Defibrillation-guided radiofrequency ablation of atrial fibrillation secondary to an atrial focus
Defibrillation-guided radiofrequency ablation of atrial fibrillation secondary to an atrial focus
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DOI：
10.1016/s0735-1097(98)00691-3
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发表时间：
1999-04-01
影响因子：
24
通讯作者：
Ayers, GM
中科院分区：
文献类型：
--
作者：
Lau, CP;Tse, HF;Ayers, GM
目的探讨经静脉心房除颤(TADF)后房颤(房颤)早期自发再发的潜在局灶性来源，并描述一种利用重复TADF标测和消融房颤的方法。病灶标测和射频消融可能是治愈的，但如果患者处于房颤或如果病灶静止，则是有限的。除颤后可以观察到房颤的早期再发，这可能有局部机制。方法我们在药物难治性孤立性房颤患者中使用右心房和冠状静脉窦电极进行TADF。当在TADF后2分钟内观察到可重现的房颤再发时，采用标测和射频消融来抑制房颤的再发。结果44例孤立性房颤患者接受TADF治疗，其中男性40例，女性4例，持续性房颤32例，阵发性房颤12例，平均年龄58±13岁。16例TADF术后房颤早期再发，9例(20%；5例阵发性)表现为局灶性再发。在7名接受进一步研究的患者中，最早的心房激动被映射到右上肺静脉(n=4)和左上肺静脉(n=3)，恰好在开口内。在房颤重新启动时，最早的激活位置比RA参考电信号早86+/-38ms。此部位的心房活动呈碎片化，表现为逐渐缩短的周期长度，与心房其余部分的传导减少，直到房颤重新启动。尽管可诱发起搏，但在最早的激活点进行射频消融可抑制房颤的重新启动。在8+/-4个月的随访中，临床结果得到改善。结论经静脉心房除颤可以帮助阵发性和持续性房颤患者显露、标测和消融潜在的心房病灶。在20%的孤立性房颤患者中，持续的房颤灶是房颤早期再次发作的原因，这些患者可能会从这项技术中受益。(C)美国心脏病学会1999年。
OBJECTIVE Our aim was to evaluate a potential focal source of atrial fibrillation (AF) by unmasking spontaneous early reinitiation of AF after transvenous atrial defibrillation (TADF), and to describe a method of using repeated TADF to map and ablate the focus.BACKGROUND Atrial fibrillation may develop secondary to a rapidly discharging atrial focus that the atria cannot follow synchronously with suppression of the focus once AF establishes. Focus mapping and radiofrequency (RF) ablation may be curative but is limited if the patient is in AF or if the focus is quiescent. Early reinitiation of AF has been observed following defibrillation, which might have a focal mechanism.METHODS We performed TADF in patients with drug-refractory lone AF using electrodes in the right atrium (RA) and the coronary sinus. When reproducible early reinitiation of AF within 2 min after TADF was observed that exhibited a potential focal mechanism, both mapping and RF ablation were performed to suppress AF reinitiation. Clinical and ambulatory ECG monitoring was used to assess AF recurrence.RESULTS A total of 44 lone AF patients (40 men, 4 women; 32 persistent, 12 paroxysmal AF) with a mean age of 58 +/- 13 years underwent TADF. Sixteen patients had early reinitiation of AF after TADF, nine (20%; 5 paroxysmal) exhibited a pattern of focal reinitiation. Earliest atrial activation was mapped to the right superior(n = 4) and the left superior (n = 3) pulmonary vein, just inside the orifice, in the seven patients who underwent further study. At the onset of AF reinitiation, the site of earliest activation was 86 +/- 38 ms ahead of the RA reference electrogram. The atrial activities from this site were fragmented and exhibited progressive cycle-length shortening with decremental conduction to the rest of the atrium until AF reinitiated. Radiofrequency ablation at the earliest activation site resulted in suppression of AF reinitiation despite pace-inducibility. Improved clinical outcome was observed over 8 +/- 4 months' follow-up.CONCLUSIONS Transvenous atrial defibrillation can help to unmask, map, and ablate a potential atrial focus in patients with paroxysmal and persistent AF. A consistent atrial focus is the cause of early reinitiation of AF in 20% of patients with lone AF, and these patients may benefit from this technique, (C) 1999 by the American College of Cardiology.