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© Borgis - Postępy Nauk Medycznych 8/2015, s. 570-574
*Andrzej Głowniak, Andrzej Wysokiński
Izolacja żył płucnych – nadal podstawa ablacji podłoża migotania przedsionków?
Pulmonary vein isolation – still the cornerstone in atrial fibirillation ablation?
Chair and Department of Cardiology, Medical University, Lublin
Head of Department: prof. Andrzej Wysokiński, MD, PhD
Streszczenie
Ablacja podłoża migotania przedsionków jest uznaną formą terapii w przypadku pacjentów z nawracającymi, lekoopornymi epizodami arytmii. Aktualne wytyczne Europejskiego Towarzystwa Kardiologicznego (ESC) przyjmują uzyskanie pełnej elektrycznej izolacji żył płucnych jako podstawę zabiegu ablacji migotania przedsionków, którą można uzupełnić o dodatkową modyfikację substratu arytmii, jak dodatkowe linie aplikacji w lewym przedsionku, ablacja stref rozfragmentowanych potencjałów przedsionkowych (CFAE) lub zwojów układu współczulnego położonych w lewym przedsionku. Niektóre opublikowane prace sugerują, że wykonanie wyłącznie ablacji pozażylnych ognisk arytmii może mieć podobną skuteczność w zapobieganiu nawrotom arytmii. Z drugiej strony, przedstawione ostatnio wyniki randomizowanych badań klinicznych wykazują, że wykonanie dodatkowej modyfikacji substratu lub ablacji ognisk pozażylnych istotnie wydłuża czas trwania zabiegu bez uzyskania dodatkowych korzyści klinicznych. Ponadto coraz szerzej w praktyce klinicznej stosowane są cewniki dedykowane do zabiegu izolacji żył płucnych, skracające czas procedury przy porównywalej skuteczności. W przedstawionej pracy dokonano przeglądu aktualnego piśmiennictwa poruszającego ten temat oraz omówiono optymalną strategię inwazyjnego leczenia migotania przedsionków.
Summary
Catheter ablation of atrial fibrillation (AF) has become an important treatment option for patients with symptomatic, drug refractory AF. Both European Sociaty of Cardiology (ESC) and Heart Rhythm Society (HRS) guidelines consider complete electrical pulmonary vein isolation (PVI) as the cornerstone of the AF ablation procedure, which can be supported with additional substrate modification targeting extrapulmonary triggers, like additional left atrial lines, complex fractionated atrial electrograms (CFAE) and ganglionated plexi of autonomic nervous system ablation. There is a body of evidence suggesting that targeting the extrapulmonary triggers may have similar or better results, compared to PVI alone. On the contrary, we have strong data proving that PVI alone is superior to the supplementary substrate modification. Furthermore, there are several techniques developed to achieve durable PVI in a straightforward manner with circumferential multipolar or balloon ablation catheters. We review the literature and discuss the optimal strategy for non-farmacological treatment of atrial fibrillation.



Introduction
Atrial fibrillation (AF) is the most common cardiac arrhythmia with significant morbidity and mortality. It increases the risk of stroke 5-fold and doubles the risk of all-cause mortality (1, 2). Recent data suggest that AF hospitalizations have increased to overtake myocardial infarction and heart failure as the most common cause of cardiovascular admissions globally (3, 4). This common arrhythmia also significantly reduces the quality of life in affected patients (5). Considering the limited efficacy and possible side-effects of antiarrhythmic drugs (AAD), radiofrequency (RF) catheter ablation become a standard procedure as a second-line therapy after failure of at least one AAD, or alone as a first-line therapy in selected patients. The latter strategy is supported by numerous trials demonstrating superiority of catheter ablation over AAD therapy in maintaining sinus rhythm. For instance, multiple clinical trials report
AF free survival of 50-75% at 1-year post ablation, opposing to 10-30% with AADs only (6-11). In most of the multi-center, randomized clinical trials the ablation arm strategy was to achieve complete electrical pulmonary vein isolation, confirmed by the presence of exit and entrance block to the left atrium. In consequence, current ESC and HRS guidelines recognize PVI as “the cornerstone” in atrial fibrillation ablation. On top of pulmonary vein isolation, additional ablation targets can be considered, especially in patient with non-paroxysmal atrial fibrillation. Of these strategies, the most often applied are complex fractionated atrial electrograms (CFAE), ganglionated plexi ablation, additional linear ablation, and focal impulse or rotor modulation (FIRM).
Pulmonary vein isolation
The initial concept of electrical isolation of pulmonary veins as treatment modality for paroxysmal AF was first proposed by Haïssaguerre et al. in 1998 (12). They demonstrated than ectopic beats originating from pulmonary veins can trigger AF, and electrical isolation of ectopic foci by means of catheter ablation may prevent the recurrence of arrhythmia. Out of 45 patients they studied a single point of origin of atrial ectopic beats was found in 29 patients, two points were identified in 9 patients, and three or four ectopic sites were identified in 7 patients. The important fact was that for a total of 69 ectopic foci, 65 were localized in the pulmonary veins (94%). In this initial study, RF catheter ablation of the ectopic foci resulted in freedom from AF recurrences in 62% patients in the follow up of 8 ± 6 months. This pioneer study by Haïssaguerre and colleagues launched the era of non-farmacological treatment of atrial fibrillation, based on pulmonary vein isolation by means of catheter ablation. Numerous radnomized clinical trials comparing PVI to antiarrhythmic therapy proved PVI to be far better effective in maintaining sinus rhythm than AADs alone (6-11).
The “gold standart” to achieve complete electrical pulmonary vein isolation is to perform point-by-point ablation with irrigated-tip catheter with the support a tree-dimensional (3D) electroanatomical system (fig. 1) and usually multipolar diagnostic catheter for pulmonary vein potentials assessment (fig. 2).
Fig. 1. Linear point-by-point isolation of pulmonary veins with 3D electroanatomical system.
Fig. 2. Pulmonary vein potentials recorded by circumferential diagnostic catheter.

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Piśmiennictwo
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otrzymano: 2015-06-08
zaakceptowano do druku: 2015-07-09

Adres do korespondencji:
*Andrzej Głowniak
Chair and Department of Cardiology, Medical University
ul. Jaczewskiego 8, 20-954 Lublin
tel. +48 (81) 724-41-51
andrzej.glowniak@gmail.com

Postępy Nauk Medycznych 8/2015
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