1. Re-ablation strategy for patients with recurrent atrial fibrillation?
mainly includes: ① Conservative methods, including pulmonary vein re-isolation + induction test + mapping and ablation of non-pulmonary vein triggering foci; ② Radical methods, including pulmonary vein re-isolation + induction test + non-pulmonary vein foci triggering Mapping and ablation of lesions + electrical isolation of the superior vena cava + ablation of the right atrial isthmus, etc.
For persistent atrial fibrillation, there are mainly: ① Conservative methods, including pulmonary vein re-isolation + local ablation of fragmentation potential + induction test after termination of atrial fibrillation + mapping and ablation of non-pulmonary vein triggering lesions; or pulmonary vein re-isolation + local fragmentation potential Ablation + left atrial linear ablation + superior vena cava electrical isolation after electroconversion + right atrial isthmus ablation; ② Radical method, including pulmonary vein re-isolation + fragmentation potential local ablation + coronary sinus ablation + left atrial linear ablation + atrial fibrillation termination as the end point + Superior vena cava electrical isolation + right atrial isthmus ablation + postoperative intensive application of anti- arrhythmia drugs.
2. How to improve the success rate of one-time ablation of atrial fibrillation?
Improving the success rate of primary ablation mainly depends on the following factors:
a. The type of atrial fibrillation, that is, the success rate of paroxysmal atrial fibrillation without organic heart disease is significantly higher than that with organic heart disease The ablation success rate of chronic atrial fibrillation with disease or cardiac enlargement; the ablation success rate of paroxysmal atrial fibrillation dominated by pulmonary vein triggering or with a clear trigger site is also significantly higher than that of persistent atrial fibrillation whose exact mechanism cannot be clarified. Ablation success rate;
b. The main preset surgical endpoints are stable, that is, the circumferential pulmonary vein ablation must achieve the disappearance of the pulmonary vein potential or the outflow block of the spontaneous potential in the pulmonary veins; linear ablation must be able to verify the conduction resistance of the ablation line lag; To perform fragmentation potential ablation, it is necessary to achieve the disappearance of fragmentation potential or the regularization of atrial electrical activity. When atrial matrix ablation is used to treat persistent atrial fibrillation, the end point of ablation should be the termination of atrial fibrillation.
c. The effective ablation point energy and ablation time are strengthened by appropriately extending the discharge time and appropriately increasing the ablation energy at key points or locations where the ablation effect occurs.
d. Extension of the observation time, that is, extending the observation time and verifying (30 minutes) and timely supplementing the ablation after reaching the ablation end point.
e. The choice of a radical strategy, such as taking the termination of atrial fibrillation or failure to induce atrial fibrillation during the ablation process as the end point, and routine ablation of possible trigger lesions ( superior vena cava and tricuspid annular isthmus, etc.).
f. Use drugs that can reduce the onset of atrial fibrillation after surgery. For example, for paroxysmal atrial fibrillation, you can continue to take arrhythmide, for persistent atrial fibrillation, you can continue to take amiodarone , and at the same time, take beta-blockers and ACEI. , ARB drugs, etc.
Since there is currently neither an energy source nor a catheter that can ensure consistent, transmural and thorough ablation damage, nor a stable and reliable method that can effectively predict the success rate, the higher recurrence rate after ablation of atrial fibrillation will always be is the main problem we have to face. During the first and second ablation treatments, we must make scientific and reasonable balance and choices in terms of indications, ablation procedures, ablation strategies, atrial damage, success rates, complications, and treatment costs.
3. What is the mechanism of recurrence of atrial fibrillation after electrical isolation?
At present, the recurrence rate of target vein-atrial electrical isolation therapy for paroxysmal atrial fibrillation is still high. It is currently believed that the reasons for postoperative recurrence may be related to the following points:
①Recovery of target vein and interatrial conduction. After the initial venous-atrial electrical isolation treatment of the target vein, it was found that pulmonary vein potential reappeared in the vein. It was speculated that the initial ablation was only damage rather than complete isolation of the pulmonary veins.
②The location during the initial ablation was not precise enough and was too deep in the vein, leading to recurrence.
③Not originating from a single pulmonary vein. Haissagurre et al reported that the ablation success rate for patients with single-focal origin can be as high as 93%, while the success rate for patients with multi-focal origin is only 50%-70%.Repeated electrophysiological examination of the recurrent cases also confirmed that there were ectopic foci, namely pulmonary vein potentials, that could not be completely eliminated by the initial ablation. and failure to detect all arrhythmogenic pulmonary veins.
④ There may also be electrical connections between adjacent pulmonary veins. After one pulmonary vein is isolated, the electrical activity of the pulmonary vein can be transmitted into the right atrium through other pulmonary vein openings, so as much pulmonary vein-atrium electrical isolation as possible is necessary.
⑤There are targets other than the origin of pulmonary veins. At present, some cases of paroxysmal atrial fibrillation have been studied to have ectopic lesions originating from the superior and inferior vena cava openings of the right atrium, terminal ridge , free wall, coronary sinus ostium and other non-pulmonary vein origins.
Authors: Xia Yunlong, Tang Min, Jia Yuhe
Expert profile
Member of the American Heart Rhythm Society (FHRS); Member of the European Society of Cardiology (FESC). Vice president of the First Affiliated Hospital of Dalian Medical University and president of the Cardiovascular Hospital of Dalian Medical University. Graduated from China Medical University in 1996; obtained a master's degree from Dalian Medical University in 2001; and obtained a doctorate from the Department of Cardiology, Lund University, Sweden, in 2007.
Expert Profile
Tang Min, chief physician, professor, doctoral supervisor, cardiovascular medicine, deputy director of the third arrhythmia ward of Fuwai Hospital, Chinese Academy of Medical Sciences, electrocardiography and diagnosis and treatment of arrhythmia.
; Part-time Chairman of the Cardiac Electrophysiology and Pacing Branch of the Chinese Medical Association - Chairman of the First Young and Middle-aged Electrophysiology Working Committee of the Cardiac Rhythm Professional Committee of the Chinese Medical Doctor Association; Vice Chairman of the Cardiac Rhythm and Cardiac Electrophysiology Branch of the China Association for the Promotion of International Healthcare Exchange.
Expert profile
Jia Yuhe , director of the Functional Testing Department of Fuwai Hospital, Chinese Academy of Medical Sciences. China Union Medical College MD, chief physician, Chinese Academy of Medical Sciences and Peking Union Medical College master's tutor.
The 5th Youth Committee of the Cardiac Electrophysiology and Pacing Branch of the Chinese Medical Association, the Standing Committee of the Cardiovascular Group of the Chinese Society for Ethnographic Medicine, the Chairman of the Remote Electrocardiography Group of the China International Healthcare Promotion Association, the Member of the Beijing Medical Accident Appraisal Committee, and the Beijing Municipal Committee of Jiusan Society Member of the Science and Technology Committee.
