PVI's Inconvenient Truths: Lights Out for Dormant Reconnection?
PVI's Inconvenient Truths: Lights Out for Dormant Reconnection?
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PVI 难以忽视的真相：休眠重新连接熄灯？
DOI：
10.1111/j.1540-8167.2011.02215.x
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发表时间：
2012
影响因子：
2.7
通讯作者：
R. Kowal
中科院分区：
文献类型：
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作者：
R. Kowal
肺静脉隔离(PVI)作为房颤(AF)的有效治疗方法的出现，伴随着人们对持久、长期PVI难以实现的不便认识。几个小组发现，消融后复发的房颤患者的共同特征是肺静脉重新连接。1-3再次隔离可使许多此类患者免于心律失常。小型研究表明，没有复发的受试者比那些持续房颤的受试者有更少的再通静脉。因此，PVI最初设计用于隔离已知和潜在的房颤肺静脉来源，同时限制与直接触发消融相关的风险，成为房颤消融的“基石”。4尽管临床上预测消融成功的指标，如左房容量和疤痕负担、房颤持续时间和合并并发症的存在，有助于确定最佳和次佳的消融候选者，但术中预测消融成功的指标更加难以捉摸。异丙肾上腺素注射和突发起搏对房颤PVI后的非PV触发因素有不同的识别能力；然而，这两种方法都不能可靠地预测急性或慢性PV重新连接，这是房颤复发的最重要原因。5，6无论是节段性或某种形式的周向隔离消融方法，PV重新连接似乎是由于病变集合中的小间隙，而不是大的不完全消融。解剖、底物和技术因素都可能导致不能在所有靶点形成跨壁病变。在初始过程中可靠地识别和处理未来消融间隙的位置将是提高PVI的长期疗效和耐久性的宝贵工具。当两个小组分别描述了在PVI后注入腺苷可以瞬时揭示不完全隔离的静脉，称为休眠重新连接或重新传导时，出现了一个潜在的突破。Arentz等人7发现，在PVI后，腺苷在34%的左侧和13%的右侧上静脉暴露了一过性的重新连接。检查PVI后的所有静脉曲张，Tritto等人相似地在35%的静脉曲张中发现了与腺苷的短暂(和少量的永久)重新连接。与长期重新连接的静脉曲张一样，特里托和其他研究这种现象的人发现，重新隔离
The advent of pulmonary vein isolation (PVI) as an effective therapy for atrial fibrillation (AF) was accompanied by the inconvenient realization that durable, long-term PVI is difficult to achieve. PV reconnection was found by several groups to be a common feature in patients with recurrent AF after ablation.1-3 Re-isolation could render many of such patients free of arrhythmia. Small studies suggest that subjects without recurrence appear to have fewer reconnected veins than those with ongoing AF. As a result, PVI, originally devised to isolate known and potential pulmonary vein sources of AF while limiting the risks associated with direct trigger ablation, became the “cornerstone” of AF ablation.4 Although clinical predictors of ablation success such as LA volume and scar burden, AF duration, and the presence of comorbidities have helped identify optimal and suboptimal ablation candidates, intraoperative predictors of ablation success have been more elusive. Isoproterenol infusion and burst pacing have varying ability to identify non-PV triggers of AF post-PVI; however, neither have allowed for dependable prediction of either acute or chronic PV reconnection, the most important cause of AF recurrence.5,6 Regardless of the ablation approach—segmental or some form of circumferential isolation—PV reconnection appears to result from small gaps in the lesion set rather than large sectors of incomplete ablation. Anatomic, substrate, and technical factors may each contribute to the inability to create transmural lesions at all targeted locations. A means of reliably identifying and treating the sites of future ablation gaps during the initial procedure would be an invaluable tool to improve the long-term efficacy and durability of PVI. A potential breakthrough emerged when 2 groups separately described that adenosine, infused after PVI, could transiently unmask incompletely isolated veins, dubbed dormant reconnection, or re-conduction. Arentz et al.7 found that immediately post-PVI, adenosine exposed transient reconnection in 34% of left and 13% of right superior PVs. Examining all PVs after PVI, Tritto et al.8 similarly found transient (and a small degree of permanent) reconnection with adenosine in 35% of PVs. As with chronically reconnected PVs, Tritto and others studying this phenomenon found that re-isolation