Circulation：不同消融策略对合并AF和AFL患者长期预后有差异

无心律失常发生的Kaplan-Meier生存曲线（未用心律失常药物）CTI：三尖瓣环峡部，PVAI：肺静脉前庭隔离

A和B显示SF-36和BDI量表在研究开始时与1年后生活质量评分的变化

在临床上常见到心房颤动（AF）和心房扑动（AFL）共存发生，这些房性心律失常患者除了栓塞危险增加外，诸如心悸，呼吸困难，胸部不适，乏力等症状影响着他们的生活质量。对药物治疗无效的患者通过射频消融恢复窦性心律可减少栓塞风险，提高他们的生活质量。目前同时合并AF和AFL的患者消融策略有肺静脉前庭隔离加或不加AFL消融以及仅行AFL消融术，美国研究人员Mohanty等通过本研究旨在比较这两种不同的消融策略对长期手术情况和生活治疗的影响。该结果发表在2013年5月7日的Circulation杂志上。
该研究纳入360名有AF和AFL记录的患者，采用双盲、随机的方法将患者分配至AF±AFL消融组（n=182，组1）和AFL消融组（n=178，组2）。用事件记录和在3、6、8及12个月随访的7d动态心电图评估房颤的复发。分别在基线和12个月随访时对患者进行问卷调查评价生活质量。问卷调查包括4个量表：医疗结果研究量表（the Medical Outcome Study Short Form），医院焦虑抑郁量表（the Hospital Anxiety and Depression Score），贝克抑郁量表（the Beck Depression Inventory）和状态-特质焦虑量表（the State- Trait Anxiety Inventory）。
在组1的182名患者中，有58名患者（年龄63±8岁； 78%男性；左室射血分数，59±8%）接受AF+AFL消融，其余124名患者（年龄 61±11 岁； 72% 男性；左室射血分数，59±7%）仅行AF消融术。在组2 中，所有患者均行出现峡部双向传导阻滞的AFL消融。两组基线资料无差异。在 21±9的随访中，组1中的117名患者（64%）和组2中34名患者（19%）无心律失常发生（P<0.001）。
在组1中大多数生活质量量表评分在随访中有明显提高，而在组2患者受益相对较少。
作者指出，合并AF和AFL的患者，AF消融或AF±AFL消融与单行AFL消融比较可降低心律失常再发生率，更好的改善患者生活质量。此外，研究人员指出这是首次在采取双盲手术的研究中发现生活质量与无心律失常发作直接相关。

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).
BACKGROUND
This study examined the impact of different ablation strategies on atrial fibrillation (AF) recurrence and quality of life in coexistent AF and atrial flutter (AFL).
METHODS AND RESULTS
Three-hundred sixty enrolled patients with documented AF and AFL were blinded and randomized to group 1, AF±AFL ablation (n=182), or group 2, AFL ablation only (n=178). AF recurrence was evaluated with event recording and 7-day Holter at 3, 6, 9, and 12-month follow-ups. Quality of life was assessed at baseline and at the 12-month follow-up with 4 questionnaires: the Medical Outcome Study Short Form, the Hospital Anxiety and Depression Score, the Beck Depression Inventory, and the State-Trait Anxiety Inventory. Of the 182 patients in group 1, 58 (age, 63±8 years; 78% male; left ventricular ejection fraction, 59±8%) had AF+AFL ablation and 124 (age, 61±11 years; 72% male; left ventricular ejection fraction, 59±7%) had AF ablation only. In group 2 (age, 62±9 years; 76% male; left ventricular ejection fraction, 58±10%), only AFL was ablated by achieving bidirectional isthmus conduction block. Baseline characteristics were not different across groups. At 21±9 months of follow-up, 117 in group 1 (64%) and 34 in group 2 (19%) were arrhythmia free (P<0.001). In group 1, scores on most quality-of-life subscales showed significant improvement at follow-up, whereas group 2 patients derived relatively minor benefit.
CONCLUSIONS
In coexistent AF and AFL, lower recurrence rate and better quality of life are associated with AF ablation only or AF+AFL ablation than with lone AFL ablation. Furthermore, quality of life directly correlates with freedom from arrhythmia, as shown in this study for the first time in patients blinded to the procedure.