比较射频消融与抗心律失常药物作为有症状性房颤一线治疗的随机临床试验

Context Treatment with antiarrhythmic drugs and anticoagulation is considered first-line therapy in patients with symptomatic atrial fibrillation(AF). Pulmonary vein isolation(PVI) with radiofrequency ablation may cure AF, obviating the need for antiarrhythmic drugs and anticoagulation. Objective To determine whether PVI is feasible as first-line therapy for treating patients with symptomatic AF. Design, Setting, and Participants A multicenter prospective randomized study conducted from December 31, 2001, to July 1, 2002, of 70 patients aged 18 to 75 years who experienced monthly symptomatic AF episodes for at least 3 months and had not been treated with antiarrhythmic drugs. Intervention Patients were randomized to receive either PVI using radiofrequency ablation(n=33) or antiarrhythmic drug treatment(n=37), with a 1-year follow-up. Main Outcome Measures Recurrence of AF, hospitalization, and quality of life assessment. Results Two patients in the antiarrhythmic drug treatment group and 1 patient in the PVI group were lost to follow-up. At the end of 1-year follow-up, 22(63%) of 35 patients who received antiarrhythmic drugs had at least 1 recurrence of symptomatic AF compared with 4(13%) of 32 patients who received PVI(P< .001). Hospitalization during 1-year follow-up occurred in 19(54%) of 35 patients in the antiarrhythmic drug group compared with 3(9%) of 32 in the PVI group(P< .001). In the antiarrhythmic drug group, the mean(SD) number of AF episodes decreased from 12(7) to 6(4), after initiating therapy(P=.01). At 6-month follow-up, the improvement in quality of life of patients in the PVI group was significantly better than the improvement in the antiarrhythmic drug group in 5 subclasses of the Short-Form 36 health survey. There were no thromboembolic events in either group. Asymptomatic mild or moderate pulmonary vein stenosis was documented in 2(6%) of 32 patients in the PVI group. Conclusion Pulmonary vein isolation appears to be a feasible first-line approach for treating patients with symptomatic AF. Larger studies are needed to confirm its safety and efficacy.

有或无心脏外科手术史患者肺静脉窦隔离术后心房扑动消融的必要性

Objectives: The aim of this study was to assess the incidence of atrial flutter(AFL) after pulmonary vein antrum isolation(PVAI) in patients with previous cardiac surgery(PCS) in comparison to patients without PCS and to assess the need for AFL ablation in both groups. Background: Atrial fibrillation(AF) and AFL often co- exist. Pulmonary vein antrum isolation may be sufficient to control both arrhythmias. However, in patients with PCS, atrial incisions, cannulations, and scar areas may cause AFL recurrence despite elimination of pulmonary vein triggers. Methods: Data from 1,345 patients who had PVAI were analyzed. Patients with a history of AFL ablation and patients who had concomitant AFL ablation during PVAI were excluded from analysis. Sixty- three patients constituted the PCS group(Group 1, age 57± 13 years, 12 female) and 1,062 patients constituted the non- PCS group(Group 2, age 55± 12 years, 212 female). Patients in Group 1 had larger left atria, higher incidence of AFL pre- PVAI, and lower ejection fraction. Results: There was no significant difference in post- PVAI AF recurrence between Groups 1 and 2, but AFL incidence after PVAI was higher in Group 1(33% vs. 4% , p< 0.0001). Ablation of AFL in Group 1 patients resulted in an 86% acute success rate and 11% recurrence over a mean follow- up of 357± 201 days. Conclusions: In patients with PCS, post- PVAI AF recurrence is similar to patients without PCS. However, history of PCS is associated with a higher recurrence of AFL after PVAI. In a significant number of patients with PCS, AFL ablation is required to achieve a cure.

致心律失常性右室发育不良患者室性心动过速的基质标测和消融:近期和长期成功率研究

Background-Multiple morphologies,hemodynamic instability, or noninducibility may limit ventricular tachycardia(VT) ablation in patients with arrhythmogenic right ventricular dysplasia(ARVD). Substrate-based mapping and ablation may overcome these limitations. We report the results and success of substrate based VT ablation in ARVD. Methods and Results-Twenty-two patients with ARVD were studied. Traditional mapping for VT was limited because of multiple/changing VT morphologies(n=14), nonsustained VT(n=10),or hemodynamic intolerance(n=5). Sinus rhythm CARTO mapping was performed to define areas of “scar”(< 0.5 mV) and “abnormal”myocardium(0.5 to 1.5 mV). Ablation was performed in “abnormal”regions, targeting sites with good pace maps compared with the induced VT(s). Linear lesions were created in these areas to(1) connect the scar/abnormal region to a valve continuity or other scar or(2) encircle the scar/abnormal region. Eighteen patients had implanted cardioverter defibrillators, 15 had implanted cardioverter defibrillator therapies, and 7 had sustained VT(6 with syncope). VTs(3±2 per patient) were induced(cycle length, 339±94 ms), and scar was identified in all patients. Scar areas were related to the tricuspid annulus, proximal right ventricular outflow tract, and anterior/inferior-apical walls. Lesions connected abnormal regions to the annulus(n=12) or other scars(n=4) and/or encircled abnormal regions(n=13). Per patient, a mean of 38±22 radiofrequency lesions was applied. Shortterm success was achieved in 18 patients(82%). VT recurred in 23%, 27%, and 47%of patients after 1, 2, and 3 years’follow-up, respectively. Conclusions-Substrate-based ablation of VT in ARVD can achieve a good short-term success rate. However, recurrences become increasingly common during long-term follow-up.