环肺静脉与复合消融治疗阵发性心房颤动的远期疗效

Long-term outcomes of circumferential pulmonary-vein ablation and complex ablation in patients with paroxysmal atrial fibrillation

目的比较环肺静脉消融和复合消融治疗阵发性心房颤动(paroxysmal atrial fibrillation,PAF)后长期随访的成功率,探讨导管消融治疗PAF的路线和终点。方法选择2006年1月至2007年8月接受导管消融治疗的PAF患者141例,分为两组。第1组:单纯环肺静脉消融,在三维心脏电解剖标测系统(CARTO系统)和单环状标测电极(LASSO电极)指导下行同侧环肺静脉左心房线性消融至左心房-肺静脉电活动双向传导阻滞;第2组:复合消融,即在环肺静脉消融后,常规进行心房高频刺激,根据术中是否有自发或诱发的房性心律失常而选择右心房峡部、左心房峡部、左心房顶部、冠状窦左心房心内膜面、左心耳部、碎裂电位、冠状静脉窦内消融或上腔静脉隔离等附加消融方式。比较两组的消融结果和并发症发生情况。结果第1组消融过程中6例出现自发的持续房性心动过速(auricular tachycardia,AT)转为复合消融。结果按照实际治疗原则进行分析,即第1组64例,第2组77例。两组性别、年龄、病程、左心房内径、左心室射血分数及手术时间比较,差异无统计学意义(P>0.05)。第2组X-线曝光时间较第1组显著增加,差异有统计学意义[(39.8±14.2)min vs.(33.1±10.7)min,P=0.002]。随访(39.2±5.2)个月,两组单次消融术后房性心律失常复发率比较,差异无统计学意义[23.4%(15/64)vs.26.0%(20/77),P=0.729]。第1组5例AT和4例PAF接受重复消融,其中5例AT及2例PAF治疗成功;第2组6例AT和6例PAF接受重复消融,其中5例AT和3例PAF治疗成功。两组两次或三次消融后总的窦性心律维持率比较,差异无统计学意义[87.5%(56/64)vs.84.4%(65/77),P=0.603)。结论导管消融治疗PAF的远期成功率高;环肺静脉消融与复合消融治疗PAF的远期效果相似,但X-线曝光时间相对较短,损伤较小;对于复发的患者,寻找肺静脉以外的靶点可进一步提高导管消融治疗PAF的成功率。

Objectives To compare the long-term outcomes of circumferential pulmonary-vein ablation （CPVA） and complex ablation in patients with paroxysmal atrial fibrillation （PAF） and to investigate the best ablation strategy and endpoint for PAF. Methods One hundred and forty one patients with PAF from January 2006 to August 2007 were randomized into two groups. All the patients underwent CPVA guided by CARTO system and single LASSO electrode. Group 1 underwent only CPVA. Group 2 underwent complex ablation including linear lesion,additional focal ablation and complex fraction atrial electrogram （CFAE） guided by the atrial arrhythmias during the procedures and inducement. We compared the ablation results and complications of the 2 groups. Results Six patients transferred to complex ablation due to the persistent atrial tachycardias （AT） during the procedures. We analyzed the results by on time- treatment, that was 64 patients in group 1 and 77 patients in group 2. There were no significant differences of age, sex, course of disease, left auricle diameter, left ventricular ejection fraction and procedure times between the 2 groups （P 〉0.05 ）. Group 2 had a significant longer fluoroscopy time than group 1 [ （39.8± 14.2） min vs. （33.1±10.7） min, P=0.002 ]. After a follow-up of （39.2±5.2） months, the recurrent rates of atrial arrhythmia were similar in two groups [23.4%（15/64） vs. 26.0%（20/77）,P=0.729]. Five AT and 4 PAF patients in group 1 underwent redo. All the AT and 2 PAF were eliminated. There were 12 patients （6 AT and 6 PAF） in group 2 undergoing redo. Three mitral isthmus-related AT, 1 right atrial isthmus-related AT, 1 focal AT located at ostium of coronary sinus, and 3 PAF succeeded. The total successful rates were similar in the two groups [ 87.5% （56/64） vs. 84.4% （65/77）,P=0.603）. Conclusions The successful rate of catheter ablation for PAF is high. CPVA for PAF, with less fluoroscopy time and atrial lesion, had a similar long-term outcomes with complex ablation.Targeting outside pulmonary veins would be important to improve successful rate during the repeated procedures.