节段性肺静脉电隔离术后心房颤动早期复发的处理对策

Treatment strategy of early recurrence of atrial fibrillation after segmental pulmonary veins isolation in patients with paroxysmal atrial fibrillation

目的 对比分析阵发性心房颤动 (房颤 ,AF)患者行节段性肺静脉电隔离 (PVI)术后早期复发房颤的不同治疗方法 ,以探讨对早期复发房颤的处理对策。方法 顽固性阵发AF患者 6 6例 ,其中男性 5 0例 ,平均年龄 5 5± 17(35～ 76 )岁。术前部分患者行多层螺旋CT肺静脉血管成像 ,术中先行非选择性或选择性逆行肺静脉造影 ,Lasso环形标测电极导管指导下 ,在肺静脉口逐一标测 4根肺静脉 ,行节段性PVI,并常规标测和消融上腔静脉。消融温度控制在 5 0～ 5 5℃ ,功率 2 5～ 35W。结果 电学隔离肺静脉 2 19根 ,电隔离成功 2 10根 ,即刻成功率 96 %。PVI术后 2周内AF复发 2 6例 ,占39 3%。其中 9例再次行PVI,发现 9根原隔离的PV恢复袖房传导 ,2个左房后游离壁异位兴奋灶。其余 17例患者用抗心律失常药物控制AF发作。随访 10± 6 (4～ 2 4 )月 ,再次行PVI的 9例患者中 5例无AF发作 (成功率 5 5 6 % ) ,17例药物控制者中 6例无AF发作 (成功率 35 3% ) ,P >0 0 5。 4 0例无早期复发AF患者中 34例无AF发作 (成功率 85 % )。总成功率为 6 8 2 % (45 / 6 6 )。术中 1例发生心包压塞 ,术后 1例左上肺静脉狭窄 6 0 %。结论 阵发性房颤患者行节段性PVI术后房颤早期复发在临床上并非罕见 。

Objective To investigate the treatment strategy of early recurrence of atrial fibrillation (ERAF) after segmental pulmonary veins isolation (PVI) in patients with paroxysmal atrial fibrillation (AF) Methods Segmental pulmonary veins isolation was performed using radiofrequency energy in 66 consecutive patients with recurrent documented symptomatic paroxysmal AF (Male: 50; mean age: 55±17 years) After unselective/selective angiography data of all pulmonary veins (PV) were obtained, Lasso mapping catheter and ablation catheter were positioned into target pulmonary vein ostium We routinely mapped the four PVs and the superior vena cava lest any foci that triggered Paroxysmal AF should be omitted RF power: 25-35 W; temperature: 50-55℃ Results Of the 66 patients 219 PVs were targeted for segmental RF ablation, and 210 PVs were isolated completely Immediate success rate was 96% Early recurrence of AF occurred in 26 of the 66 patients (39 3%) within two weeks after PVI An early repeat ablation was attempted in 9 patients (repeat ablation group) A second approach demonstrated either new foci in left atrial posterior free wall ( n =2) or recurrence of previously isolated PVs ( n =9) The other 17 patients were treated with class Ⅰ or Ⅲ of antiarrhythmic drugs (drug control group) Long term success was achieved in 5 of 9 patients (55 6%) in repeat ablation group, and in 6 of 17 patients (35 3%) in drug control group in the mean 10±6 months of follow up, P >0 05 There was 1 case of cardiac tamponand and 1 case of 60% stenosis of the left superior PV associated with the procedure Conclusion ERAF after segmental PV isolation is common, occurring in approximately 39% of patients with paroxysmal AF However, approximately 35% of ERAF patients without early repeat ablation have no further AF during long term follow up It is suggested that temporary antiarrhymic drug therapy may be more appropriate than early repeat ablation in patients with ERAF