| Objective:To explore safety and validity of performing linear ablation of CFAEs (Complex fractionated atrial electrograms) displaying QS morphology of the atrial wave on unipolar electrogram combined with circumferential pulmonary vein isolation(CPVI) in patients with persistent atrial fibrillation(PeAF), comparing CPVI combined with traditional linear ablation. Meanwhile, exploring the formation mechanism of CFAEs displaying QS morphology on unipolar electrogram, which maked for illustrating the effect of fragmented potential on PeAF.Methods:99 patients with PeAF successively seen at our hospital from Sep 2012 to Feb 2014 were enrolled in our study, those cases were divided into two groups, group A received CPVI+ablation of CFAEs displaying QS morphology on on unipolar electrogram (51 cases), group B received CPVI+traditional linear ablation (48 cases). In group A, unipolar mapping was performed to identify the distribution of CFAEs, whose were divided into two groups based on whether the unipolar electrogram displayed QS morphology or not, group A1(displaying QS morphology) had 35 cases whose were received routine CPVI+linear ablation area of CFAEs by unipolar mapping QS-type; group A2(without displaying QS morphology) had 16 cases whose were underwent only CPVI. Procedure of ablation: in group A1, after beening performed CPVI, the standard of CFAEs was defined, Ensite-Velocity electroanatomic mapping system was applied to identify the distribution of CFAEs of AF patients, circumferential pulmonary lead was linked with quadrupole electrodes to form unipolar electrogram, ablating the CFAEs displaying QS morphology on unipolar electrogram. Ablation line design of group Al:if unipolar electrogram displays QS morphology in CFAEs areas, we performed lamellar ablation, if ablation area was close to pulmonary vein antrum, mitral ring, atria sinistrum septal surface, left auricle, we performed linear ablation between them; if ablation area located on left atrial cupular part or between the two orifices of left superior pulmonary vein, we perform linear ablation via left atrial cupular part; if ablation area located on posterior wall or central zone of anterior wall, we perform lamellar ablation. If the patients presented AF after ablation, they need be performed direct current countershock; after converting to sinus rhythm, In group B, we performed CPVI+left atrial linear catheter ablation. The endpoint of ablation:circumferential pulmonary lead identified electrical isolation of pulmonary vein electrical, the integrity of circumferential pulmonary ablation line and bidirectional block of ablation line. Total ablation time, auxiliary operation time, X-ray exposure time, the incidence of intraoperative atrial tachycardia, the ratio of conversion from atrial fibrillation to sinus rhythm after ablation, the incidence of surical complications, the recurrence rate of AF after operation were analyzed statistically in group A1,A2 and group B. After surgery, all patients have taken amiodarone or sotalol for 3 months; some patients could stop taking warfarin if they didn’t recur after 6-month treatment of warfarin. The patients received resting electrocardiogram and dynamic electrocardiogram at 6th,12th month after surgery. After one year’s follow-up, the patients reveived a follow-up every 6 months.Results:There was statistical significance in group A(51 cases), including 16 cases underwent only CPVI, and 35 cases underwent routine CPVI+linear ablation area of CFAEs displaying QS morphology on unipolar electrogram, and in group B(48 cases); in group A, group Al and group B, the incidence of conversion to sinus rhythm or atrial tachycardia has no statistical significance (P> 0.05); the total ablation time and X-ray exposure time in group A and group A1 are shorter than those in group B (P< 0.05); moreover, the ablation time of QS in group Al is shorter than linear ablation time in group B (P< 0.001).2. the recurrence rate of AF is recorded at 3 months,6 months,12 months after operation in group A and group B, the incidence of atrial tachycardia has no statistical significance (P> 0.05);12 months after surgery, the recurrence rate of AF reaches up to 56.2%in group A2(Pa2-B,=0.013,PA1-A2=0.002,PA1-b=0.750).3. after 12 months follow-up, 27 patients recurred, whose heart rhythm was AF in 16 patients(10 in group A,6 in group B), pulmonary vein potential (PVP) recovered in 12 patients(75%). The 4 patients with AF of group Al, two cases of whose the distribution of CFAEs area by unipolar mapping on QS-type recoveried, one case of non-QS-shaped CFAEs original distribution area which unipolar mapping was presenting QS-type,and one case no CFAEs area, the 6 patients with AF of group A2 (4 cases with PeAF,2 cases with PAF),three cases of who were mapped by unipolar mapping on QS-type in the distribution of CFAEs area.in group B, AF recurred in 6 patients(Mitral isthmus line unblocked 3cases, Left atrial top line unblocked 2cases and Tricuspid isthmus line unblocked 1 case), four patients of who were mapped by unipolar mapping on QS-type in the distribution of CFAEs area.4, atrial tachycardia recurred in 11 patients, among them,6 patients with auricular flutter(2 in group A,4 in group B),5 patients with atrial tachycardia (4 in group A,1 in group B). Conclusion:1, there was better safety and efficacy of performing CPVI+linear ablation of CFAEs presenting QS morphology on unipolar electrogram on patients with PeAF, with shorter ablation time, lower incidence of complication.2, the distributution area of CFAEs is the major atrial substrate of maintaining PeAF, the distribution area of CFAEs displaying QS morphology on unipolar electrocardiogram may be not only the key positon of maintaining PeAF, but also the core area between functional block area and initiative reentrant cycle, it may be more targeted to perform ablation on this region, in order to destroy the substrate of AF and the foundation of initiative reentrant cycle, hence, it would have higher clinical application value. |
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