Targeted ablation at stable atrial fibrillation sources improves success over conventional ablation in high-risk patients: a substudy of the CONFIRM Trial.
Targeted ablation at stable atrial fibrillation sources improves success over conventional ablation in high-risk patients: a substudy of the CONFIRM Trial.
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DOI：
10.1016/j.cjca.2013.07.672
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发表时间：
2013-10
期刊：
影响因子：
--
通讯作者：
CONFIRM Investigators
中科院分区：
文献类型：
--
作者：
Baykaner T;Clopton P;Lalani GG;Schricker AA;Krummen DE;Narayan SM;CONFIRM Investigators
肺静脉（PV）隔离在肥胖、心力衰竭、阻塞性睡眠呼吸暂停（OSA）和左心房（LA）扩大患者中的结果令人失望，原因不明。我们假设这些合并症导致房颤源的数量或非肺静脉位置较高，靶向源消融（局灶性脉冲和转子调制，FIRM）应提高消融的单次手术成功率。CONFIRM试验前瞻性入组了92例接受107次AF消融术的患者，其中计算标测识别出AF转子或局灶性源。患者接受了FIRM加传统消融（FIRM引导）或仅接受传统消融，并每季度进行一次复发性AF评估，并进行严格的、通常植入的监测。我们报告了n=73例接受首次消融术的患者，其中人口统计学信息可用（n= 52例常规消融术，n=21例FIRM引导消融术）。在97.1%的患者中发现了稳定的房颤源。每例患者的并发源数量（2.1±1.1）随着左心房直径（p=0.021）、左心室射血分数（p=0.039）和阻塞性睡眠呼吸暂停（OSA，p=0.002）或低镁血症（p=0.017）的存在而增加。右心房源与肥胖相关（BMI≥30 kg/m2，p=0.015）。在肥胖、高血压、阻塞性睡眠呼吸暂停和左心房直径> 40 mm的患者中，FIRM引导的单次手术无房颤率>80%，而传统消融术的无房颤率<50%（所有; p<0.05）。与其他患者相比，“难以治疗”的AF患者在更广泛的双心房分布中表现出更多的并发AF源。这些机制解释了肺静脉隔离的令人失望的结果，以及FIRM如何识别患者特异性房颤源，从而在该人群中成功消融。
Pulmonary vein (PV) isolation has disappointing results in patients with obesity, heart failure, obstructive sleep apnea (OSA) and enlarged left atria (LA), for unclear reasons. We hypothesized that these comorbidities cause higher numbers or non-PV locations of AF sources, where targeted source ablation (Focal Impulse and Rotor Modulation, FIRM) should improve the single-procedure success of ablation. The CONFIRM trial prospectively enrolled 92 patients at 107 AF ablation procedures, in whom computational mapping identified AF rotors or focal sources. Patients underwent FIRM plus conventional ablation (FIRM-guided), or conventional ablation only, and were evaluated for recurrent AF quarterly with rigorous, often implanted, monitoring. We report the n=73 patients undergoing first ablation in whom demographic information was available (n= 52 conventional, n=21 FIRM-guided). Stable sources for AF were found in 97.1% of patients. The numbers of concurrent sources per patient (2.1±1.1) rose with LA diameter (p=0.021), lower LV ejection fraction (p=0.039), and the presence of obstructive sleep apnea (OSA, p=0.002) or hypomagnesemia (p=0.017). Right atrial sources were associated with obesity (BMI≥30 kg/m2, p=0.015). In patients with obesity, hypertension, OSA and LA diameter > 40 mm, single-procedure freedom from AF was >80% by FIRM-guided versus <50% by conventional ablation (all; p<0.05). Patients with ‘difficult to treat’ AF exhibit more concurrent AF sources in more widespread biatrial distributions than other patients. These mechanisms explain the disappointing results of PV isolation, and how FIRM can identify patient-specific AF sources to enable successful ablation in this population.
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稳定转子或焦点源的直接或巧合消除可能解释了成功的房颤消融：确认试验的对治疗分析（对AF的常规消融有或没有局灶性脉冲脉冲和转子调制）。
影响因子：
24
作者：
Narayan, Sanjiv M.;Krummen, David E.;Clopton, Paul;Shivkumar, Kalyanam;Miller, John M.
通讯作者：
Miller, John M.
影响因子：
37.8
作者：
Charitos, Efstratios I.;Stierle, Ulrich;Hanke, Thorsten
通讯作者：
Hanke, Thorsten
影响因子：
24
作者：
Chen, MS;Marrouche, NF;Natale, A
通讯作者：
Natale, A
影响因子：
39.3
作者：
Berruezo, Antonio;Tamborero, David;Brugada, Josep
通讯作者：
Brugada, Josep
影响因子：
24
作者：
Narayan, Sanjiv M.;Krummen, David E.;Miller, John M.
通讯作者：
Miller, John M.