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Relationship between Aggressive Septal Ablation and Significant Left Atrial Appendage Activation Delay following Catheter Ablation of Persistent Atrial Fibrillation
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摘要:
目的 探讨持续性心房颤动(简称房颤)导管消融术后左心耳激动显著延迟与术中强化间隔消融的关系。 方法 对2007年6月至2009年2月在本科接受导管消融术的201例持续性房颤患者行步进式导管消融, 术后行左房激动标测并记录左心耳电活动, 术后1月行经胸心脏超声评估左房功能。 结果 术后23例出现左心耳激动显著延迟, 其中14例为初次消融病例, 9例接受了间隔线消融(OR 15.2, 95%CI 4.6~50.8, P < 0.001);另9例为第2次消融(包括2例左房隔离)病例, 9例患者也于初次消融中行广泛间隔复杂碎裂电位消融(P=0.002)。激动标测提示21例患者中18例(85.7%)左房最早激动部位转向冠状窦。术后1个月二尖瓣前向血流A峰为(18.2±17.0)cm/s, 与术前为窦性心律者比较显著下降, (20.2±19.1)cm/s vs.(58.2±17.9)cm/s(P=0.037)。随访(10.6±6.2)个月, 14例患者维持窦性心律。 结论 持续性房颤导管消融术行间隔线或广泛间隔复杂碎裂电位消融可导致左心耳激动显著延迟, 可能影响左房功能, 持续性房颤患者采用此术式应该慎重。 Abstract:Objective To elucidate the significant left atrial appendage activation following ablation of persistent atrial fibrillation, and explore its relationship with aggressive septal ablation. Methods A total of 201 patients with persistent atrial fibrillation underwent catheter ablation from June 2007 to February 2009. Action mapping of left atrium was performed and the local potential of left atrial appendage was recorded at the end of the procedure. Transthroacic ultrasound was performed one month later to evaluate the function of left atrium. Results Significant left atrial appendage activation delay was found in 23 out of 201 patients undergoing persistent atrial fibrillation ablation. Of these 23 patients, 14 patients suffered from this condition in their first were found at index procedures, of whom septal line ablation was performed in nine (odds ratio 15.2, 95% confidence interval 4.6-50.8, P < 0.001). The delay was found in another 9 patietns during their redo procedures (including two with biatrial activation dissociation), all of whom received extensive left septal complex fractionated elegrams ablation in their prior procedures (P=0.002). Activation mapping demonstrated the earliest breakthrough of the left atrium changed to coronary sinus in 18 (85.7%) patients. After 1 month, the mitral A wave velocity was 18.2±17.0 cm/s, and decreased significantly as compared with preablation (20.2±19.1 vs. 58.2±17.9 cm/s, P=0.037) in patients undergoing redo procedures. Fourteen (60.9%) remained arrhythmia-free during follow-up, which lasted 10.6 ±6.2 months. Conclusion Septal line ablation and extensive septal complex fractionated elegrams ablation are correlated with significant left atrial activation delay or even biatrial activation dissociation, and should be performed with prudent consideration. -
Key words:
- atrial fibrillation /
- ablation /
- activation delay, left atrial appendage
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图 1 间隔线消融所致左心耳激动显著延迟
A.间隔线消融后左心耳根部电位显著延迟（蓝点），术后一个月心脏超声示二尖瓣前向血流A峰显著下降；B.窦性心律下激动标测示左房最早激动点转为冠状窦附近，在后壁沿足头方向传导，左心耳最晚激动
图 2 导管消融术后左心耳隔离
A.双侧肺静脉隔离、左房顶部线和二尖瓣环部线阻滞及广泛间隔复杂破裂电位消融后左心耳电位消失；B.窦性心律下激动标测示左房最早激动点位于冠状窦，间隔部存在大范围低点位区
图 3 第2次消融术后左房隔离
患者在首次消融中接受了双侧肺静脉隔离、间隔线、左房顶部线、二尖瓣环峡部线和三尖瓣环峡部线消融; 第2次消融中行广泛左房后下部复杂碎裂电位和冠状窦内消融后右房恢复窦性心律(绿点), 但左房仍为房性心律支配(蓝点, 箭头所示为A波), 冠状窦A波显著延迟
表 1 左心耳激动显著延迟与无显著延迟患者主要临床指标比较
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