| Objective: Atrial fibrillation(AF)is one of the most common heart diseases and the prevalence rate increased as the increasing of age.Atrial fibrosis is one of significance influence factors which could lead to recurrence of AF after radiofrequency catheter ablation(RFCA).Many fibrosis biomarkers is related to the degree of atrial fibrosis and the recurrence of AF after treatment,meanwhile,which could potentially be useful in predicting risk of AF and possibly targeted for treatment.Transforming growth factor(TGF)-?1,N-terminal type III collagen peptide(PIIINP)and galactoselectin-3(Galectin-3)mediated atrial fibrosis plays a major role in the development of vulnerable atrial substrate for AF.However,whether the expression of the TGF-?1,PIIINP and Galectin-3 are associated with result of the substrate mapping of left atrial and the outcome after catheter ablation for AF remains unclear.In this study,we investigate that the role of Galectin-3,TGF-?1 and PIIINP play in atrial structural remodeling via their correlation with result of the substrate mapping of left atrial.Meanwhile,we try to investigate whether plasma TGF-?1,PIIINP and Galectin-3 were an independent predictor of AF recurrence after catheter ablation.To promote better understanding of pathogenesis and risk factors of AF,provide more ideas for the screening patients and treatment of atrial fibrillation in clinic.Circumferential pulmonary vein isolation(CPVI)alone or combined with adjuvant substrate modifications is unsatisfactory for persistent atrial fibrillation(AF)patients.Therefore,more aggressive ablation strategies were developed,targeting extensive areas of the atria harboring sites perceived to be necessary for AF perpetuation.However,selection criteria of these targets were often empirical and subjective.Increased efficacy in preventing AF recurrence with extensive atrial ablation was achieved at the expense of greater occurrence of probably iatrogenic postablation atrial tachycardia(AT).Hence,we hypothesized and proposed that a strategy of targeting linear ablation guided by complex fractionated atrial electrograms(CFAEs)ablation in the left atrium after CPVI.To evaluate the efficiency of substrate modification and avoiding postablation AT using linear ablation following CPVI guided by CFAEs ablation on patients with persistent AF.Methods and Results: Our study was performed on 140 patients,who had underwent the first catheter ablation from December 2015 to May 2017 in our Hospital(the number of paroxysmal AF was 50,the persistent AF was 50 and control group was 40).There were no significant differences in age,gender,and left ventricular ejection fraction in the AF and control groups.Their plasma TGF-?1,PIIINP and Galectin-3 levels and clinical and echocardiographic data were collected before ablation.The TGF-?1,PIIINP and Galectin-3 levels were significantly higher in the AF group than in the control group,and significantly different in the persistent AF than in the paroxysmal AF too.Substrate mapping of left atrial(Low voltage point is defined as a bipolar voltage of 0.2-0.5mV,scar point is defined as a bipolar voltage <0.2 mV)were measured during AF procedure in sinus rhythm,showed left atrial low-voltage distribution points and scar point area of each group,measured low voltage and scar area accounted for the proportion of left atrial area.The mean proportion of scar areas was 15.10±5.74% in persistent AF and 8.76±3.58% in paroxysmal AF.For persistent AF group,the mean atrial voltage amplitude in persistent AF was lower than paroxysmal AF group(1.35±0.41 mv VS 2.24±0.39 mv,p<0.001).Left atrial low-voltage was associated with a significantly larger left atrial volume,and higher the expression of the TGF-beta 1,but not with Galectin-3,PIIINP and left atrial size by multivariate analysis.Atrial tachyarrhythmia(AF and AFL/AT)recurrence was observed in 27 patients at mean follow-up 15.8±7.6 months after ablation.Multivariate analysis showed revealed larger LA volume,the expression of the TGF-beta 1,Galectin-3 and left atrial low-voltage as predictors of recurrence after RFCA.Consecutive patients with drug refractory persistent AF undergoing index AF ablation between August 2015 and December 2016 were enrolled.135 persistent AF patients were included in the study and divided into three groups randomly and averagely.Group A: CPVI combined with left atrial isthmus line and roof line ablation strategy;Group B: CPVI combined with left atrial anterior line and roof line ablation strategy;Group C: CPVI was first applied,followed by linear ablation guided by result of CFAEs mapping.The procedural parameters such as proportion of AF termination and subsequent clinical effectiveness were evaluated among these groups.45 patients were enrolled in each group.There were no significant differences in baseline characteristics between both the groups.High density CFAEs mapping of the left atrial substrate was performed in all patients(408±86)LA surface points.From high to low of the distribution ratio of CFAEs are,in order,pulmonary vein(PV)antrum,septum,roof,anterior wall,et al.The CFAEs were distributed in the around the PV(92.5%),anterior wall(70.1%)and roof(65.9%).All ablation lines were finished in group A.Of note,complete conduction block was not achieved in all linear ablations(conduction block was achieved in the roof line in 93.3%,mitral isthmus line in 73.3%)and epicardia ablation was performed in 46.7% patients in group A.All ablation lines were finished in group B.Conduction block was achieved in the roof line in 95.6%,anterior mitrial line in 88.9%.For group C,the ablation lines include the anterior wall line,roof line,septum line and isthmus line,et al.According to the result of substrate mapping,the mean ablation lines was(1.9±0.4)for each patient.Anterior mitrial lines(ablation from right surperior PV to mtrial annlus)were performed in 82.2% patients and the conduction block was 89.1%.Roof lines(ablation from right surperior PV to left surperior PV)were performed in 73.3% patients and the conduction block was 93.9%.Mitral isthmus line(ablation from left inferior PV to mtrial annlus)in 20% patients and the conduction block was 66.7%.Posterior wall line(ablation from left inferior PV to right inferior PV)in 15.6% patients and the conduction block was 85.7%.During 16.5±3.9 months of follow-up after a single ablation procedure,74.1% of patients were in sinus rhythm without antiarrhythmic drugs for all patients,35 patients had a recurrence of AF after the first procedure.23 patients had AF and 12 patients had atrial tachycardia and atrial flutter.With the Kaplan–Meier analysis,the proportion of maintain SR did not differ significantly between the three groups.The success rate was increased trend in group C compared the other two groups.However,there was no significant difference between three groups.Conclusion: 1)The expression of the serum TGF-?1,PIIINP and Galectin-3 levels have significant differences between three groups.The difference is more obvious between patients with paroxysmal AF and with persistent AF.2)The area of the left atrial low-voltage zone positively correlated with TGF-?1 and concentrations.3)There is a certain correlation between low voltage zone and PIIINP and Galectin-3.But,it doesn't reach statistical significance.Fibrosis factor of TGF-?1 and left volum can predict left atrial low voltage and scar formation.4)After ablation of AF recurrence in fibrosis factor regression analysis results Galectin-3 and TGF-?1 can predict relapse after AF ablation.Left atrial volume and left atrial low-voltage zone,at the same time,are predictor factors of AF recurrence in patients with AF and may help identify patients likely to have better outcomes after catheter ablation.5)Linear ablation guided by CFAEs followed by CPVI is safe and effective to treat patients with persistent AF compared other groups,which could significantly decrease the incidence of AT post AF ablation. |
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