Advertisement

Herz

, Volume 40, Issue 1, pp 31–36 | Cite as

Katheterablation bei persistierendem Vorhofflimmern

Pulmonalvenenisolation, Ablation fraktionierter Elektrogramme, „stepwise approach“ oder Rotorablation?
  • D. ScherrEmail author
Schwerpunkt

Zusammenfassung

Während sich bei der Katheterablation von paroxysmalem Vorhofflimmern (VHF) Erfolgsraten von bis zu 80% erzielen lassen, sind die Erfolgsraten der Ablation des persistierenden VHF signifikant geringer. Eine Begründung liegt, neben der bereits erfolgten Progression der Erkrankung, im inkompletten Verständnis dieser Arrhythmie. Auf der Basis der möglichen pathophysiologischen Mechanismen („Multiple-wavelet“-Theorie, fokale Trigger aus den Pulmonalvenen, Rotoren) haben sich verschiedene Ablationskonzepte entwickelt, von denen heute vor allem die Pulmonalvenenisolation (PVI), der „stepwise approach“ (PVI, Ablation fraktionierter Elektrogramme und Linienablation) sowie Magnetresonanztomographie (MRT)- und rotorbasierte Ablationskonzepte Anwendung finden. Die Katheterablation des persistierenden VHF ist dennoch eine etablierte „Second-line“-Therapie und als solche einer weiteren antiarrhythmischen Therapie überlegen. Jedoch sollten Faktoren wie die Dauer des persistierenden VHF, das Vorhandensein einer strukturellen Herzerkrankung sowie der Dilatationsgrad des linken Atriums die Entscheidung über eine Ablation beeinflussen.

Schlüsselwörter

Fibrose Ablation Kardiale Arrhythmien Pulmonalvenenisolation Rotor 

Catheter ablation of persistent atrial fibrillation

Pulmonary vein isolation, ablation of fractionated electrograms, stepwise approach or rotor ablation?

Abstract

Catheter ablation is an established treatment option for patients with atrial fibrillation (AF). In paroxysmal AF ablation, pulmonary vein isolation alone is a well-defined procedural endpoint, leading to success rates of up to 80% with multiple procedures over 5 years of follow-up. The success rate in persistent AF ablation is significantly more limited. This is partly due to the rudimentary understanding of the substrate maintaining persistent AF. Three main pathophysiological concepts for this arrhythmia exist: the multiple wavelet hypothesis, the concept of focal triggers, mainly located in the pulmonary veins and the rotor hypothesis. However, the targets and endpoints of persistent AF ablation are ill-defined and there is no consensus on the optimal ablation strategy in these patients. Based on these concepts, several ablation approaches for persistent AF have emerged: pulmonary vein isolation, the stepwise approach (i.e. pulmonary vein isolation, ablation of fractionated electrograms and linear ablation), magnetic resonance imaging (MRI) and rotor-based approaches. Currently, persistent AF ablation is a second-line therapy option to restore and maintain sinus rhythm. Several factors, such as the presence of structural heart disease, duration of persistent AF and dilatation and possibly also the degree of fibrosis of the left atrium should influence the decision to perform persistent AF ablation.

Keywords

Fibrosis Ablation Cardiac arrhythmias Pulmonary vein isolation Rotor 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt. D. Scherr gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Camm AJ, Kirchhof P, Lip GY et al (2010) Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace 12:1360–1420CrossRefPubMedGoogle Scholar
  2. 2.
    Camm AJ, Lip GY, De Caterina R et al (2012) 2012 focused update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation. Europace 14:1385–1413CrossRefPubMedGoogle Scholar
  3. 3.
    Moe GK, Rheinboldt WC, Abildskov JA (1964) A computer model of atrial fibrillation. Am Heart J 67:200–220CrossRefPubMedGoogle Scholar
  4. 4.
    McCarthy PM, Castle LW, Trohman RG et al (1993) The Maze procedure: surgical therapy for refractory atrial fibrillation. Cleve Clin J Med 60:161–165CrossRefPubMedGoogle Scholar
  5. 5.
    Swartz J, Pellerseis G, Silvers G et al (1994) A catheter based curative approach to atrial fibrillation in humans. Circulation 90(Suppl):1–335CrossRefGoogle Scholar
  6. 6.
    Haïssaguerre M, Jaïs P, Shah DC et al (1998) Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 339:659–666CrossRefPubMedGoogle Scholar
  7. 7.
    Nademanee K, McKenzie J, Kosar E et al (2004) A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol 43:2044–2053CrossRefPubMedGoogle Scholar
  8. 8.
    Haïssaguerre M, Sanders P, Hocini M et al (2005) Catheter ablation of long-lasting persistent atrial fibrillation: critical structures for termination. J Cardiovasc Electrophysiol 16:1125–1137CrossRefPubMedGoogle Scholar
  9. 9.
    Haïssaguerre M, Hocini M, Sanders P et al (2005) Catheter ablation of long-lasting persistent atrial fibrillation: clinical outcome and mechanisms of subsequent arrhythmias. J Cardiovasc Electrophysiol 16:1138–1147CrossRefPubMedGoogle Scholar
  10. 10.
    Oakes RS, Badger TJ, Kholmovski EG et al (2009) Detection and quantification of left atrial structural remodeling with delayed-enhancement magnetic resonance imaging in patients with atrial fibrillation. Circulation 119:1758–1767CrossRefPubMedCentralPubMedGoogle Scholar
  11. 11.
    Marrouche NF, Wilber D, Hindricks G et al (2014) Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA 311:498–506CrossRefPubMedGoogle Scholar
  12. 12.
    Ouyang F, Tilz R, Chun J et al (2010) Long-term results of catheter ablation in paroxysmal atrial fibrillation: lessons from a 5-year follow-up. Circulation 122:2368–2377CrossRefPubMedGoogle Scholar
  13. 13.
    Tilz RR, Rillig A, Thum AM et al (2012) Catheter ablation of long-standing persistent atrial fibrillation: 5-year outcomes of the Hamburg Sequential Ablation Strategy. J Am Coll Cardiol 60:1921–1929CrossRefPubMedGoogle Scholar
  14. 14.
    Brooks AG, Stiles MK, Laborderie J et al (2010) Outcomes of long-standing persistent atrial fibrillation ablation: a systematic review. Heart Rhythm 7:835–846CrossRefPubMedGoogle Scholar
  15. 15.
    O’Neill MD, Wright M, Knecht S et al (2009) Long-term follow-up of persistent atrial fibrillation ablation using termination as a procedural endpoint. Eur Heart J 30:1105–1112CrossRefGoogle Scholar
  16. 16.
    Hocini M, Nault I, Wright M et al (2010) Disparate evolution of right and left atrial rate during ablation of long-lasting persistent atrial fibrillation. J Am Coll Cardiol 55:1007–1016CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Scherr D, Khairy P, Miyazaki S et al (2014) Five-year outcome of catheter ablation of persistent atrial fibrillation using termination of atrial fibrillation as a procedural endpoint. Circ Arrhythm Electrophysiol [Epub ahead of print]Google Scholar
  18. 18.
    Zhang XD, Gu J, Jiang WF et al (2014) Optimal rhythm-control strategy for recurrent atrial tachycardia after catheter ablation of persistent atrial fibrillation: a randomized clinical trial. Eur Heart J 35:1327–1334CrossRefPubMedGoogle Scholar
  19. 19.
    Verma A, Wazni OM, Marrouche NF et al (2005) Pre-existent left atrial scarring in patients undergoing pulmonary vein antrum isolation: an independent predictor of procedural failure. J Am Coll Cardiol 45:285–292CrossRefPubMedGoogle Scholar
  20. 20.
    Mandapati R, Skanes A, Chen J et al (2000) Stable microreentrant sources as a mechanism of atrial fibrillation in the isolated sheep heart. Circulation 101:194–199CrossRefPubMedGoogle Scholar
  21. 21.
    Narayan SM, Krummen DE, Shivkumar K et al (2012) Treatment of atrial fibrillation by the ablation of localized sources: CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial. J Am Coll Cardiol 60:628–636CrossRefPubMedCentralPubMedGoogle Scholar
  22. 22.
    Narayan SM, Baykaner T, Clopton P et al (2014) Ablation of rotor and focal sources reduces late recurrence of atrial fibrillation compared with trigger ablation alone: extended follow-up of the CONFIRM trial (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation). J Am Coll Cardiol 63:1761–1768CrossRefPubMedGoogle Scholar
  23. 23.
    Haissaguerre M, Hocini M, Denis A et al (2014) Driver domains in persistent atrial fibrillation. Circulation 130:530–538CrossRefPubMedGoogle Scholar
  24. 24.
    Mont L, Bisbal F, Hernández-Madrid A et al (2014) Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study). Eur Heart J 35:501–507CrossRefPubMedCentralPubMedGoogle Scholar
  25. 25.
    Mohanty S, Mohanty P, Di Biase L et al (2013) Results from a single-blind, randomized study comparing the impact of different ablation approaches on long-term procedure outcome in coexistent atrial fibrillation and flutter (APPROVAL). Circulation 127:1853–1860CrossRefPubMedGoogle Scholar
  26. 26.
    Cappato R, Calkins H, Chen SA et al (2010) Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 3:32–38CrossRefPubMedGoogle Scholar
  27. 27.
    Arbelo E, Brugada J, Hindricks G et al (2012) ESC-EURObservational Research Programme: the Atrial Fibrillation Ablation Pilot Study, conducted by the European Heart Rhythm Association. Europace 14:1094–1103CrossRefPubMedGoogle Scholar
  28. 28.
    Deshmukh A, Patel NJ, Pant S et al (2013) In-hospital complications associated with catheter ablation of atrial fibrillation in the United States between 2000 and 2010: analysis of 93 801 procedures. Circulation 128:2104–2112CrossRefPubMedGoogle Scholar
  29. 29.
    Di Biase L, Burkhardt JD, Santangeli P et al (2014) Periprocedural stroke and bleeding complications in patients undergoing catheter ablation of atrial fibrillation with different anticoagulation management: results from the Role of Coumadin in Preventing Thromboembolism in Atrial Fibrillation (AF) Patients Undergoing Catheter Ablation (COMPARE) randomized trial. Circulation 129:2638–2644CrossRefGoogle Scholar
  30. 30.
    Bassiouny M, Saliba W, Rickard J et al (2013) Use of dabigatran for periprocedural anticoagulation in patients undergoing catheter ablation for atrial fibrillation. Circ Arrhythm Electrophysiol 6:460–466CrossRefPubMedCentralPubMedGoogle Scholar

Copyright information

© Urban & Vogel 2015

Authors and Affiliations

  1. 1.Klinische Abteilung für Kardiologie, Universitätsklinik für Innere MedizinMedizinische Universität GrazGrazÖsterreich

Personalised recommendations