Randomized comparison between pulmonary vein antral isolation versus complex fractionated electrogram ablation for paroxysmal atrial fibrillation

Catheter Ablation of Paroxysmal AF. Introduction: Circumferential pulmonary vein antral isolation (PVAI) and atrial complex fractionated electrograms (CFEs) are both ablative techniques for the treatment of paroxysmal atrial fibrillation (PAF). However, data on the comparative value of these 2 ablation strategies are very limited. Methods and Results: We randomized 118 patients with drug‐refractory PAF to receive PVAI ablation (n = 60) or CFE ablation (n = 58). For CFE group, spontaneous/induced AF was mapped using validated, automated software to guide ablation until all CFE areas were eliminated. For PVAI group, all 4 pulmonary vein antra were electrically isolated as confirmed by circular mapping catheter. Patients with spontaneous/inducible AF after the initial ablation procedure were crossed over to the other arms. After initial ablation procedure, AF persisted/inducible in 24/59 patients (41%), and 34/58 patients (59%) assigned to PVAI and CFE ablation, respectively (P = 0.05). Then 58 patients underwent PVAI + CFE ablation. After 22.6 ± 6.4 months, PVAI ablation group was more likely than CFE ablation group to achieve control of any AF/atrial tachycardia (AT) off drugs (43/60, 72% vs 33/58, 57%, P = 0.075) and lower recurrence rate of AT (11.9% vs 34.5%, P = 0.004). Patients who received CFE ablation alone (38%) had significantly lower overall success rate to achieve control of AF/AT off drugs compared with patients who received PVAI ablation (77%, P = 0.002) alone or PVAI + CFE ablation (69%, P = 0.008) due to higher recurrence rate of AT (50% vs 6% vs 13%, P < 0.01). Conclusions: CFE ablation in PAF patients was associated with higher occurrence rate of postprocedure AT compared with PVAI ablation, whereby making it less likely to be a sole ablation strategy for PAF patients. (J Cardiovasc Electrophysiol, Vol. 22, pp. 973‐981, September 2011)     

Spectral profiles of complex fractionated atrial electrograms are different in longstanding and acute onset atrial fibrillation atrial electrogram spectra

Spectral Profiles of CFAE. Background: Spectral analysis of complex fractionated atrial electrograms (CFAE) may be useful for gaining insight into mechanisms underlying paroxysmal and longstanding atrial fibrillation (AF). The commonly used dominant frequency (DF) measurement has limitations. Method: CFAE recordings were acquired from outside the 4 pulmonary vein ostia and at 2 left atrial free wall sites in 10 paroxysmal and 10 persistent AF patients. Two consecutive 8s‐series were analyzed from recordings >16s in duration. Power spectra were computed for each 8s‐series in the range 3–12 Hz and normalized. The mean and standard deviation of normalized power spectra (MPS and SPS, respectively) were compared for paroxysmal versus persistent CFAE. Also, the DF and its peak amplitude (ADF) were compared for pulmonary vein sites only. Power spectra were computed using ensemble average and Fourier methods. Results: No significant changes occurred in any parameter from the first to second recording sequence. For both sequences, MPS and SPS were significantly greater, and DF and ADF were significantly less, in paroxysmals versus persistents. The MPS and ADF measurements from ensemble spectra produced the most significant differences in paroxysmals versus persistents (P < 0.0001). DF differences were less significant, which can be attributed to the relatively high variability of DF in paroxysmals. The MPS was correlated to the duration of uninterrupted persistent AF prior to electrophysiologic study (P = 0.01), and to left atrial volume for all AF (P < 0.05). Conclusions: The MPS and ADF measurements introduced in this study are probably superior to DF for discerning power spectral differences in paroxysmal versus longstanding CFAE. (J Cardiovasc Electrophysiol, Vol. 23, pp. 971‐979, September 2012)     

Incidence of asymptomatic cerebral microthromboembolism after atrial fibrillation ablation guided by complex fractionated atrial electrogram

Cerebral Microthromboembolism After CFAE Ablation . Background: The incidence of cerebral thromboembolism after pulmonary vein isolation (PVI) ranges from 2% to 14%. This study investigated the incidence of cerebral thromboembolism after complex fractionated atrial electrogram (CFAE) ablation with or without PVI. Methods: One hundred consecutive atrial fibrillation (AF) patients (50 paroxysmal and 50 persistent, including 10 longstanding) who underwent CFAE ablation combined with (n = 41, PVI+CFAE group) or without (n = 59, CFAE group) PVI were studied. Coronary angiography (CAG) was conducted with AF ablation in 5 cases in which coronary artery stenosis was suspected on 3D‐computed tomography. PVI was performed before CFAE ablation without circular catheter during AF. After termination of AF, additional ablation was performed to complete PVI with a circular catheter. All patients underwent cerebral magnetic resonance imaging (MRI) including diffusion‐weighted MRI and T2‐weighted MRI the day after ablation. Results: New thromboembolism was detected in 7.0%, and there was no significant difference between the 2 strategies (7.3% in PVI+CFAE group, 6.8% in CFAE group). CHADS2 score (1.6 ± 1.0 vs 0.8 ± 0.9, P < 0.05), left atrial volume (LAV; 83.8 ± 27.1 vs 67.8 ± 21.8, P < 0.05), and left ventricular ejection fraction (LVEF, 53.1 ± 9.2 vs 65.1 ± 9.7, P < 0.01) were significantly different when comparing patients with or without thromboembolism. In multivariate analysis, LVEF (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.84–0.99; P < 0.05) and concomitant CAG (OR 18.82; 95% CI, 1.77–200.00; P < 0.05) were important predictors of new cerebral thromboembolism. Conclusions: The incidence of cerebral microthromboembolism after CFAE ablation was not greater than previous reports in PVI. Cautious management is required during AF ablation, especially in the patients with low LVEF. (J Cardiovasc Electrophysiol, Vol. 23, pp. 567–573, June 2012)     

肺静脉电隔离术联合碎裂电位消融治疗持续性房颤疗效观察

目的：观察肺静脉电隔离术（ pulmonary vein isolation , PVI ）联合碎裂电位（ complex fractionated atrial electrograms , CFAE）消融对持续性房颤的疗效。方法对比观察23名于本院行房颤射频消融术的持续性房颤患者,所有患者均行PVI及左房顶部线性消融,其中12例联合CFAE消融,术后随访1年;观察两组手术时间、X线曝光时间、消融时间、手术并发症、左房大小、左房血栓、一次手术成功率等指标。结果联合CFAE消融组总手术时间（252±35） min、X线曝光时间（42±9．1）min、消融时间（94±11）min,单纯行PVI 组分别为（176±22）min、（34±7．6）min、（63±8）min,联合CFAE消融组手术各时间均明显延长（P＜0．01）;两组手术并发症、对左房大小及左房血栓的影响比较差异均无统计学意义;联合CFAE消融组一次手术成功率（75％）明显高于单纯行PVI组（64％）（ P＜0．05）。结论 PVI联合CFAE消融治疗持续性房颤虽增加手术、消融及X线曝光时间,但并不会提高并发症发生率,可提高房颤消融的一次手术成功率。     

Diagnostic accuracy of a new software for complex fractionated electrograms identification in patients with persistent and permanent atrial fibrillation

Introduction: The elimination of complex fractionated atrial electrograms (CFAEs) has been proposed as a potential target for guiding successful AF substrate ablation. The possibility to efficiently map the atria and rapidly identify CFAEs sites is necessary, before the CFAEs ablation becomes a routine approach. The aims of this study, conducted in patients with persistent and permanent atrial fibrillation (AF), were to analyze by CARTO mapping in the right (RA) and in the left atrium (LA) during AF: (1) the diagnostic accuracy of a new software for CFAEs analysis, (2) the spatial distribution of CFAEs, (3) the regional beat to beat AF intervals (FF). Methods and Results: Twenty‐five consecutive patients (four women, 58.8 ± 11.4 years) undergoing radiofrequency catheter ablation for persistent and permanent AF were enrolled in the study. The CFAE software showed a high sensitivity (90%) and specificity (91%) in the identification of CFAEs, using a specific setting of parameters. The LA had a significantly higher prevalence of CFAEs as compared with the RA (30.5% vs 20.3%, P = 0.016). The CFAEs were mostly present in the septum and in the area of coronary sinus ostium (CS os). The FF intervals were significantly shorter in the LA than in the RA (P < 0.01). Conclusion: CARTO system has a high diagnostic accuracy in the identification of CFAEs. Atrial electrical activity (CFAEs, mean FF intervals) during AF showed a significant spatial inhomogeneity.     

老年对慢性心房颤动患者左房复杂碎裂电位的影响

目的 评价老年对非瓣膜病心房颤动（简称房颤）患者左房复杂碎裂电位（CFAEs）的影响。方法 前瞻性入选116例行导管消融的慢性房颤患者。 以60岁为界,分为老年组（n=48）与非老年组（n=68）。 在CARTO系统指导下记录局部稳定的心内膜电图。 应用CARTO系统内置的CFAEs分析软件进行分析。 以间期置信水平（ICL）来评估CFAEs的特点。 CFAEs指数定义为 ICL≥7 区域的面积与左房表面积的比值。 将左房分为前壁、后壁、顶部、下壁、外侧壁、间隔六个部分,评价CFAEs在左房不同位置的分布特征。 结果 老年组男性患者比例显著低于非老年组,合并高血压、脑卒中的比例显著高于非老年组（P均〈0. 05）。 老年组最大ICL显著大于非老年组[（16.7±2.0） vs （15.7±2.2）,P=0. 014）],老年组CFAEs指数显著高于非老年组[（60. 4%±22.9% ） vs （48. 6%±22. 3% ）,P=0. 007）]。 老年组左房前壁、间隔的CFAEs的分布比例显著大于非老年组。 年龄与CFAEs指数呈正相关（r=0. 244, P=0. 008）。 结论 老年慢性房颤具有广泛的 CFAEs。     

A novel finding of the atrial substrate properties and long-term results of catheter ablation in chronic atrial fibrillation patients with left atrial spontaneous echo contrast

Atrial Substrate Properties in Chronic AF Patients with LASEC. Background: The atrial substrate in chronic atrial fibrillation (AF) patients with a left atrial spontaneous echo contrast (LASEC) has not been previously reported. The aim of this study was to investigate the atrial substrate properties and long‐term follow‐up results in the patients who received catheter ablation of chronic AF. Methods: Of 36 consecutive patients with chronic AF who received a stepwise ablation approach, 18 patients with an LASEC (group I) were compared with 18 age‐gender‐left atrial volume matched patients without an LASEC (group II). The atrial substrate properties including the weighted peak‐to‐peak voltage, total activation time during sinus rhythm (SR), dominant frequency (DF), and complex fractionated electrograms (CFEs) during AF in the bi‐atria were evaluated. Result: The left atrial weighted bipolar peak‐to‐peak voltage (1.0 ± 0.6 vs 1.6 ± 0.7 mV, P = 0.04), total activation time (119 ± 20 vs 103 ± 13 ms, P < 0.001) and DF (7.3 ± 1.3 vs 6.6 ± 0.7 Hz, P < 0.001) differed between group I and group II, respectively. Those parameters did not differ in the right atrium. The bi‐atrial CFEs (left atrium: 89 ± 24 vs 92 ± 25, P = 0.8; right atrium: 92 ± 25 vs 102 ± 3, P = 0.9) did not differ between group I and group II, respectively. After a mean follow‐up of 30 ± 13 month, there were significant differences in the antiarrhythmic drugs (1.1 ± 0.3 vs 0.7 ± 0.5, P = 0.02) needed after ablation, and recurrence as persistent AF (92% vs 50%, P = 0.03) between group I and group II, respectively. After multiple procedures, there were more group II patients that remained in SR, when compared with group I (78% vs 44%, P = 0.04). Conclusion: There was a poorer atrial substrate, lesser SR maintenance after catheter ablation and need for more antiarrhythmic drugs in the chronic AF patients with an LASEC when compared with those without an LASEC. (J Cardiovasc Electrophysiol, Vol. pp. 1‐8)     

Radiofrequency ablation of complex fractionated atrial electrograms (CFAE): preferential sites of acute termination and regularization in paroxysmal and persistent atrial fibrillation

Introduction: Complex fractionated atrial electrograms (CFAE) have been described as a new target for ablation of atrial fibrillation (AF). This prospective study evaluates the acute effects of CFAE ablation in patients with paroxysmal or persistent AF and analyzes the preferential anatomic sites where these effects occur.
Methods and Results: Ablation of CFAE was performed in 66 symptomatic patients (mean age of 58 ± 12 years) with paroxysmal (n = 36) or persistent AF (n = 30). Termination or regularization of AF during ablation of CFAE was achieved in 56 of 66 patients (84%), with termination in 28 of 66 patients (42%) and regularization of AF in 28 of 66 patients (42%). Ablation of CFAE showed no effect in 10 of 66 patients (16%). Termination of AF occurred at 53 sites and AF regularization at 81 sites. The preferential sites of AF termination or regularization were found around the pulmonary veins (termination n = 15; regularization n = 22), at the anterior wall (termination n = 14; regularization n = 19) and at the interatrial septum (termination n = 8; regularization n = 17).
Conclusion: Termination or regularization of AF was achieved acutely in 84% of patients by ablation of CFAE. The preferential sites of AF termination or regularization were found around the pulmonary veins, at the anterior wall of the LA and at the interatrial septum. These findings may have implications for future ablation concepts.     

Autonomic mechanism to explain complex fractionated atrial electrograms (CFAE)

Objective:  To simulate complex fractionated atrial electrograms (CFAE) during sustained atrial fibrillation (AF) in experimental animals.
Background:  The mechanism(s) underlying CFAE has not been fully elucidated.
Methods:  Twenty-two dogs were subjected to a right and/or left thoracotomy. A gauze patch soaked with acetylcholine (ACh) was placed on the right atrial appendage (RAA) to induce sustained AF. During AF, varying concentrations of ACh (1, 10, 100 mM) were "painted" on the RA where electrograms showed regular organized activity. In another six dogs, anterior right ganglionated plexi (ARGP) near the sino-atrial node and inferior right GP (IRGP) at the junction of inferior vena cava and atria were sequentially ablated. In five dogs, ACh was injected into ARGP to induce CFAE.
Results:  During sustained AF, local "painting" with ACh 1 mM and 10 mM induced intermittent CFAE in 1 of 11 and 10 of 11 dogs, respectively. With 100 mM ACh, all 11 showed CFAE (two intermittent, nine continuous). In six other dogs, continuous CFAE induced by topical application of 100 mM ACh were markedly attenuated by ARGP + IRGP ablation. In another five of five dogs, ACh injection into ARGP induced a gradient of CFAE with the continuous CFAE always occurring near the ARGP and CFAE also occurring at left pulmonary vein-atrial junctions. During ARGP ablation, AF was terminated in all five dogs immediately after regularization of the rotor-like electrograms or continuous CFAE.
Conclusions:  This study demonstrates an autonomic basis for CFAE formation, suggesting that graded hyperactive states of the autonomic nervous system (ANS) may induce various types of CFAE observed clinically.     

慢性心房颤动导管消融:碎裂电位消融和线性消融的比较

目的评价环肺静脉隔离(CPVI)基础上采用心房碎裂电位(CFAEs)消融或(和)线性(Linear)消融进行心房基质改良的疗效。方法回顾性分析156例慢性心房颤动(简称房颤)消融病例,房颤病程2.5±2.3年,左房内径42.4±4.5 mm。根据消融术式改进分为三组CPVI+CFAEs、CPVI+linear和CPVI+CFAEs+Linear组。比较消融术中房颤终止比例及随访疗效。结果三组消融总时间有显著性差异(160±14 min vs 178±9 min vs 241±8min,P<0.01)。CPVI+CFAEs组终止房颤/转变房性心动过速(简称房速)的比例(52.7%)显著高于CPVI+Line-ar组(18.4%),但低于CPVI+CFAEs+Linear组(73.1%)。术后3.1±1.2个月,三组二次消融比例47.3%、51%、38.5%,P=0.43。术后平均随访9.5±1.8个月,三组无房性快速性心律失常复发例数分别为39例(70.9%)、33例(67.3%)和41例(78.8%),P=0.41(服用抗心律失常药物比例25.6%、24.2%和22%,P=0.96)。结论 CP-VI基础上CFAEs消融的房颤终止比例高于单纯线性消融,但低于联合应用CFAEs消融和Linear消融。尽管如此,三组术后二次消融比例和随访成功率无显著性差异。     

Substrate modification by pulmonary vein isolation and left atrial linear ablation in patients with persistent atrial fibrillation: its impact on complex-fractionated atrial electrograms

PV and Linear Ablation for CFAEs . Introduction: Linear ablations in the left atrium (LA), in addition to pulmonary vein (PV) isolation, have been demonstrated to be an effective ablation strategy in patients with persistent atrial fibrillation (PsAF). This study investigated the impact of LA linear ablation on the complex‐fractionated atrial electrograms (CFAEs) of PsAF patients. Methods and Results: A total of 40 consecutive PsAF patients (age: 54 ± 10 years, 39 males) who underwent catheter ablation were enrolled in this study. Linear ablation of both roofline between the right and left superior PVs and the mitral isthmus line joining from the mitral annulus to the left inferior PV were performed following PV isolation during AF. High‐density automated CFAE mapping was performed using the NAVX, and maps were obtained 3 times during the procedure (prior to ablation, after PV isolation, and after linear ablations) and were compared. PsAF was terminated by ablation in 13 of 40 patients. The mean total LA surface area and baseline CFAEs area were 120.8 ± 23.6 and 88.0 ± 23.5 cm² (74.2%), respectively. After PV isolation and linear ablations in the LA, the area of CFAEs area was reduced to 71.6 ± 22.6 cm² (58.7%) (P < 0.001) and 44.9 ± 23.0 cm² (39.2%) (P < 0.001), respectively. The LA linear ablations resulted in a significant reduction of the CFAEs area percentage in the region remote from ablation sites (from 56.3 ± 20.6 cm² (59.6%) to 40.4 ± 16.5 cm² (42.9%), P < 0.0001). Conclusion: Both PV isolation and LA linear ablations diminished the CFAEs in PsAF patients, suggesting substrate modification by PV and linear ablations. (J Cardiovasc Electrophysiol, Vol. 23, pp. 962‐970, September 2012)     

单纯碎裂电位指导心房颤动消融的初步临床观察

目的探讨碎裂电位指导心房颤动（房颤）射频导管消融的可行性。方法22例药物治疗无效有症状的房颤患者（阵发性16例,持续性6例）,在自发或诱发房颤时,用Carto构建左心房或左、右心房的三维模型并标测、消融碎裂电位,终点是消除标测到所有碎裂电位或转复窦性心律。结果碎裂电位消融后,13例（59％）转复为窦性心律（直接转复7例,先转为房性心动过速（房速）／心房扑动（房扑）然后转复6例）,9例消融未转复窦性心律患者行电复律或药物复律成功。6例复发（5例房速／房扑,1例阵发性房颤）再次消融,5例成功,随访3—18（10．9±4．8）个月,共有16例（73％）无快速房性心律失常事件,碎裂电位主要分布于左侧房间隔、肺静脉周围、左心房顶部。碎裂电位消融后房颤终止前房颤周期与碎裂电位消融前相比明显延长[（157±18）ms vs （211±32）ms,P〈0．05]。除一例发生心脏压塞且心包穿刺成功引流外,无消融术相关的并发症和后遗症。结论碎裂电位指导房颤导管射频消融安全有效可行。     

Relationship between arrhythmogenic pulmonary veins and the surrounding atrial substrate in patients with paroxysmal atrial fibrillation

Arrhythmogenic PVs and the Fibrillatory Activities . Introduction: The relationship between pulmonary veins (PVs) with atrial fibrillation (AF) initiating triggers and their surrounding atrial substrate has not been elucidated. We aimed to clarify the atrial substrate properties around the PVs. Methods and Results: Twenty‐three paroxysmal AF patients were studied with the identification of PV initiating triggers. High‐density mapping of the dominant frequency (DF, 1200 Hz) and the mean degree of the complex fractionated electrograms (CFE mean interval over 6 seconds) was evaluated in 2 zones (zone 1: < 5 mm, zone 2: 5–15 mm from the PVs) and the left atrial (LA) using a NavX system prior to the PV isolation. High‐DFs (>8 Hz) and continuous CFEs (<50 ms) were identified in 1.5 ± 0.9 and 2.3 ± 1.1 regions per patient, respectively. Most of the high‐DF regions (86%) and continuous CFE regions (77%) were located within 15 mm of the PV ostia. Of those, 75% of the high‐DF regions and 54% of the continuous CFE regions were related to arrhythmogenic PVs. There was a significant DF gradient from arrhythmogenic PV zone 1 to zone 2, while the mean CFE exhibited a significant gradient between arrhythmogenic PV zone 2 and the rest of the LA. Additionally, 69% of the procedural AF termination sites were at arrhythmogenic PV zone 2. Conclusion: Evaluation of the atrial substrate properties may be useful for locating arrhythmogenic PVs during AF and defining the extent of the circumferential PV isolation. (J Cardiovasc Electrophysiol, Vol. 22, pp. 405‐410)     

心房颤动肺静脉前庭和左房内连续碎裂电位的电生理特点

目的探讨阵发性和持续性心房颤动(简称房颤)患者肺静脉前庭(PVO)和左房(LA)内连续碎裂电位(CFEAs)的电生理特点。方法入选24例药物治疗无效的房颤患者,依房颤节律分为阵发性房颤(PAF)组与持续性房颤(PeAF)组,每组各12例,根据距离肺静脉口远近,将肺静脉分成距肺静脉5～10 mm(Ⅰ区)与10～20 mm(Ⅱ区)两区。在房颤时,应用EnSite NavX标测系统高密度标测PVO和LA,比较两组平均CFE值(碎裂间期)≤70ms的CFAEs的电生理特点。结果①PeAF组LA内径大于PAF组(P<0.05),PAF组LA后壁CFAES分布比例最低,顶部最高,PeAF组前后壁最低,左心耳最高;PAF组PVO较LA高(P<0.05),PeAF组PVO和LA无差异。②两组间总PVO区域连续CFAEs比例无差异,PeAF组LA明显高于PAF组(P<0.05),PAF左下PVO连续CFAEs分布比例高于PeAF(P=0.02),另三支PVO无明显差别。除顶部PAF组连续CFAEs分布高于PeAF组(P=0.02)外,PeAF组下壁、左心耳及二尖瓣环均显著高于PAF组(P均<0.001)。③PAF组各支Ⅰ区连续CFAEs分布高于Ⅱ区(P<0.05),PeAF组左下PVOⅠ区高于Ⅱ区(P<0.05),右上PVOⅡ区高于Ⅰ区(P<0.05),另两支PVO无差异。④PAF组PVO平均CFE明显低于LA(P<0.0001),PeAF组两区域及两组间PVO则无差异;PeAF组LA平均CFE值较低,连续CFAEs数量较多,房颤周长较短。结论 LA电解剖重构在房颤维持中起重要作用,PeAF LA内连续CFAEs分布较PAF广泛,碎裂程度更高,房颤周长较短。PVO绝大多数连续CFAEs位于5～10 mm区域。     

Autonomic mechanism for complex fractionated atrial electrograms: evidence by fast fourier transform analysis

Introduction: The mechanism(s) underlying complex fractionated atrial electrograms (CFAE) is not well understood. We hypothesized that CFAE may be caused by enhanced activity of the intrinsic cardiac autonomic nervous system.
Methods and Results: In 35 anesthetized dogs, via a right or left thoracotomy, sustained atrial fibrillation was induced by local application of acetylcholine (ACh; 10, 100 mM) to the surface of the atrial appendage (AA) or by injection of ACh (10 mM) into the ganglionated plexi (GP). Fast Fourier transform analysis was performed from recordings at AA, atrial sites near the AA, mid portion of the atrium, atrial sites near the GP, and the pulmonary veins. After AF was induced with ACh either by topical application to the AA or by direct injection into the GP, CFAE exhibited a significant gradient of progressively decreasing dominant frequency and incidence of CFAE (CFAE%) from the GP toward distant sites, while regularity index progressively decreased in the opposite direction. Ablation of GP markedly attenuated CFAE and eliminated these gradients.
Conclusions: These results suggest CFAE may result from activation of the intrinsic cardiac autonomic nervous system in these animal models of sustained AF. Ablation of GP attenuates CFAE and eliminates the DF gradient.     

左心房高主频及连续碎裂电位电生理特点与持续性心房颤动射频消融临床疗效的关系

目的 探讨左心房（LA）高主频（HDF）及连续碎裂电位（CCFAE）的电生理特点对持续性心房颤动（AF）射频消融术疗效的影响.方法 入选宁波市第一人民医院2011年10月至2012年6月间,至少经2种抗心律失常药物治疗无效且有症状的持续性AF患者42例,在三维标测系统NavX指导下首先行环肺静脉电隔离术（PVI）,对未转复窦性心律（窦律）者继续行LA内CCFAE及HDF（最高频率位点与邻近点频率相差≥20％,DF值≥7 Hz）标测,消融终点：转为窦律且不能被诱发或消除所有CCFAE,对仍维持AF者,行直流电复律;如转为规则的房性心动过速（房速）,明确其电生理机制后进行消融终止.根据随访结果,分为PVI联合CCFAE消融窦律维持组22例（组1）与复发组16例（组2）,其中4例患者在PVI中恢复窦律,回顾性分析影响预后的因素.结果 继续CCFAE消融后15例转复窦律（10例直接转复）,5例房速经消融终止,18例接受直流电复律.随访（1.4±0.2）年,接受PVI联合CCFAE消融22例（57.9％,组1）维持窦律,两组临床特点为LA内CCFAE均值（CCFAE-mean）、CCFAE最大值（CCFAE-max）、CCFAE/LA面积比差异无统计学意义（P＞0.05）,组2平均LA内HDF值（HDF-mean）、HDF最大值（HDF-max）、HDF/LA面积比、CCFAE区域的外周（＞2 cm） HDF、CCFAE-max至HDF-max距离大于组1（P＜0.05）,组1邻近（≤2 cm） HDF的CCFAE区域数量多于组2（P＜0.05）,组1HDF-max位点频谱下降值明显高于组2（P＜0.05）.HDF/LA面积比（OR=2.19,95％CI 1.22～3.92,P＜0.05）、外周HDF的CCFAE区域（OR=0.38,95％CI0.15～0.98,P＜0.05）为射频消融复发的两个独立预测因素.结论 LA内HDF分布及CCFAE与HDF空间关系可能与持续性AF射频消融术后维持有关,提示邻近HDF的CCFAE基质改良策略有效的同时,可减少消融面积.     

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.     

Automatic 3D mapping of complex fractionated atrial electrograms (CFAE) in patients with paroxysmal and persistent atrial fibrillation

Background: Complex fractionated atrial electrograms (CFAE) are a possible target for atrial fibrillation (AF) ablation and can be visualized in three‐dimensional (3D) mapping systems with specialized software. Objective: To use the new CFAE software of CartoXP® (Biosense Webster, Diamond Bar, CA, USA) for analysis of spatial distribution of CFAE in paroxysmal and persistent AF. Methods: We included 16 consecutive patients (6 females; mean 59.3 years) with AF (6 paroxysmal and 10 persistent) undergoing AF ablation. Carto maps of left atrium (LA) were reconstructed. Using the new CFAE software, the degree of local electrogram fractionation was displayed color‐coded on the map surface. LA was divided into four regions: anterior wall, inferior wall, septum, and pulmonary veins (PV). The relationship among regions with CFAE visualized and CFAE ablation regions (persistent AF only) was analyzed retrospectively. Results: In paroxysmal and persistent AF, CFAE were observed in all four LA regions. In paroxysmal AF, the density of CFAE around the PV was significantly higher than in other regions (P < 0.05) and higher than in persistent AF (P < 0.05). In persistent AF, CFAE were evenly distributed all over the LA. Of 40 effective ablation sites with significant AF cycle length prolongation, 33 (82.5%) were judged retrospectively by CFAE map as CFAE sites. Conclusion: CFAE software can visualize the spatial distribution of CFAE in AF. CFAE in persistent AF were observed in more regions of LA compared to paroxysmal AF in which CFAE concentrated on the PV. Automatically detected CFAE match well with ablation sites targeted by operators.