环肺静脉消融治疗慢性房颤

Background: We conducted a randomized, controlled trial of circumferential pulmonary-vein ablation for the treatment of chronic atrial fibrillation. Methods: A total of 146 patients with a mean(± SD) age of 57± 9 years who had chronic atrial fibrillation were randomly assigned to receive amiodarone and undergo two cardioversions during the first three months alone(the control group) or in combination with circumferential pulmonary-vein ablation. Cardiac rhythm was assessed with daily telephonic transmissions for one year. The left atrial diameter and the severity of symptoms were assessed at 12 months. Results: Among the 77 patients assigned to undergo circumferential pulmonary-vein ablation, ablation was repeated because of recurrent atrial fibrillation in 26 percent of patients and atypical atrial flutter in 6 percent. An intention-to-treat analysis showed that 74 percent of patients in the ablation group and 58 percent of those in the control group were free of recurrent atrial fibrillation or flutter without antiarrhythmic-drug therapy at one year(P=0.05). Among the 69 patients in the control group, 53(77 percent) crossed over to undergo circumferential pulmonary-vein ablation for recurrent atrial fibrillation by one year and only 3(4 percent) were in sinus rhythm without antiarrhythmic-drug therapy or ablation. There were significant decreases in the left atrial diameter(12± 11 percent, P< 0.001) and the symptom severity score(59± 21 percent, P< 0.001) among patients who remained in sinus rhythm after circumferential pulmonary-vein ablation. Except for atypical atrial flutter, there were no complications attributable to circumferential pulmonary-vein ablation. Conclusions: Sinus rhythm can be maintained long term in the majority of patients with chronic atrial fibrillation by means of circumferential pulmonary-vein ablation independently of the effects of antiarrhythmic-drug therapy, cardioversion, or both. The maintenance of sinus rhythm is associated with a significant decrease in both the severity of symptoms and the left atrial diameter.

施行房颤左房消融后冠状窦内非典型房扑和房性心动过速的导管消融

OBJECTIVES: The goal of this study was to describe the prevalence and ablation of coronary sinus(CS) arrhythmias after left atrial ablation for atrial fibrillation(AF). OBJECTIVES: The CS has been implicated in a variety of supraventricular arrhythmias. METHODS: Thirty-eight patients underwent mapping and ablation of atypical flutter that developed during(n=5) or after(n=33) ablation for AF. Also included were two patients with focal CS arrhythmias that occurred during an AF ablation procedure. A tachycardia was considered to be originating from the CS if the post-pacing interval in the CS matched the tachycardia cycle length and/or if it terminated during ablation in the CS. RESULTS: Among the 33 patients who developed atypical flutter late after AF ablation, 9(27%) were found to have a CS origin. Overall, 16 of the 40 patients in this study had a CS arrhythmia. The tachycardia was macro-re-entrant in 14 patients(88%) and focal in two patients. Radiofrequency ablation with an 8-mm-tip catheter was successful in 15 patients(94%) without complication. In eight patients(50%),< 45 W was required for successful ablation. Thirteen of the 15 patients(87%) with a successful ablation acutely remained arrhythmia free during 5±5 months of follow-up. CONCLUSIONS: The musculature of the CS serves as a critical component of the re-entry circuit in approximately 25%of patients with atypical flutter after ablation for AF. The CS may also generate focal atrial arrhythmias that may play a role in triggering and/or maintaining AF. Catheter ablation of these arrhythmias in the CS can be performed safely.

复杂电描记引导下的慢性房颤射频导管消融治疗

背景:已有报道指出,在复杂心房碎裂电位引导下施行房颤(AF)射频导管消融可消除大部分患者的AF。但是,先前的研究仅包含很少的慢性AF患者。方法和结果:100例慢性AF患者(平均年龄57±11岁)

对阵发性房颤进行导管消融治疗的个体化方法

Background -Because the genesis of atrial fibrillation(AF)is multifactorial and variable, an ablation strategy that involves pulmonary vein isolation and/or a particular set of ablation lines may not be equally effective or efficient in all patients with AF. A tailored strategy that targets initiators and drivers of AF is a possible alternative to a standardized lesion set. Methods and Results -Catheter ablation was performed in 153 consecutive patients(mean age, 56±11 years) with symptomatic paroxysmal AF with the use of an 8-mm tip radiofrequency ablation catheter. The esophagus was visualized with barium. The pulmonary veins and left atrium were mapped during spontaneous or induced AF. Arrhythmogenic pulmonary veins were isolated or encircled. If AF was still present or inducible, complex electrograms in the left atrium, coronary sinus, and superior vena cava were targeted for ablation. The end point of ablation was absence of frequent atrial ectopy and spontaneous AF during isoproterenol infusion and noninducibility of AF. Routine energy applications near the esophagus were avoided. During follow-up, left atrial flutter developed in 19%of patients and was still present in 10%at >12 weeks of follow-up. A repeat ablation procedure was performed in 18%of patients. During a mean follow-up of 11±4 months, 77%of patients were free from AF and/or atrial flutter without antiarrhythmic drug therapy. Pericardial tamponade or transient neurological events occurred in 2%of procedures. Conclusions -A tailored ablation strategy that only targets triggers and drivers of AF is feasible and eliminates paroxysmal AF in ≈80%of patients.