以环肺静脉消融为基础分步消融治疗心房颤动

Stepwise ablation in treatment of atrial fibrillation based on circumferential pulmonary vein ablation

目的探讨在三维标测系统指导下,以环肺静脉消融为基础,分步消融治疗心房颤动(房颤)的可行性和有效性。方法对12例药物治疗无效的阵发性房颤(10例)和持续性房颤(2例)患者,以三步消融方法进行消融:环肺静脉前庭消融、节段性肺静脉消融和碎裂电位(CFAEs)消融。以每个阶段房颤不再被诱发作为消融终点,或完成三个阶段。结果消融结束时,10例阵发性房颤不再被诱发,其中第1阶段7例,第2阶段2例,第3阶段1例。2例持续性房颤在完成所有3个阶段后仍持续发作,最后经体外电转复。3例于术后2 d内短暂复发,继续随访后未再房颤复发,1例房颤并典型心房扑动(房扑)患者术后复发房扑,无房颤复发。所有患者经(10±4)个月随访后,均无房颤复发,无左房房性心律失常出现。手术无并发症发生。手术中放电时间(38±11)min,X线透视时间(37±11)min,操作时间(3.0±0.5)h。结论以房颤不再被诱发为手术终点、以环肺静脉消融为基础的分步消融治疗房颤策略是安全可行的。对于阵发性房颤采用环肺静脉消融术式即有良好效果,而对单纯环肺静脉消融不成功者结合节段性肺静脉消融及碎裂电位消融可进一步提高成功率。

Objective To investigate the feasibility and efficacy of a stepwise ablation procedure in treatment of atrial fibrillation （AF） on the basis of circumferential pulmonary vein（PV） ablation guided by a three-dimensional mapping system（Carto）. Methotis Twelve patients with drug-refractory paroxysmal （ n = 10） and persistent （ n = 2） atrial fibrillation were subjected to threeablation stages during one session： circumferential ablation around the pulmonary vein antrum, segmental pulmonary vein ablation, and ablation of complex fractionated atrial electrograms （ CFAEs）. Endpoint of the procedure was a non-inducibility of AF at any stage or completion of all three-ablation stages. Results Ten patients with a paroxysmal AF had a non-inducible AF at the end of the procedure： seven patients after the first stage, two after the second and one after the third. Two patients with a persistent AF who remained AF after all stages required an external cardioversion. Three patients had a recurrent AF within two days, but were free of recurrent AF after further follow-up. One patient with a paroxysmal AF and typical atrial flluter（AFL） had a recurrent AFL and was free of recurrent AF. During 10 ± 4 months of follow-up, all patients were free of recurrent AF or had left atrial arrhythmias without an anti-arrhythmic drug therapy, and no complications occurred. Average radiofrequency energy delivery, fluoroscopy time and procedure time were （38±11） min, （37± 11） min and （3.0 ±0.5） h, respectively. Conclusion A stepwise ablation procedure on the basis of circumferential pulmonary vein ablation with the AF noninducibilty as a endpoint is effective and safe. Circumferential pulmonary vein ablation alone is enough for paroxysmal AF treatment, while it combined with segmental pulmonary vein ablation and CFAEs ablation may result in high successful rates.