| The morbidity of atrial fibrillation?AF?in China is increasing year by year.Previous epidemiological investigation have shown that the morbidity of atrial fibrillation in China is about 0.77%.In recent years,the incidence of atrial fibrillation has increased significantly with the problem aging of the population.About 33.5 million people worldwide suffered from atrial fibrillation in 2010.By 2030,there are an estimated 14 to 17 million cases of atrial fibrillation in the European Union,with an additional 120,000 to 215,000 new cases a year.There are about 27 million to 61 million people with atrial fibrillation in America.The number of patients worldwide with atrial fibrillation is expected to add two times by 2060.In patients with atrial fibrillation,the atrium loses effective systolic function,the atrial structure is damaged,ventricular filling is impaired,and mural thrombus forms in the left atrial appendage.Ventricular arrhythmia directly leads to the decline of cardiac pumping function,which seriously affects ventricular systolic and diastolic functions.Atrial fibrillation is considered to be an independent predictor of cardiovascular death and all-cause death.The goal of atrial fibrillation management is to reduce symptoms and prevent complications associated with this arrhythmia,which depends on anticoagulation therapy,control of ventricular rate,and treatment of arrhythmia complications.These interventions may reduce symptoms in some cases,but a significant number of patients will need additional rhythm control therapy.In recent years,the status of radiofrequency catheter ablation in the treatment of atrial fibrillation has been significantly improved.According to the 2006 AHA/ACC/ESC atrial fibrillation management guidelines,screening patients for radiofrequency catheter ablation depends on the type of atrial fibrillation,age,structural heartdisease and patient propensity.The 2014 AHA/ACC/HRS atrial fibrillation management guidelines recommend that radiofrequency catheter ablation as the initial treatment is reasonable for symptomatic paroxysmal atrial fibrillation patients.Radiofrequency catheter ablation is reasonable after at least one antiarrhythmic drug?class I or III?has failed in symptomatic patients with persistent atrial fibrillation.The 2016 ESC atrial fibrillation management guidelines recommend that,with full consideration of patients' selection,benefits and risksfor patients with paroxysmal atrial fibrillation,radiofrequency catheter ablation can be used as the first-line treatment to prevent the recurrence of atrial fibrillation and improve the symptoms.The updated 2019 AHA/ACC/HRS atrial fibrillation management guidelines recommend that catheter ablation may be reasonable in selected patients with symptomatic atrial fibrillation and heart failure reduced left ventricular to potentially lower mortality rate and reduce hospitalization for heart failure.Clinical studies have shown that radiofrequency catheter ablation is more effective than antiarrhythmic drugs in the treatment of atrial fibrillation and could improve patients' quality of life significantly.In recent decade,cryoballoon ablation has been gradually applied in clinical practice.Cryoballoon ablation is being applied in pulmonary vein?PV?isolation more and more widely because of the relatively short learning cycle,the relatively simple procedure operation,and the relatively small discomfort of the patient.Cryoballoon ablation and radiofrequency ablation are considered to have similar long-term effects in both paroxysmal and persistent atrial fibrillation.The second-generation cryoballoon is the most commonly used at present.Compared with the first-generation cryoballoon,the second-generation cryoballoon has the maximal cooling zone on this catheter and spans the entire distal half of its surface including the distal tip,which in turn offers a greater cooling surface area while minimizing the impact of cryoballoon orientation on optimal tissue contact.However,whether radiofrequency catheter ablation or cryoballoon ablation,atrial fibrillation recurrence is still a difficult problem.At present,it is believed that myocardial injury markers,inflammatory factors,atrial structural remodeling and atrial electrical remodeling can predict the high risk of recurrence after radiofrequency ablation.Further research is needed to explore the factors could predict recurrence of atrial fibrillation after radiofrequency ablation in order to select appropriate treatment strategy for patients.The major cardiovascular risk factors associated with atrial fibrillation,such as coronary artery disease,hypertension,diabetes,and congestive heart failure,are all thought to be associated with inflammation.The inflammatory responses play a important role in the development and progression of atrial fibrillation.Inflammation can lead to atrial fibrillation,which can also promote inflammation,leading to a vicious cycle.Systemic inflammatory responses are associated with intracellular and extracellular inflammation as well as with atrial remodeling.Tumor necrosis factor,interleukin,platelet derived factor and other factors cause abnormal triggering of pulmonary veins and shorten the duration of atrial action potential.They,together with myeloperoxidase and heat shock protein,induce disregulation of gap connectin,myocardial fibrosis,myolysis and apoptosis,slow down atrial conduction and increase the heterogeneity of atrial conduction.The potential mechanisms of inflammatory mediators promoting atrial structural remodeling and electrical remodeling include: atrial myocardial fibrosis,gap connectin misregulation and intracellular calcium overload.All of them could slow down atrial conduction,increase atrial ectopic activity,affect atrial impulse conduction and promote reentry.The purpose of this study was to analyze the collected inflammatory markers in order to explore the relationship between the patient's baseline inflammatory markers and the post-ablation atrial fibrillation recurrence and early recurrence.Therefore,we can provides an optimal strategy for patients with atrial fibrillation.We also observed and analyzed the indicators in procedure of cryoballoon ablation.This study consists of three parts:The first part is value of cystatin C in predicting atrial fibrillation recurrence after radiofrequency catheter ablation.The second part is value of inflammatory markers in predicting atrialfibrillation early recurrence after catheter ablation.The third part is the observations of the indicators in procedurethe and inflammatory markers before and after cryoballoon ablation.Part one Value of cystatin C in predicting atrial fibrillation recurrence after radiofrequency catheter ablationObjective: Previous studies have showed that cystatin C is a valuable risk marker for cardiovascular disease.Therefore,we explore the association between pre-ablation cystatin C level and post-ablation atrial fibrillation recurrence.Methods: A total of 207 patients were enrolled and completed the prospective observational study.Patients with atrial fibrillation?AF?scheduled for receive radiofrequency catheter ablation?RFCA?therapy were screened for this study.Before ablation procedure,24 h holter monitor,electrocardiogram,transesophageal echocardiography?TEE?,serum cystatin C,high sensitivity C-reactive protein,serum creatinine,and routine blood examinations were examined.After RFCA,patients were followed up for at the 1,2,3 and 4week,and then at 2,3,6,9,and 12 months.And then,patients were invited to out-patient clinic every 6 months regularly.24 h holter monitor or electrocardiogram were repeated at any time if the patient experienced palpitations.AF recurrence was defined as atrial fibrillation/atrial tachycardia or atrial flutter lasting no less than 30 seconds 3 months after ablation therapy.Results: Compared to patients with no recurrence of AF,patients with recurrence had longer AF history?P =0.007?,a larger left atrium?P =0.004?,more early recurrence?P =0.000?,lower eG FR?P =0.019?and higher pre-ablation cystatin C levels?P =0.000?.Multivariate regression showed that cystatin C and early recurrence were the risk factors for recurrence of AF.After adjusting for early recurrence,the risk of AF recurrence increased 47% with each milligram cystatin C was increased?95% CI: 1.256-1.717?.Summary: Pre-ablation cystatin C levels were associated with recurrence of AF after RFCA therapy,with an optimal cut-off value of 1.190 mg/L?sensitivity =0.576;specificity =0.851?.Part two Value of inflammatory markers in predicting atrial fibrillation early recurrence after radiofrequency catheter ablation.Objective: Inflammation plays an important role in the development of atrial fibrillation.Early recurrence is considered a risk factor for recurrence.We aimed to explore the relationship between inflammatory markers and early atrial fibrillation recurrence after radiofrequency ablation.Methods: 169 patients with atrial fibrillation were enrolled.All patients received electrocardiogram,24 h holter monitor,blood routine,cystatin C,creatinine and hypersensitive C-reactive protein.Transesophageal ultrasonography was performed to exclude left atrial thrombus pre-ablation.After cryoballoon ablation,patients were followed up every week for the first month,and then at 2?3 ?6?9?12months.And then,patients were invited to out-patient clinic every 6 months regularly.Electrocardiogram or 24 h holter monitor were repeated if the patients experienced palpitations at any time.Results: Patients with atrial fibrillation were followed up for 3 months,including 62 patients with paroxysmal atrial fibrillation?14 early recurrence patients,17 recurrence patients?and 107 patients with persistent atrial fibrillation?24 early recurrence patients,32 recurrence patients?.Logistic regression analysis showed that hypersensitive C-reactive protein was the risk factor for early recurrence of atrial fibrillation?95%CI:1.062-1.246,OR:1.150,P=0.001??The risk of atrilal fibrillation early recurrence increased 14% with every milligram hypersensitive C-reactive protein was increased.Taking prediction probability?PRE1?as the test variable and early recurrence as the state variable?the gold standard?,the area under the ROC curve was 0.731,the 95% CI was 0.644-0.817,P=0.000.The area under the curve is between 0.7 and 0.9,with a certain accuracy.The sensitivity and specificity were 0.531 and 0.833 respectively.Summary: Elevated levels of pre-ablation hypersensitive C-reactive protein are risk factors for atrial fibrillation early recurrence.For every 1 mg increase in hypersensitive C-reactive protein level,the risk of early recurrence increased by 15%.Hypersensitive C reactive protein has no predictive valuefor atrial fibrillation recurrence.Part three The observations of the indicators in procedure and inflam-matory markers after cryoballoon ablationObjective: We aim to observe the indicators during the cryoballoon ablation?CBA?and inflammation after cryoballoon ablation in patients with ongoing atrial fibrillation?AF?during the whole procedure compared with those in sinus rhythm?SR?.Methods: 213 AF patients were enrolled in this prospective observational study.140 patients completed this study.The patients were divided into AF group and SR group according to whether AF occurred during the whole cryoballoon ablation procedure.Age,gender,AF history,history of smoking and alcohol,ultrasonic data,CHA2DS2-VASc score and procedural data were compared between the two groups.Results: During the cryoballoon ablation,65?46.43%?patients were in SR and 75?53.57%?patients in AF.Patients in AF group presented larger LA diameters?P=0.006?and more persistent AF patients.The maximal warming time was significantly different in LSPVs,LIPVs and RSPVs between the SR group and AF group?P=0.001,P=0.007 and P=0.040,respectively?,which was similar in RIPVs?P=0.227?.The degree of occlusion was significantly different in RIPVs between the SR group and AF group?P=0.006?.The maximal warming time was not only correlated with CT-Diameter of PV ostium?r=0.263,P=0.000?,but also correlated with the nadir temperature?r=0.588,P=0.000?.The WBC elevated to the highest levels on the 1st day after cryoballoon ablation,and decreased gradually the 2nd day both in SR group and AF group.There was no significant difference between the two groups at each time point?P values were 0.779,0.302,0.164,0.713,0.247,0.190,0.082,0.429,0.695,0.397,respectively?.The hypersensitive C reactive protein increased to the highest levels on the 3rd day after cryoballoon ablation both in SR group and AF group.There was no significant difference between the two groups at each time point?P values were 0.779,0.302,0.164,0.713,0.247,0.190,0.082,0.429,0.695,0.397,respectively?.The SR group showed atendency of higher elevation of inflammatory indicators than AF group.Summary: The maximal warming time during CBA was significantly longer in patients with ongoing AF than those in SR,which showed in each PV ablation except for RIPVs.And the maximal warming time was not only related to the CT-Diameter of PV ostium but also to the nadir temperature.The SR group showed a tendency of higher elevation of inflammatory indicators than AF group.Conclusions: 1.Pre-ablation cystatin C levels were associated with AF recurrence after radiofrequency catheter ablation therapy,with an optimal cut-off value of 1.190 mg/L?sensitivity =0.576;specificity =0.851?.2.Elevated levels of pre-ablation hypersensitive c-reactive protein are risk factors for atrial fibrillation early recurrence.For every 1 mg increase in hypersensitive c-reactive protein level,the risk of early recurrence increased by 15%.Hypersensitive C reactive protein has no predictive value for AF recurrence.3.The warming time during CBA was significantly longer in patients with ongoing AF than those in SR,which presented in each PV cryoballoon except for RIPVs.And the maximal warming time was not only related to the CT-Diameter of PV ostium but also to the nadir temperature.The SR group showed a tendency of higher elevation of inflammatory indicators than AF group. |
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