持续性心房颤动导管消融策略

心房颤动(房颤)是常见的快速性心律失常之一,其发病率随着年龄递增,我国人口老龄化逐步凸显,房颤的发病率增加,其卒中发生风险明显升高。2014年美国心脏协会(AHA)、美国心脏病学会(ACC)、美国心律学会(HRS)房颤指南将持续性房     

慢性心房颤动导管消融:碎裂电位消融和线性消融的比较

目的评价环肺静脉隔离(CPVI)基础上采用心房碎裂电位(CFAEs)消融或(和)线性(Linear)消融进行心房基质改良的疗效。方法回顾性分析156例慢性心房颤动(简称房颤)消融病例,房颤病程2.5±2.3年,左房内径42.4±4.5 mm。根据消融术式改进分为三组CPVI+CFAEs、CPVI+linear和CPVI+CFAEs+Linear组。比较消融术中房颤终止比例及随访疗效。结果三组消融总时间有显著性差异(160±14 min vs 178±9 min vs 241±8min,P<0.01)。CPVI+CFAEs组终止房颤/转变房性心动过速(简称房速)的比例(52.7%)显著高于CPVI+Line-ar组(18.4%),但低于CPVI+CFAEs+Linear组(73.1%)。术后3.1±1.2个月,三组二次消融比例47.3%、51%、38.5%,P=0.43。术后平均随访9.5±1.8个月,三组无房性快速性心律失常复发例数分别为39例(70.9%)、33例(67.3%)和41例(78.8%),P=0.41(服用抗心律失常药物比例25.6%、24.2%和22%,P=0.96)。结论 CP-VI基础上CFAEs消融的房颤终止比例高于单纯线性消融,但低于联合应用CFAEs消融和Linear消融。尽管如此,三组术后二次消融比例和随访成功率无显著性差异。     

持续性心房颤动导管消融技术与策略

环肺静脉隔离（PVI）是心房颤动（房颤）导管消融的基石,作为阵发性房颤的消融策略被广泛接受。对于持续性房颤,单纯PVI疗效欠佳,常需要对心房基质进行改良。目前常见的基质改良策略主要包括腔内指导的消融策略（如转子消融、碎裂电位消融）和解剖消融策略（如线性消融）等。目前尚无临床证据表明任何一种基质改良策略能够在PVI的基础...     

心房颤动碎裂电位消融进展

心房颤动(房颤)消融始于20世纪90年代中叶,目前,已取得较大进展.消融术式经历了局灶消融、节段性肺静脉电隔离、环肺静脉线性消融、左房或(和)右房线性消融、神经丛消融、碎裂电位(CFAEs)消融、逐级消融等,由于对其机制认识的不同导致其消融策略多样化.CFAEs消融作为消融策略之一,最近几年进展很快,效果明显,下面对此作一综述.     

环肺静脉电隔离联合左心房连续碎裂电位射频导管消融治疗持续性心房颤动的临床研究

目的 观察环肺静脉消融(CPVI)联合连续心房碎裂电位(CFAE)射频导管消融治疗持续性心房颤动的有效性和安全性.方法 入选64例经药物治疗无效且有症状的持续性心房颤动(PeAF)患者,CPVI后分为转复窦性心律(A 组)及未转复窦性心律组(B 组),未转复窦性心律患者行左心房连续CFAE(CFE-mean≤70ms)标测与消融后,分为转复窦性心律组(B1 组)与未转复窦性心律组(B2 组).两者终点分别为消除所有肺静脉电位与连续CFAE 或转复窦性心律.结果 A 组年龄、术前左心房内径(LAD)、左心室舒张末期内径(LVEDD)及手术前后心房颤动周长(AFCL)明显高于B 组(P＜0.05).B1 组术前LAD、LVEDD 及手术前后AFCL 明显高于B2 组(P＜0.05).A 组15 例(23%)与B1组21 例(45%)直接转复为窦性心律,B1组患者中3 例(6%)二尖瓣峡部依赖与2 例(4%)三尖瓣峡部依赖心房扑动经线性消融后转为窦性心律,1 例(2%)二尖瓣环局灶性房性心动过速患者消融后转为窦性心律,28 例(57%)维持心房颤动患者行体外直流电复律成功.随访(5.8±2.3)个月,36 例(56%)维持窦性心律,A 组发生3 例(20%)快速性房性心动过速,明显低于B 组25例患者(51%,P＜0.01).B1组发生快速性房性心动过速,低于B2组患者(33%、64%,P＜0.01).术中及术后均未发生严重并发症.结论 CPVI 联合连续CFAE 指导持续性心房颤动射频导管消融术有效安全,CPVI及CFAE消融对于心房电解剖重构程度较低患者的消融效果可能更好.     

持续性心房颤动导管消融方法及策略

心房颤动是临床上最常见的心律失常,其节律控制治疗主要有药物治疗和非药物治疗两种方式。目前非药物治疗心房颤动发展迅速,其中导管消融作为非药物治疗心房颤动手段之一已被人们广泛接受。肺静脉电隔离作为阵发性心房颤动的消融终点已经得到共识,而持续性心房颤动消融术式及终点尚未统一,现就目前持续性心房颤动消融方法及策略做一简要介绍。     

心房颤动的导管消融

<正>导管消融能够有效地使药物治疗无效的心房颤动(房颤)患者长期维持窦性心律,对减少包括严重症状、脑卒中、起搏器需求、心力衰竭等危害具有重要意义。导管消融的方法也因房颤类型和医院的不同而异,虽然仍存在争议,但是随着实践的深入和认识的提高,这些争议逐渐会被共识所替代。     

导管消融心房颤动的新进展

心房颤动(房颤)的导管消融是唯一有望根治房颤的疗法,但目前主流的肺静脉大环隔离术主要适于阵发性房颤,持续性房颤的消融需要结合线性消融、碎裂电位消融,但难以实现透壁是治疗失败的主要原因。也有学者试图寻找新的机制理论来实现突破,转子学说应运而生但未得到检验。冷冻消融主要为不熟练的术者提供了简便的手段但只限于阵发性房颤。压力感知导管有望改善消融效果和安全性。分期或同期的内外科联合消融是值得推广的策略。     

肺静脉前庭隔离联合碎裂电位指导线性消融治疗持续性心房颤动

目的评价环肺静脉隔离(CPVI)基础上采用心房碎裂电位(CFAEs)指导的线性消融进行心房基质改良的疗效。方法分析66例持续性心房颤动(简称房颤)消融病例,所有患者标测碎裂电位,行环肺静脉隔离后根据标测结果设计消融径线。明确消融术中房颤终止比例及随访疗效。结果所有入选患者CFAEs分布比例从高向低依次为:肺静脉前庭、左房间隔、顶部、前壁等,消融径线主要为顶部线、前壁线、间隔线、峡部线等。入选患者平均消融线(1.9±0.4)根。随访(16.5±3.9)个月,52例(78.8%)患者经过一次消融术未再发心律失常。14例复发,1例为典型心房扑动,10例为阵发性房颤,1例为持续房颤,2例房性心动过速。结论持续性房颤接受CPVI附加CFAEs标测后线性消融有效、安全。     

导管射频消融治疗心房颤动

心房颤动发生与维持机制研究的深入使导管射频消融治疗房颤逐步进入临床。为提高导管消融治疗的成功率 ,仍有许多问题亟待解决。作者就此作一综述。     

Frontier of catheter ablation for atrial fibrillation

The sudden evolution of catheter ablation (CA) therapy for atrial fibrillation (AF) was brought by the discovery of a new insight into the triggering mechanism of AF by Haïssaguerre et al. in 1998. This discovery opened a new era of evolution of ablation therapy of paroxysmal AF (PAF). At the frontier of AF ablation, technical development of CA for long-standing persistent AF (CAF) has been done enthusiastically, although the detailed electrophysiologic mechanism and anatomical substrate of persistent AF remain unknown. Stepwise ablation composed of multiple procedures, circumferential pulmonary vein isolation (PVI), biatrial defragmentation, and anatomical linear ablation with the endpoint of AF termination has been the most widely accepted method, because the efficacy of this method was reported to be surprisingly high during a relatively short duration of follow-up. Recently, they showed this strategy has a significant limitation in efficacy for CAF with long AF duration (>7 years), enlarged left atrium (>50 mm in left anterior descending artery), short AF cycle length (AFCL) (<130 ms) and impaired cardiac function. For cases associated with these clinical, anatomical, and electrophysiological parameters, AF termination as an endpoint might be abandoned if peak prolongation of AFCL, reduction of intra-/inter-atrial AFCL gradient, and low defibrillation threshold are attained after predetermined lesion set is completed. Prolonged procedure with massive tissue ablation to attain AF termination should be avoided, because it potentially increases adverse events during and immediately after the procedure and causes extensive scar-formation in both atria with atrial mechanical dysfunction.     

单纯碎裂电位指导心房颤动消融的初步临床观察

目的探讨碎裂电位指导心房颤动（房颤）射频导管消融的可行性。方法22例药物治疗无效有症状的房颤患者（阵发性16例,持续性6例）,在自发或诱发房颤时,用Carto构建左心房或左、右心房的三维模型并标测、消融碎裂电位,终点是消除标测到所有碎裂电位或转复窦性心律。结果碎裂电位消融后,13例（59％）转复为窦性心律（直接转复7例,先转为房性心动过速（房速）／心房扑动（房扑）然后转复6例）,9例消融未转复窦性心律患者行电复律或药物复律成功。6例复发（5例房速／房扑,1例阵发性房颤）再次消融,5例成功,随访3—18（10．9±4．8）个月,共有16例（73％）无快速房性心律失常事件,碎裂电位主要分布于左侧房间隔、肺静脉周围、左心房顶部。碎裂电位消融后房颤终止前房颤周期与碎裂电位消融前相比明显延长[（157±18）ms vs （211±32）ms,P〈0．05]。除一例发生心脏压塞且心包穿刺成功引流外,无消融术相关的并发症和后遗症。结论碎裂电位指导房颤导管射频消融安全有效可行。     

"组合"消融术式治疗慢性心房颤动临床疗效

目的 评价"组合"消融术式治疗慢性心房颤动(房颤)的疗效及其影响因素.方法 入选2006年1月至2007年10月慢性房颤患者340例,年龄(62.2±10.1)岁,房颤病程(5.6±6.4)年.消融术式为环肺静脉隔离(CPVI)+碎裂电位(CFAEs)消融.消融术后口服华法林和胺碘酮3个月,定期随访心电图和24 h动态心电图.对首次消融术约2个月以后复发房性心律失常的患者进行二次消融.结果 337例完成消融,3例患者因并发心脏压塞终止.消融术时间(234±31)min,X线曝光时间(25±12)min.CPVI终止房颤11例(3.26%),其中直接恢复窦性心律5例,转为房性心动过速(房速)6例.326例进行CFAEs标测和消融.CFAEs消融终止房颤138例(40.9%),其中直接终止恢复窦性心律51例(15.1%),转为房速87例(25.8%).消融结束仍为房颤188例.消融术后(2.3±1.2)个月后共有房性快速心律失常(ATa)复发143例(42.4%),其中房速52例,房颤65例,房颤合并房速26例,接受再次消融121例(35.9%).3例(0.8%)心脏压塞患者中1例外科修补,2例心包穿刺引流保守治疗痊愈.股动脉假性动脉瘤3例(0.8%),经保守治疗痊愈,脑卒中2例,左下肺静脉轻度狭窄3例(0.8%).平均随访(15.4±4.3)个月,共有256例(76%)维持窦性心律[71例(31.6%)服用胺碘酮,121例(35.9%)二次消融].多变量分析显示左心房内径和合并器质性心脏病是慢性房颤消融复发的危险因素.结论 CPVI+CFAEs消融治疗慢性房颤一次消融复发率为42.4%,二次消融可以将成功率提高到76%,左心房内径和合并器质性心脏病是慢性房颤消融复发的危险因素.     

Advanced mapping techniques in atrial fibrillation

Catheter ablation has emerged as an excellent treatment option for atrial fibrillation especially in patients with paroxysmal AF. Several obstacles however remain regarding ablation strategies for persistent and chronic AF. In this setting, adequate success rates can only be achieved with left atrial ablation in addition to complete PV isolation. Important techniques in this regard are mapping of complex fractionated atrial electrograms as well as identification of atrial sites serving as sources of persistent AF. Other mapping techniques reviewed in this article are rapid geometry acquisition with spiral catheters and the Ensite/NAVX system, the 64-pole Constellation basket catheter as well as the MESH Mapper catheter.     

Termination of persistent atrial fibrillation during left atrial mapping

Termination of Persistent AF During Mapping. Complex fractionated atrial electrograms (CFAEs) may represent critical areas for the maintenance of atrial fibrillation (AF). While AF organization and termination have been reported with CFAE ablation, no reports of arrhythmia termination during left atrial mapping exist. We report a case of reproducible AF termination with catheter pressure at a site of CFAE remote from the site of AF. (J Cardiovasc Electrophysiol, Vol. 22, pp. 1171‐1173, October 2011)     

阵发性心房颤动经导管射频消融治疗评价

目的　探讨经导管射频消融治疗阵发性心房颤动 (房颤 )的安全性和有效性。方法　 74例发作频繁、药物治疗无效的阵发性房颤 ,前 5 0例的消融靶点为房颤特异性早搏或房颤的起源部位 ,消融终点为自发和诱发的房颤特异性早搏或房颤消失 (终点 1) ;后 2 4例的消融靶点为致心律失常性肺静脉的开口部 ,消融终点为该肺静脉的肺静脉电位消失 (终点 2 )。结果　共发现 111个异位灶 ,行76次消融术 ,有 5 8例 (78 4% )达到消融终点。随访 1～ 31(12 9± 6 6 )个月 ,2 3例 (31 1% )消融成功 ,可以无需药物而维持窦性心律。术中达到消融终点者的成功率为 39 7% (2 3例 / 5 8例 ) ,其中达终点 1者为 34 1% (15例 / 44例 ) ,达终点 2者为 5 7 1% (8例 / 14例 )。并发症 :无症状的单支肺静脉狭窄 5例(6 8% )、气胸 1例 (1 4% ) ,均发生于本组的前 30例中。结论　经导管射频消融治疗阵发性房颤较为安全 ,但成功率尚待提高 ,目前可用于部分发作频繁、症状严重、而且药物治疗无效的患者。     

持续性心房颤动递进式消融术后复发双环折返性房性心动过速的电生理诊断

目的 阐明递进式消融术治疗持续性心房颤动(房颤)术后复发双环折返性房性心动过速(房速)的电生理特点.方法 入选2007年7月至2012年12月持续性房颤递进式消融术后复发房速的19例患者.结果 19例患者均通过详细的三维激动标测(＞200个采集点)和在每个折返环内拖带的方法确定了双环折返的机制,其中大折返环和大折返环组成的双环折返13例,大折返环和局部小折返环组成的双环折返6例.大多数病例消融策略采取分别消融两折返环各自的峡部,先将双环折返变为单环折返(由再次拖带结果确定),最后消融单折返环峡部终止房速.结论 双环折返性房速并非是持续性房颤递进式消融术后少见的一种心律失常,详细的三维激动标测联合拖带标测是确诊的最佳方案.     

Substrate modification combined with pulmonary vein isolation improves outcome of catheter ablation in patients with persistent atrial fibrillation: a prospective randomized comparison.

AIMS: To investigate the effectiveness of additional substrate modification (SM) by left atrial (LA) linear lesions as compared with pulmonary vein isolation (PVI) alone in patients with persistent atrial fibrillation (AF) in a prospective randomized study. Percutaneous PVI has evolved as an accepted treatment for paroxysmal AF but seemed to be less effective in patients with persistent AF. The benefit of PVI alone and additional linear lesions has not been validated in a randomized study so far. METHODS AND RESULTS: Sixty-two patients with persistent AF (median duration 7, range 1-18 months) were randomly assigned to either PVI alone (n = 30) or additional SM (n =32) consisting of a roof line connecting both left superior and right superior PV and LA isthmus ablation between left inferior PV and mitral annulus. Procedures including SM were performed using a three-dimensional mapping system (EnSite NavX, St Jude Medical, St Paul, MN, USA). Anti-arrhythmic drugs were discontinued within 8 weeks after ablation in both groups. Follow-up included daily trans-telephonic ECG transmitted irrespective of the patient's symptoms. PVI was successful in 98% of all targeted veins in both groups. Additional SM did not increase fluoroscopy time (72.1+/-18.7 vs. 72.9+/-17.3 min, P=0.92) because of the use of three-dimensional navigation in the PVI+SM group. AF recurrences within the first 4 weeks following ablation were more common after PVI alone (77%) than additional SM (44%, P=0.002). After a follow-up time of 487 (429-570) days, only 20% of patients undergoing stand alone PVI remained in sinus rhythm when compared with 69% following PVI combined with SM (P=0.0001). Two patients assigned to PVI+SM experienced procedure-related complications (cardiac tamponade and minor stroke) which resolved without sequelae. CONCLUSION: PVI alone is insufficient in the treatment of persistent AF. However, additional left linear lesions increase the success rate significantly. Early AF-relapses are associated with a negative outcome after PVI alone but not following additional SM.