持续性心房颤动递进式消融术后复发患者的再消融治疗

Reablation of recurrent atrial tachyarrythmias after catheter ablation for persistent atrial fibrillation using a stepwise approach

目的探讨递进式消融治疗持续性心房颤动(简称房颤)术后复发房性心律失常的机制。方法对50例递进式消融术后复发房性心律失常患者进行再次消融,手术步骤如下:检查双侧肺静脉是否恢复传导,针对消融环上的"gap"(缝隙)补点消融以再次达到肺静脉电学隔离;如果复发心律失常类型为持续性房颤则继续行心房碎裂电位消融,如果复发心律失常类型为规律房性心动过速(简称房速)或房颤经消融转为房速,则通过激动标测和拖带标测明确房速机制后有针对性的消融。结果 50例复发患者中9例(18%)为持续性房颤,41例(82%)为持续性房速,共标测64种房速,机制均为折返性,其中56种(87.5%)为大折返性房速,8种(12.5%)为局限性小折返房速。48种大折返房速折返环路径均经过原消融线,原消融线上遗留或传导恢复的"gap"构成折返环的关键通道。8种局部小折返房速均位于首次消融碎裂电位的区域内或曾实施过的消融线附近,50例复发患者经过再次消融转复窦性心律的比例为90%(45/50)。平均随访13.7±6.2个月,82%(41/50)患者维持稳定窦性心律。结论持续性房颤递进式消融术后复发心律失常多表现为房速,其中大部分和原消融线未阻滞或恢复传导有关,再次消融可改善临床预后。

Objective To delineate the mechanism of recurrent atrial tachyarrthmias that occured after catheter ablation for persistent atrial fibrillation（AF） using a step-wise approach. Methods Fifty patients with recurrent atrial tachyarrth- mias after ablation for persistent AF were enrolled. Ablation was performed in such a sequence ： Close all gaps on the cir- cumferential ablation lines of pulmonary veins to achieve reisolation; Ablating at sites possessing complex fraetionated atrial electrograms if atrial tachyarrthmias manifested as AF; If recurrent atrial tachyarrthmias manifested as atrial tachycardia （AT） or recurrent AF changed into AT, activation mapping and entrainment maneuvers were usecl to define the mechanisms of the tachycardias, then ablation was tried to terminate the tachycardia. Results Among the recurrent atrial tachyarrth- mias,9 manifested as AF and 41 （82%） manifested as AT, a total of 64 ATs were mapped , the mechanism of ATs were reentered in all and were further classified as macroreentry in 56 cases（ 87.5% ） and localized reentry in 8 cases（ 12.5% ）. The critical isthmus in 48 of the 56 macroreentrant ATs traversed a prior ablation line, consistent with a gap-related mecha- nism. The circuits of the 8 localized reentrant AT were near the previously lesion sites for complex fractionated atrial electro- grams or ablation lines. Catheter ablation was successful in 90% of the recurrent cases（45/50） , after a mean follow-up of 13.7±6.2 months, 82% （41/50） were free of AT/AF. Conclusion AT is the most common form of of recurrent arryth- mias after step-wise ablation for AF, most of them are related to gaps in prior ablation lines . Reablation procedure can offer a favorable clinical outcome .