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...     

Impact of Systematic Isolation of Superior Vena Cava in Addition to Pulmonary Vein Antrum Isolation on the Outcome of Paroxysmal, Persistent, and Permanent Atrial Fibrillation Ablation: Results from a Randomized Study

Impact of the Systematic Isolation of the Superior Vena Cava.   Background: Pulmonary veins (PVs) have been shown to represent the most frequent sites of ectopic beats initiating paroxysmal atrial fibrillation (AF). However, additional non-PV triggers, arising from different areas, have been reported as well. One of the most common non-PV sites described is the superior vena cava.
Aims: The purpose of the study was to investigate the impact resulting from the systematic isolation of the superior vena cava (SVCI) in addition to pulmonary vein antrum isolation (PVAI) on the outcome of paroxysmal, persistent, and permanent AF ablation.
Methods: A total of 320 consecutive patients who had been referred to our center in order to undergo a first attempt of AF ablation were randomized into 2 groups. Group I (160 patients) underwent PVAI only; Group II (160 patients) underwent PVAI and SVCI.
Results: AF was paroxysmal in 134 (46%), persistent in 75 (23%), and permanent in 111 (31%) of said patients. SVCI was performed on 134 of the 160 patients (84%) in Group II. SVC isolation was not performed on the remaining 26 patients either because of phrenic nerve capture or the lack of SVC potentials. Comparison of the outcome data between the 2 groups, after a follow-up of 12 months, revealed a significant difference in total procedural success solely with patients manifesting paroxysmal atrial fibrillation (56/73 [77%] Group I vs. 55/61 [90%] Group II; P = 0.04; OR 2.78).
Conclusions: In our study, the strategy of the empiric SVCI in addition to PVAI has improved the outcome of AF ablation solely in patients manifesting paroxysmal AF. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1–5, January 2010)     

A Focal Source of Atrial Fibrillation in the Superior Vena Cava: Isolation and Elimination by Radiofrequency Ablation with the Guide of Basket Catheter Mapping

Although it has been reported that pulmonary veins sometimes act as a focal driver of atrial fibrillation (AF), little has been reported concerning the contribution of the superior vena cava (SVC) to the maintenance of AF. Here we report a patient with sustained AF due to focal discharges inside the SVC after pulmonary vein isolation procedure. Stepwise radiofrequency current applications with the guide of multielectrode basket catheter mapping first disconnected the arrhythmogenic SVC from the right atrium and then eliminated the tachycardia.     

Image Integration-Guided Catheter Ablation of Atrial Fibrillation: A Prospective Randomized Study

Background: Several studies have provided details of left atrial anatomy by means of the image integration techniques, particularly focusing on the atypical patterns of the pulmonary veins.
Objective: To compare, in a prospective, randomized fashion, the conventional method of pulmonary vein disconnection and the image integration-guided approach.
Methods: Two hundred and ninety consecutive patients (290 patients, mean age 55 ± 11 years) with drug-refractory paroxysmal or persistent atrial fibrillation were enrolled in the study and were divided into two treatment groups: group 1 (145 patients) undergoing an imaging integration-guided (CartoMerge TM) ablation; group 2 (145 patients) treated by a conventional radiofrequency catheter ablation procedure. The arrhythmia was refractory to at least two antiarrhythmic drugs (IC, amiodarone).
Results: Electrical disconnection of all identified pulmonary veins was obtained in all patients of both groups. Bidirectional block of the cavotricuspid isthmus was achieved in 34 group 1 patients and in 40 group 2 patients. Left mitral isthmus ablation was attempted in 52 group 1 patients and in 56 group 2 patients. At a mean follow-up of 14 ± 12 months, the atrial fibrillation-free survival rate was significantly higher in group 1 patients compared with group 2 patients (88% vs 69%, P = 0.017). The analysis for the subset of patients with previously ineffective ablation (98 patients: 52 group 1 patients and 46 group 2 patients) showed a significantly lower recurrence rate in group 1 versus group 2 (19% vs 48%, P < 0.01).
Conclusions: Our data indicate a superior efficacy of the image-integration guided catheter ablation of atrial fibrillation over the long term.     

Long‐Term Outcome of Catheter Ablation in Patients with Atrial Fibrillation Originating from Nonpulmonary Vein Ectopy

Long‐Term Outcome of NPV AF Ablation . Introduction: Data regarding the long‐term outcome of catheter ablation in patients with nonpulmonary vein (NPV) ectopy initiating atrial fibrillation (AF) are limited. We aimed to evaluate the long‐term result of patients with AF who had NPV triggers and underwent catheter ablation. Methods and Results: The study included 660 consecutive patients (age 54 ± 11 years old, 477 males) who had undergone catheter ablation for AF. Group 1 consisted of 132 patients with AF initiating from the NPV, and group 2 consisted of 528 patients with AF initiating from pulmonary vein (PV) triggers only. Patients from Group 1 were younger than those from Group 2 (51 ± 12 years old vs 54 ± 11 years old, P = 0.001) and were more likely to be females (34.4% vs 25.8%, P = 0.049). The incidences of nonparoxysmal AF (36.4% vs 16.3%, P < 0.001) and right atrial (RA) enlargement (31.3% vs 19%, P = 0.004) were higher, and the biatrial substrates were worse in Group 1 than those in Group 2 (left atrial voltage 1.5 ± 0.7 mV vs 1.9 ± 0.7 mV, P < 0.001, RA voltage 1.6 ± 0.5 mV vs 1.8 ± 0.6 mV, P = 0.014). During a follow‐up period of 46 ± 23 months, there was a higher AF recurrence rate in Group 1 than in Group 2 (57.6% vs 38.8%, P < 0.001). The independent predictors of AF recurrence were NPV trigger (P < 0.001, HR 2, 95% CI 1.4–2.85), nonparoxysmal AF (P = 0.021, HR 1.55, 95% CI 1.07–2.24), larger left atrial diameter (P = 0.002, HR 1.04, 95% CI 1.02–1.07) and worse left atrial substrate (P = 0.028, HR 1.3, 95% CI 1.03–1.64). Conclusion: Compared to AF originating from the PV alone, AF originating from the NPV ectopy showed a worse outcome. (J Cardiovasc Electrophysiol, Vol. 24, pp. 250‐258, March 2013)     

Ablation of Focally Induced Atrial Fibrillation:

INTRODUCTION: Focally induced atrial fibrillation (AF) often is due to ectopic activity in the pulmonary veins (PV). Although initial approaches were aimed at ablating only the ectopic foci, more extensive ablation approaches have evolved that isolate all PVs empirically and/or create circumferential ablation lines in the left atrium (LA). These techniques last longer and may be associated with more risks. We retrospectively evaluated the outcome and risks of ablation for focally induced AF in a single-center patient population. METHODS AND RESULTS: We report on 47 patients (32 men and 15 women; age 47 +/- 10 years) in whom 52 ablations were performed. In 19 patients (22 sessions), ablation was directed at the site(s) of overt ectopic activity ("selective" group), whereas in 28 patients (30 sessions) without sufficient ectopy to determine the culprit PV a mean of 3.5 PVs were empirically targeted for bidirectional disconnection from the LA ("extensive" group). On a preprocedural Holter recording, the "selective" group had significantly more isolated atrial ectopy (3,276 +/- 2,933 vs 620 +/- 937 beats/24 hours) and runs of atrial tachycardia (330 +/- 202 vs 53 +/- 87 runs/24 hours) than the "extensive" group (P < 0.01 for both). Only 11% had persistent AF before ablation. Acute procedural success was 81% (elimination of all ectopy) and 83%, respectively (bidirectional and fully circumferential isolation of all targeted PVs). Procedure and fluoroscopy times were significantly shorter in the "selective" group. There were no major complications, but 7 minor complications and 2 acute PV stenoses > 50% in the 30 "extensive" procedures were observed. Mean follow-up was 8.4 +/- 8.5 months (median 6.9). Kaplan-Meier analysis, excluding recurrences during only the first month ("delayed cure"), showed AF recurrence in 45% after 6 months and in 55% after 1 year. Outcome was not dependent on ablation approach ("selective" or "extensive") nor was time to first AF (22 +/- 64 days and 30 +/- 69 days). AF recurrence tended to be higher in patients with larger LA (P = 0.08), underlying heart disease or hypertension (P = 0.08), and those "extensive" patients in whom not all 4 PVs were targeted (P = 0.07). CONCLUSION: Trigger-directed ablation for focally induced AF is associated with a relatively high recurrence rate during follow-up. Apart from recurrence of the ectopic trigger, this may point to underlying structural changes in the atrial substrate not addressed by the ablation. Prospective evaluation of the risk-to-benefit profile of any technique (selective, extensive, including linear lines) is required.     

Study Design of the Man and Machine Trial: A Prospective International Controlled Noninferiority Trial Comparing Manual with Robotic Catheter Ablation for Treatment of Atrial Fibrillation

Study Design of the Man and Machine Trial. Background: Pulmonary vein isolation (PVI) has become the cornerstone procedure for the treatment of symptomatic drug‐resistant atrial fibrillation (AF). At the present time, circumferential PVI (CPVI) using irrigated radiofrequency (RF) is the mostly used ablation technique. However, for CPVI, precise catheter navigation and excellent catheter stability is crucial thereby requiring experienced operators. Robotic navigation systems have been introduced to facilitate catheter navigation and to improve catheter stability, therefore potentially increasing procedural success and making CPVI accessible to less experienced operators. To date, no prospective randomized trial has evaluated the efficacy and safety of CPVI using RNS compared to manually performed ablation. Methods: In this prospective international multicenter noninferiority trial, 258 patients with either paroxysmal or short‐standing persistent AF will be randomized for comparison of PVI using either manual or robotic ablation. In all patients, CPVI will be performed using irrigated RF ablation in combination with a 3D mapping system. The primary endpoint of the trial is the absence of AF or atrial tachycardia without antiarrhythmic drug therapy during 12‐month follow‐up. Secondary endpoints will be evaluation of periprocedural complications and procedural data such as procedure time, fluoroscopy time, as well as the incidence of esophageal injury assessed by endoscopy within 48 hours after the procedure. Conclusion: The “Man and Machine Trial” is the first prospective international randomized controlled multicenter noninferiority trial to compare manually performed CPVI with robotically navigated CPVI, evaluating both the safety and efficacy of the 2 techniques during a 12‐month follow‐up period. (J Cardiovasc Electrophysiol, Vol. 24, pp. 40‐46, January 2013)     

Catheter Ablation for Long-Standing Persistent Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and represents a major burden to health care systems. Atrial fibrillation is associated with a 4- to 5-fold increased risk of thromboembolic stroke. The pulmonary veins have been identified as major sources of atrial triggers for AF. This is particularly true in patients with paroxysmal AF but not always the case for those with long-standing persistent AF (LSPAF), in which other locations for ectopic beats have been well recognized. Structures with foci triggering AF include the coronary sinus, the left atrial appendage (LAA), the superior vena cava, the crista terminalis, and the ligament of Marshall. More than 30 studies reporting results on radiofrequency ablation of LSPAF have been published to date. Most of these are observational studies with very different methodologies using different strategies. As a result, there has been remarkable variation in short- and long-term success, which suggests that the optimal ablation technique for LSPAF is still to be elucidated. In this review we discuss the different approaches to LSPAF catheter ablation, starting with pulmonary vein isolation (PVI) through ablation lines in different left atrial locations, the role of complex fractionated atrial electrograms, focal impulses and rotor modulation, autonomic modulation (ganglionated plexi), alcohol ablation, and the future of epicardial mapping and ablation for this arrhythmia. A stepwise ablation approach requires several key ablation techniques, such as meticulous PVI, linear ablation at the roof and mitral isthmus, electrogram-targeted ablation with particular attention to triggers in the coronary sinus and LAA, and discretionary right atrial ablation (superior vena cava, intercaval, or cavotricuspid isthmus lines).