Treatment of Atrial Fibrillation by the Ablation of Localized Sources CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) Trial
Treatment of Atrial Fibrillation by the Ablation of Localized Sources CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) Trial
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DOI：
10.1016/j.jacc.2012.05.022
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发表时间：
2012-08-14
影响因子：
24
通讯作者：
Miller, John M.
中科院分区：
文献类型：
--
作者：
Narayan, Sanjiv M.;Krummen, David E.;Miller, John M.
目的我们假设人类心房颤动（AF）可能是由局部源持续的（电转子和焦点脉冲），其消除（焦点脉冲和转子调制[FIRM]）可以改善AF消融的结果。背景用于AF的导管消融是一种有前途的治疗，其成功部分受到维持AF机制的不确定性的限制。我们开发了一种计算方法来绘制AF是否由以下因素维持：几个蜿蜒的波浪方法我们在107例阵发性或持续性房颤（72%）的连续消融术中招募了92例受试者。2设计，通过源处的消融（FIRM引导），随后进行常规消融（n = 36），或单独进行常规消融结果在101例持续性AF患者中，98例（97%）检测到局部转子或局灶性脉冲，每个显示2.1 +/- 1.0个源。86%的FIRM指导病例达到了急性终点（AF终止或持续减慢），而FIRM盲法病例仅为20%（p < 0.001）。在主源单独进行FIRM消融终止AF的中位时间为2.5 min（四分位距：1.0 - 3.1 min）。两组之间的总消融时间无差异（57.8 ± 22.8 min vs. 52.1 ± 17.8 min，p = 0.16）。在单次手术后的中位数273天（四分位距：132至681天）内，FIRM指导的病例在单次手术后的无AF率（82.4% vs. 44.9%; p < 0.001）高于FIRM盲法病例（通常采用严格的植入式心电图监测）。不良事件并没有不同groups.Conclusions局部电动转子和局灶性脉冲源是普遍的人类AF的持续机制。在患者特定的源FIRM消融急性终止或减缓AF，并改善结果。这些结果为AF提供了一种新的机制框架和治疗范例。（有或无局灶性脉冲和转子调制的房颤常规消融[CONFIRM]; NCT 01008722）（J Am科尔Cardiol 2012;60：628-36）（C）2012，美国心脏病学会基金会
Objectives We hypothesized that human atrial fibrillation (AF) may be sustained by localized sources (electrical rotors and focal impulses), whose elimination (focal impulse and rotor modulation [FIRM]) may improve outcome from AF ablation.Background Catheter ablation for AF is a promising therapy, whose success is limited in part by uncertainty in the mechanisms that sustain AF. We developed a computational approach to map whether AF is sustained by several meandering waves (the prevailing hypothesis) or localized sources, then prospectively tested whether targeting patient-specific mechanisms revealed by mapping would improve AF ablation outcome.Methods We recruited 92 subjects during 107 consecutive ablation procedures for paroxysmal or persistent (72%) AF. Cases were prospectively treated, in a 2-arm 1:2 design, by ablation at sources (FIRM-guided) followed by conventional ablation (n = 36), or conventional ablation alone (n = 71; FIRM-blinded).Results Localized rotors or focal impulses were detected in 98 (97%) of 101 cases with sustained AF, each exhibiting 2.1 +/- 1.0 sources. The acute endpoint (AF termination or consistent slowing) was achieved in 86% of FIRM-guided cases versus 20% of FIRM-blinded cases (p < 0.001). FIRM ablation alone at the primary source terminated AF in a median 2.5 min (interquartile range: 1.0 to 3.1 min). Total ablation time did not differ between groups (57.8 +/- 22.8 min vs. 52.1 +/- 17.8 min, p = 0.16). During a median 273 days (interquartile range: 132 to 681 days) after a single procedure, FIRM-guided cases had higher freedom from AF (82.4% vs. 44.9%; p < 0.001) after a single procedure than FIRM-blinded cases with rigorous, often implanted, electrocardiography monitoring. Adverse events did not differ between groups.Conclusions Localized electrical rotors and focal impulse sources are prevalent sustaining mechanisms for human AF. FIRM ablation at patient-specific sources acutely terminated or slowed AF, and improved outcome. These results offer a novel mechanistic framework and treatment paradigm for AF. (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation [CONFIRM]; NCT01008722) (J Am Coll Cardiol 2012;60:628-36) (C) 2012 by the American College of Cardiology Foundation