Identification of circumferential pulmonary vein isolation responders among patients with persistent atrial fibrillation

识别持续性房颤患者中的环肺静脉隔离应答 

It is well known that circumferential pulmonary vein isolation (CPVI) works well as sole therapy in certain patients with persistent atrial fibrillation (AF). However, the key question is how to identify the patients who respond well to this approach. Recent research has shown that the following strategies could provide a venue for filling this gap in clinical practice.

众所周知，环肺静脉隔离术(CPVI)是治疗部分持续性心房颤动(AF)患者的唯一有效方法。然而，关键问题是如何识别对这种治疗方法反应良好的患者。最近的研究表明，以下策略可以在临床实践中填补这一空白。

Patient segmentation: “early” persistent AF:

Several multicenter clinical trials recently reported that CPVI alone was a reasonably effective strategy for patients with short-lasting persistent AF. In the PRECEPT trial, which enrolled patients with continuous AF that lasted beyond 7 days but less than 1 year, investigators reported a primary effectiveness success rate of 62% and a clinical success rate of 80% at 15 months.

患者划分：“早期”持续性房颤：

近期几项多中心临床试验报告单纯CPVI治疗短期持续性房颤是一种相当有效的治疗策略。在PRECEPT试验中，纳入了房颤持续时间超过7天但少于1年的持续性房颤患者，研究人员报告在15个月时其主要有效性终点率为62%，临床成功率为80%。

“Health” of atrial substrate:

Atrial fibrosis has been shown to play a critical role in the maintenance of persistent AF. Multiple modalities, including magnetic resonance imaging and high-density mapping of atrial endocardial activation during sinus rhythm, can identify the fibrotic tissue before or during the ablation procedure. In the STABLE-SR trial, 74% of patients with persistent AF and without abnormal left atrial electrograms who underwent CPVI alone maintained freedom from AF at 18 months.

“健康”的心房基质：

心房纤维化已被证实在持续性房颤的维持中起着重要的作用，包括MRI和窦性心律时心房内膜激动高密度标测在内的多种方式可在消融前或消融过程中识别纤维化组织。在STABLE-SR试验中，左房心电图无异常的持续性房颤患者接受单纯CPVI治疗后，74%的患者在术后18个月无房颤再发。

Sequential low dose ibutilide test

In early 2020, we reported our clinical team's experience with a novel method for identifying CPVI responders, the sequential low-doseibutilide test (EUROPACE 2020). In a prospective cohort of 180 consecutive patients with persistent AF, intravenous low-dose (0.004 mg/kg) ibutilide was administered 3 days before ablation and after the completion of CPVI. In patients in whom ibutilide did not terminate AF pre-procedurally, but successfully terminated it after CPVI, no further atrial substrate modification was performed. Using this test, approximately one-third (30.6%) of patients with persistent AF were found to be suitable candidates for CPVI alone,with a 2-year success rate of 70.9%.

低剂量伊布利特序贯试验

在2020年初，我们报道了我们的临床团队识别CPVI应答者新方法的经验，即低剂量伊布利特序贯试验（EUROPACE 2020）。在180例持续性房颤患者的前瞻性队列研究中，在消融前3天和CPVI完成后静脉注射低剂量（0.004 mg/kg）伊布利特。对于伊布利特未在术前终止房颤，但在CPVI后成功终止房颤的患者，不进行进一步的心房基质改良治疗。通过这个试验，约三分之一(30.6%)的持续性房颤患者被发现适合行单纯CPVI治疗，2年的成功率为70.9%。