The continuous challenge of AF ablation: From foci to rotational activity.
The continuous challenge of AF ablation: From foci to rotational activity.
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房颤消融的持续挑战：从病灶到旋转活动。
DOI：
10.1016/j.repc.2017.09.007
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发表时间：
2017
期刊：
影响因子：
--
通讯作者：
Wang,PaulJ
中科院分区：
文献类型：
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作者：
Narayan,SanjivM;Vishwanathan,MohanN;Kowalewski,ChristopherAB;Baykaner,Tina;Rodrigo,Miguel;Zaman,JunaidAB;Wang,PaulJ
肺静脉隔离（PVI）是房颤（AF）消融方法的核心，但尽管采用了最新的肺静脉隔离技术，许多患者在一次或多次手术后仍有心律失常复发。消融房颤的旋转源或局灶源（许多患者位于肺静脉外）是一种实用的方法，已被许多组证明可以提高成功率。在人类AF的光学标测和临床研究以及计算和动物研究中，局部源位于心房区域，机械地显示为维持AF。因为它们出现在局部心房区域，AF源可以解释临床实践中的中心悖论-例如，在患者特定部位的有限消融如何终止持续性AF，而在常规位置的广泛解剖消融（应消除紊乱波）并不能提高临床试验的成功率。正在进行的研究可能有助于解决AF旋转源领域的许多争议。现在的研究验证了相同患者在消融终止持续性AF的部位采用多种标测方法进行旋转激活。然而，这些研究也表明，某些标测方法在检测AF源方面不如其他方法有效。还认识到房颤源消融的成功取决于技术。这篇综述文章提供了消融局部源（旋转和局灶性）的机制和临床依据，并描述了成功的消融技术以及应避免的陷阱。我们希望这篇综述将成为未来复杂心律失常患者定制消融术改进的平台。
Pulmonary vein isolation (PVI) is central to ablation approaches for atrial fibrillation (AF), yet many patients still have arrhythmia recurrence after one or more procedures despite the latest technology for PVI. Ablation of rotational or focal sources for AF, which lie outside the pulmonary veins in many patients, is a practical approach that has been shown to improve success by many groups. Localized sources lie in atrial regions shown mechanistically to sustain AF in optical mapping and clinical studies of human AF, as well as computational and animal studies. Because they arise in localized atrial regions, AF sources may explain central paradoxes in clinical practice – such as how limited ablation in patient specific sites can terminate persistent AF yet extensive anatomical ablation at stereotypical locations, which should extinguish disordered waves, does not improve success in clinical trials. Ongoing studies may help to resolve many controversies in the field of rotational sources for AF. Studies now verify rotational activation by multiple mapping approaches in the same patients, at sites where ablation terminates persistent AF. However, these studies also show that certain mapping methods are less effective for detecting AF sources than others. It is also recognized that the success of AF source ablation is technique dependent. This review article provides a mechanistic and clinical rationale to ablate localized sources (rotational and focal), and describes successful techniques for their ablation as well as pitfalls to avoid. We hope that this review will serve as a platform for future improvements in the patient-tailored ablation for complex arrhythmias.