Persistent Pulmonary Vein Isolation: The Elusive Goal of Atrial Fibrillation Ablation
Persistent Pulmonary Vein Isolation: The Elusive Goal of Atrial Fibrillation Ablation
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持续性肺静脉隔离：心房颤动消融的难以实现的目标
DOI：
10.1111/j.1540-8167.2007.00768.x
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发表时间：
2007
影响因子：
2.7
通讯作者：
E. Gerstenfeld
中科院分区：
文献类型：
--
作者：
E. Gerstenfeld
一个42岁的男人来诊所几年前评估复发，持续性心房颤动（AF）。他在1999年接受了左上肺静脉（PV）内AF触发点的局部消融治疗，然后在2002年接受了所有四个PV的节段性口隔离治疗。两种方法对他都没有什么好处，尽管使用了几种抗心律失常药物，但他仍然有房颤症状。在他的第三次消融手术中，左上PV在基线电隔离，PV内部分离射击。然而，当异丙肾上腺素输注6 μg/min时，PV传导至左心房，并开始触发心房早搏和房颤。由于PV在持续的房颤中近端被重新分离，罪魁祸首左上PV仍在房颤中，而心房的其余部分则转化为窦性心律。其余的pv是电隔离的。患者在消融后每天勤勉地发送经超声监测条，10天内未发生单次心房早搏。第11天发生房异位搏，第12天再次房颤。他间歇性发作心房颤动，直到两年后，他同意接受第四次消融手术。左上PV沿前侧与心房重新连接。进一步消融病灶实现电隔离。在最后一次消融手术后，他在一年多的时间里没有心房颤动。本案例突出了困扰我们研究领域的反复PV传导问题。当Haissaguerre及其同事首次描述分段PV隔离技术时，业内大多数人认为这种方法至少可以消除PV对房颤的影响。在隔离PV后，人们至少可以了解额外PV源在启动和/或维持房颤方面的作用。不久之后，我们发现在重复消融过程中，大多数先前分离的PV被重新连接Capatto和他的同事发现，在反复进行PV分离的患者中，PV重连率为80%。PV分离后房颤复发的问题导致许多人在房颤的初始消融入路中加入了“底物修饰”的附加病变。这些“辅助性病变”针对左房顶和左房峡之间
A 42-year-old man came to clinic several years ago for evaluation of recurrent, persistent atrial fibrillation (AF). He had undergone an attempt at focal ablation of an AF trigger inside the left superior pulmonary vein (PV) in 1999 and then a segmental ostial isolation of all four PVs in 2002. He had little benefit from either procedure and continued to be symptomatic from AF despite several antiarrhythmic agents. At his third ablation procedure, the left superior PV was electrically isolated at baseline with dissociated firing inside the PV. However, during isoproterenol infusion of 6 μg/min, the PV conducted to the left atrium and began triggering atrial premature beats and AF. As the PV was reisolated proximally during ongoing AF, the culprit left superior PV remained in AF while the remainder of the atrium converted to sinus rhythm. The remaining PVs were electrically isolated. The patient was diligent about sending transtelephonic monitor strips daily after the ablation, and for 10 days he did not have a single atrial premature beat. On Day 11, atrial ectopic beats occurred and he was back in AF on Day 12. He had intermittent episodes of AF until two years later, when he agreed to undergo a fourth ablation procedure. The left superior PV had reconnected to the atrium along its anterior aspect. Further ablation lesions achieved electrical isolation. He remains AF-free for more than one year after the last ablation procedure. This case highlights the problem of recurrent PV conduction that has vexed our field. When Haissaguerre and colleagues first described the technique of segmental PV isolation,1 most in the field thought that this approach would at least eliminate the PV contribution to AF. After isolating the PVs, one could then at least learn the role of extra-PV sources on initiating and/or maintaining AF. It did not take long before we discovered that during repeat ablation procedures, most previously isolated PVs were reconnected.2 Capatto and colleagues3 found a PV reconnection rate of 80% in patients undergoing repeat PV isolation. The problem of recurrent AF after PV isolation has led many to incorporate additional lesions focused on “substrate modification” to the initial ablation approach for AF. These “adjunctive lesions,” targeting the left atrial roof,4 left atrial “isthmus” between