对射频消融术后心房颤动复发患者在三维标测系统指导下再次手术治疗

Circumferential pulmonary vein linear ablation for treating patients with recurrent atrial fibrillation

目的探讨射频消融术后心房颤动(房颤)复发的原因及再次手术对房颤的影响。方法入选随访3个月以上自觉症状较术前无好转、心电图证实仍有房颤发作的患者,于三维标测系统指导下行电生理研究及环肺静脉线性消融术,手术终点为环肺静脉消融线的完整及肺静脉的彻底电学隔离。所有患者再次手术后随访至少4个月,观察再次射频消融治疗对复发房性心律失常的影响。结果总计23例复发患者在2005年2月以前入院接受再次手术治疗,占同期复发患者的51.1%(2345)。其中13例首次手术时消融策略为节段性肺静脉消融(SPVA),另外10例为环肺静脉线性消融(CPVA),慢性持续性房颤患者占56.5%(1323)。首次手术为节段性肺静脉消融者肺静脉左心房电传导恢复率(以每根肺静脉为单位计算)为92.3%(4852),而首次接受环肺静脉线性消融术者肺静脉左心房电传导恢复率(以每根肺静脉计算)为75.0%(3040)。手术中见首次接受节段性肺静脉消融术的患者再次手术的手术时间、X线时间及放电时间均较长,与首次接受环肺静脉线性消融术的患者相比差异具有统计学意义。再次手术后平均随访4.2±3.5(4.0～9.0)个月,累计无房性快速心律失常率为82.6%(1923)。结论肺静脉左心房电传导恢复是多数房颤患者复发的原因;三维标测系统指导下的环肺静脉线性消融术用于治疗复发患者同样安全有效。

Objective To investigate the underlying mechanism for recurrence of atrial fibrillation （Afib） after trans- catheter ablation and the impact of repeat ablation on Afib. Methods Patients with symptomatic and ECG confirmed recurrent Afib were enrolled in this study. All patients underwent circumferential pulmonary vein linear ablation （CPVA） under the guidance of three dimension mapping system. The end-points of the procedure were electrical iselation of pulmonary vein （PVs）s and completeness of circumferential linear lesion around PVs, A systematic follow-up was conducted to evaluate the rote of atrial tachyarrhythmia free after the second ablation. Results Twenty-three cases （51.1% of the total recurrent cases of the same time） with recurrent Afib included in this study received second ablation, Among them, 13 cases underwent segmental PV ablation and the other 10 cases received CPVA. 56.5% （13/23） of the patients suffered from persistent and chronic Afib, Recovered conduction rate of PV-left atrium （LA） was 92.3 % （48/52） in patients who had undergone SPVA during their first ablation and 75.0% （30/40） in patients who had received CPVA previously. Prolonged procedure time, more fluoroscopic exposure and higher radiofrequency needed were observed in patients who had undergone SPVA during their first ablation. 82.6% （19/23） of the patients were free from atrial tachy-arrhythmia during a mean follow-up of 4.2 ± 3.5 （4.0 - 9.0） months after the second ablation. Conclusion Recovered conduction of PV-LA was the major factor respensible for the reeurrence of Afib after the first procedure, CPVA under the guidance of three dimension mapping system may be feasiable for patient with recurrent atrial fibrilation.