HRS 2013:治疗阵发性房颤复发 重复环肺静脉电隔离或优于药物

　　第34届美国心律学会年会（HRS 2013） 公布的一项随机试验显示，重复环肺静脉电隔离（PVI）治疗阵发性心房颤动复发优于抗心律失常药物（AAD）治疗；研究进一步表明，AAD治疗阵发性房颤复发作用微乎其微，并可能延误而使房颤病情恶化。

　　指南并不支持任何一种治疗策略用于阵发性房颤复发。有的患者选择重复PVI，有的选择AAD治疗，因此临床上以患者的选择优先。

　　该研究选取154例阵发性房颤复发患者（排除LVEF <35%），分别接受AAD或重复PVI消融，利用可置入式循环记录仪监测心律失常负荷。两组患者在首次消融前均有4—5年的症状性房颤病史。试验中的AAD组用药包括由医生决定的普罗帕酮、氟卡尼和/或索他洛尔；重复消融组只进行PVI。

　　结果显示，在起始治疗3个月的空白期内，两组患者的房颤负荷平均约为15%，且急剧下降；但在此随访期间，重复消融组患者的房颤负荷明显降低。此后，接受AAD治疗的患者在12—15个月时房颤负荷逐渐增加，至研究结束时（治疗36个月）及其之后，上述患者的房颤负荷明显增加。相反，接受重复消融的患者房颤负荷在治疗最初15个月保持低水平，随后逐渐增加。

　　试验中的重复消融组出现了两例心脏压塞患者（3%），服用AAD的患者中64%因不耐受或无效而停药，无卒中发生。

　　AAD和重复消融治疗阵发性房颤复发36个月后的结果

治疗36个月后的终点	AAD，n=77 (%)	重复消融，n=77 (%)
AF 负荷（主要终点）	18.8	5.6
AF 负荷进展（相比与基线水平>30%）	79	25
永久性房颤进展	23	4
无AF/AT （快速性房性心律失常）	12	58
所有差异P<0.01

与阵发性房颤相关的拓展阅读：

• HRS 2013:医生对阵发性房颤患者口服抗凝治疗处方不足
• CIRCULATION：非阵发性房颤患者导管消融的临床预后仍不理想
• NEJM述评：导管消融是治疗阵发性房颤的合理策略
• JCE ：导管消融可用于长期透析伴阵发性房颤患者
• [HRS2012]导管消融术可做阵发性房颤的第一道防线 更多信息请点击：有关阵发性房颤更多资讯

Repeat Ablation Wins Out Over Antiarrhythmic Agents for Recurrent Paroxysmal
Should recurrences after a failed ablation in patients with paroxysmal atrial fibrillation (AF) be treated with antiarrhythmic drugs (AAD) or with a repeat pulmonary vein isolation (PVI) procedure? More likely second time's the charm, suggests a randomized trial showing that repeat ablation is much more likely than AAD to get rid of a recurrence [1]. Switching to AAD, it further suggested, may do little more than give the AF time to worsen.
"Progression to persistent AF was not uncommon on AAD but much less after the redo ablation," said Dr Jonathan S Steinberg (Valley Health System and Columbia University, New York, NY) when presenting the 154-patient study here at the Heart Rhythm Society 2013 Scientific Sessions. Therefore, he said, "reablation targeting restoration of [PVI] should be strongly considered when patients respond inadequately to the initial ablation and provides superior elimination of AF compared with antiarrhythmic drugs."
There's no way to predict whether the electrical connections causing paroxysmal AF will heal after PVI ablation, according to Dr Andrea M Russo (Cooper University Hospital, Camden, NJ), who comoderated the session with Steinberg's presentation and wasn't part of the study. The guidelines don't favor either strategy for treating such recurrences, she told heartwire. Some patients choose reablation, while others decide to go with AAD, "and that's perfectly acceptable. It's more of a patient preference."
What wasn't known, she said, is "whether we should be encouraging one [approach] or the other." The current study suggests that on AAD, "not only are they going to have recurrences, they're going to progress and have a more persistent form of atrial fibrillation that [could] be more resistant down the line. So you're not going to do them much good by waiting and just treating them with antiarrhythmic drugs short term."
Out of an initial cohort of 742 patients who had a first PVI ablation for AF, the arrhythmia had recurred by the end of a three-month blanking period in 171. After exclusions (prespecified criteria included LVEF <35% and persistent AF as the recurrences), 154 were randomized to AAD or repeat PVI ablation; arrhythmia burden was monitored on implantable loop recorders.
Patients in both randomization groups had had a four- to five-year history of symptomatic AF prior to the first ablation. AAD consisted of propafenone (Rythmol, GlaxoSmithKline), flecainide, and/or sotalol (Betapace, Berlex Laboratories; Sotalex/Sotacor, Bristol-Myers Squibb) at the physicians' discretion; repeat ablation could consist only of PVI.
Outcomes at 36 months after start of AAD vs reablation to treat recurrent AF after initial AF ablation

All differences p<0.01
AAD=antiarrhythmic drug; AF/AT=atrial fibrillation or atrial tachycardia
a. primary end point
b. by >30% compared with baseline
At the outset of the three-month blanking period, AF burden averaged about 15% in both randomization groups. It also "declined dramatically" in both groups during the blanking period. But, according to Steinberg, "as early as the three-month follow-up visit, the reablation group had a significantly lower AF burden": 1.9% vs 3.3% in the AAD group.
Thereafter, the AAD patients showed "a gradual increase in AF burden during the first 12 to 15 months, and then a much more substantial increase in AF burden for the remainder of the study until its conclusion at 36 months," he said. In contrast, the reablation group's AF burden remained low for the first 15 months and then gradually increased until the 36-month follow-up.
There were two cases of cardiac tamponade in the reablation group (3%), and 64% of patients taking AAD stopped them due to "intolerance or inefficacy," Steinberg reported; there were no strokes.