是否会有新的启示与发现?     

心房颤动导管消融治疗:未来走向平坦之路?

长久以来,心房颤动(房颤)的治疗一直困扰着我们,过去10年开展的导管射频消融术为房颤治疗带来了革命性的变化,同期,新型抗凝药物及抗心律失常药物的不断涌现也为房颤治疗增添了不少亮点.今天当我们再次从改善症状和预后的角度考虑房颤的治疗策略时,是否会有新的启示与发现?