*For medical professionals only
“img class=”responsive ” sizes=”(min-width: 320px) 320px, 100vw” src=”https://mmbiz.qpic.cn/mmbiz_png/x5F5KAyDKw19I4VvcibrfNia7lD1fial5KribXqZxjxMxtoc3ichKKz6ib3w5kJias8QNRBYGn80MM0AxEgOvRLibqE2uw/640″ width=”6400″ >Transcatheter radiofrequency ablation(RFCA)has become the first line ofradical treatmentfor various tachyarrhythmias treatment method. Frequent premature atrial contractions(PAC)usuallyaccompanied by palpitationsymptoms, span>Conventionalantiarrhythmic drug therapy is not effective. Without proper treatment, frequentPACcan induceAF or PAC Associated cardiomyopathy. Current guidelines or expert consensus still lack relevant recommendations for passingRFCAtreatmentPAC. In recent years, internationally reportspreliminarily discussedRFCA Feasibility and efficacy of treatment of symptomatic atrial fibrillation-relatedPAC. However,PACintraoperative localization and ablation is often challenging because intra-atrial manipulation of the catheter is often induced by mechanical stimulation< span>PAC, and the P wave amplitude is small, it is difficult to touch the catheter< span>PACdifferential from clinicalPAC.
Recently, the team of Prof. Zhibing Lu from Zhongnan Hospital of Wuhan University systematically reported the efficacy and strategy of idiopathic premature atrial ablation for the first time in the world in the journal Frontiers in Cardiovascular Medicine. A new method to rapidly differentiate catheter stimulation-induced PAC from clinical PAC by adding a right atrial lead. The immediate success rate of ablation in the selected 43 patients with frequent atrial ablation was 100%, and only 2 cases recurred during the follow-up. The publication of this study may play an important role in the popularization and promotion of idiopathic atrial premature ablation.
Methods
Included in Zhongnan Hospital of Wuhan University2019 year1month to 2021year6< /span>monthlypatients with symptomaticPAC. Physical examination, chest X-ray, surface electrocardiogram, 24hour Holter monitoring, echocardiography excluded organic Sexual heart disease. Exclusion criteria:Atrial tachycardia(≥5consecutive atrial beats ), atrial flutter, or atrial fibrillation. RFCAadaptationcertificationincludes:(1)PAC< span>Number/ 24h ＞10,000times;(2) Antiarrhythmic drug therapyineffective, intolerant or non-reluctance to acceptlong-termdrugs< /span>Treatment;(3) suspected to be cardiomyopathy caused by frequent PAC.
Preoperatively discontinue antiarrhythmic for at least five half-lives. During the operation, a ten-pole coronary sinus electrode was placed through the left subclavian vein or the right femoral vein. A right atrial lead is placed in the high right atrium or right atrial appendage via the right femoral vein. Preoperatively, the origin of PAC was roughly judged by the P wave morphology of PAC on the surface electrocardiogram and the activation sequence of coronary sinus and right atrium. Intraoperatively, spontaneous PAC and PAC induced by mechanical catheter stimulation were distinguished by observing the activation sequence and activation time of the right atrium, coronary sinus, and right atrium and coronary sinus during PAC (Fig. 1). Right atrium and coronary sinus activation sequence of spontaneous PAC was first recorded. The changes of atrial activation sequence or atrial activation time in the process of mapping PAC indicated that PAC was induced by catheter operation. The feasibility of the above method was confirmed by comparing the atrial activation sequence and activation time of the right atrial and coronary sinus electrodes during atrial pacing at different sites (Figure 2). Similar sequence and timing of atrial activation were observed with pacing near the origin of the PAC. Conversely, pacing far from the origin of the PAC resulted in significantly different activation sequences and/or timing of the right atrium and coronary sinus.
Simultaneous recording Right atrial (RA) and coronary sinus (CS) electrical activity differentiates spontaneous and catheter-induced PACs. Activation mapping showed that the target was located at the high boundary ridge. The ablation catheter is located in the right atrium for mapping. During spontaneous PAC, both RA and CS are activated from proximal to distal (C); when the catheter is placed in high right atrium mapping to induce PAC, the proximal and distal ends of RA are activated almost simultaneously, and CS is activated. From distal to proximal (D).
Figure 2 Spontaneous PAC from different sites of inferior vena cava origin in patients with PAC (B) and The activation sequence and activation time of right atrium (RA) and coronary sinus (CS) during beat (C~F). Pacing near the target site (C), the activation sequence and activation time of RA and CS are similar to those of spontaneous PAC; pacing away from the target site, the activation sequence and activation time of RA and CS are significantly different from those of spontaneous PAC (D~F) .
Mapping was performed using a pressure-sensing saline infusion ablation catheter (Johnson & Johnson) or a 20-pole PentaRay mapping catheter (Johnson & Johnson). The earliest atrial activation point detected by PAC time-marking was the ablation target. Ablation power and temperature were set at 30-35 W and 43 °C, respectively. First, a trial discharge was performed. If the PACs disappeared within 10 s of the discharge, the ablation was continued at the same target for 60 s. Consolidation and ablation around the target can be performed if necessary. If the PACs did not disappear within 10 s of discharge, the ablation was stopped and re-mapping was performed. Acute success was defined as the disappearance of PAC after ablation, observed for at least 30 minutes without recurrence, and no longer induced by atrial pacing or intravenous isoproterenol.
For PAC originating from the pulmonary vein or superior vena cava, culprit pulmonary vein isolation or superior vena cava isolation is performed.
All patients filled out the SF-36 quality of life questionnaire before surgery and 3 months after surgery to evaluate the effect of RFCA on the quality of life of patients.
All patients did not take any antiarrhythmic drugs after surgery. A 24-hour dynamic electrocardiogram was performed before discharge and 3 months after the operation. Clinical success was defined as the number of PACs <100/24 h.
Study Results
A total of 43cases, male23cases, female20cases, average age span>52.6±17.6 years old. average24 h PACnumberamount< /span>is21685±9596(range is10,018< /span> ~ 39,287), averagePACnegative span>loadis28.9±13.7%(range is < /span>10.6 ~ 60.3%). See table 1.
Table 1 Clinical characteristics of patients
All patients successfully completed electrophysiological mapping and ablation without any complications. Intraoperative 37 patients had spontaneous PAC, accounting for 86%. 6 cases required the use of isoproterenol to induce PAC. 32 cases (74.4%) had short paroxysmal atrial tachycardia (<5 atrial excitations). The most common targets were the pulmonary veins, coronary sinus ostia, and bordering ridges (Table 2, Figure 3).
Table 2 Mapping and ablation parameters
Figure 3 Distribution of ablation targets
< span>The activation time of the successful ablation target was 36±7.6 ms ahead of the onset time of the P wave of the surface electrocardiogram. Six patients with the origin of the left superior pulmonary vein underwent left pulmonary vein isolation. Six patients with the origin of the right superior pulmonary vein underwent right pulmonary vein isolation. Three patients were treated with right pulmonary vein isolation. The patient underwent SVC isolation.
The sequence of atrial activation and the relative activation time between the right atrium and coronary sinus during the mapping process differentiated spontaneous PAC from catheter-induced PAC (Figure 4).
Fig. Differentiate between spontaneous PAC (①) and catheter-induced PAC (②③④). In spontaneous PAC, RA1-2 atrial activation is earlier than RA3-4, CS atrial activation is proximal to distal, and CS9-10 atrial activation is earlier than RA3 -4. PAC② is consistent with spontaneous PAC at rough inspection, but RA3-4 atrial activation is earlier than CS9-10, suggesting catheter induction. RA3-4 atrial activation in PAC③ is earlier than RA1-2, and RA3-4 atrial activation in PAC④ is significantly earlier than that of RA1-2. CS9-10, suggesting that both were induced by catheter.
Follow-up 15± At 8 months, only 2 cases of PAC recurred. The 24-hour PAC numbers in the 2 patients with recurrence were significantly decreased compared with the baseline. The quality of life score was significantly increased at 3 months after RFCA compared with the baseline (Table 3).
Table 3 Quality of life scores before and after ablation
Discussion
There are currently no relevant guidelines or expert consensus to support IAP radiofrequency ablation therapy. This study confirmed the efficacy and safety of idiopathic atrial premature ablation, and systematically introduced the strategy and method of ablation for the first time. Although the origin of PACs can be roughly located by the P-wave morphology of the surface ECG, PACs often merge with the T-wave of the previous heartbeat, making the P-wave morphology difficult to identify. In addition, catheter manipulation during the mapping process can easily induce PAC, which affects the mapping. Identifying the P waves of spontaneous PACs is just as challenging as the P waves of atrial pacing. These factors make the mapping of PACs more challenging. In our study, both right atrial electrodes and coronary sinus electrodes were placed for recording and mapping. The sequence of activation of the right atrium and coronary sinus, as well as the timing of atrial activation of the right atrium and the proximal to distal coronary sinus, and the right atrium to the coronary sinus, facilitate the rapid identification of spontaneous and catheter-induced PACs (Figures 1 and 4). ), and finally achieved an immediate success rate of 100%, with only 2 recurrences during follow-up.
Although to date there is no guideline or expert consensus on catheter ablation of PACs, our study demonstrates the feasibility and effectiveness of RFCA to eliminate PACs. Frequent symptomatic and drug-refractory PAC, with or without atrial fibrillation, can be attempted catheter ablation. We look forward to further large-scale, multi-center, randomized controlled clinical studies to confirm.
Study Conclusions strong>
In without structural heart diseasepatients,viacatheter span>RadiofrequencyablationTreatment-frequentisolatedsexual, symptom< /span>sexualand drug refractorysexualPACsafe and effective. During mapping, the activation sequence of multiple cathetersand the atria< /span>Agitation timehelpsdifferentiatespontaneousPAC and CathetertouchedPAC. Catheter ablationeliminationPACsignificantly improvespatients’ Symptoms and quality of life.
Source: He B, Li Y, Huang W, Yu W, Zhao F, Wu X, Yao S, Po SS and Lu Z. Mapping and Ablation of Isolated Frequent Symptomatic Premature Atrial Contractions in Patients With Structurally Normal Heart. Front. Cardiovasc. Med., 12 April 2022 https://doi.org/10.3389/fcvm.2022.862659
Author:Lu ZhibingHe Bo< /span> Wuhan University Zhongnan Hospital
Expert Introduction
img>Lu Zhibing Professor
Wuhan University Zhongnan Hospital span>
Professor, Chief Physician, Doctoral Supervisor
Vice President of Zhongnan Hospital of Wuhan University, Vice President of Cardiovascular Hospital, Director of the Department of Cardiovascular Medicine, Luojia Young Scholar, Outstanding Youth in Hubei Province, and Top Young Talent in Hubei Province
Young Committee Member of the Chinese Medical Association Cardiac Electrophysiology and Pacing Branch, Ventricular Member of Arrhythmia Working Group, Atrial Fibrillation Working Group, and Cardiac Pacing Working Group
Member of the 11th Committee of Cardiology Branch of Chinese Medical Association, Arrhythmia Group
Vice-chairman of the Youth Committee of the Heart Rhythm Branch of the Chinese Society of Biomedical Engineering
Instructor of the National Cardiovascular Interventional Diagnosis and Treatment Training Base span>
Vice-chairman of the Cardiovascular Medicine Branch of Hubei Medical Association
Electrophysiology of Cardiovascular Medicine Branch of Hubei Medical Association Team leader
Member of the Expert Committee of Hubei Provincial Cardiovascular Disease Interventional Diagnosis and Treatment Technology Quality Control Center
Hubei Provincial Chest Pain Center Alliance The pre-review expert
is good at radiofrequency ablation, pacemaker placement, coronary intervention and other cardiac interventional procedures, and has published more than 40 SCI papers as the first author or corresponding author. The highest impact factor of a single article is 29, with an average of >5 points. Presided over four projects of the National Natural Science Foundation of China. He has won one second prize of the National Science and Technology Progress Award, one first prize of the Provincial Science and Technology Progress Award, and one third prize.
<He Bo
MD, associate professor and associate chief physician of the Department of Cardiovascular Medicine, Zhongnan Hospital, Wuhan University, visiting scholar at the Heart Rhythm Institute, University of Oklahoma Health Science Center. Young member of the Heart Rhythm Branch of the Chinese Society of Biomedical Engineering, member of the Acute and Critical Care Working Group of the Heart Rhythm Branch of the Chinese Society of Biomedical Engineering, standing member of the Cardiology Professional Committee of the Hubei Medical Association, Secretary of the Electrophysiology Group of the Cardiovascular Medicine Branch of the Hubei Medical Association, Wuhan Deputy director of the Youth Committee of the Cardiovascular Branch of the Medical Association, secretary of the Youth Committee of the Hubei CIT Arrhythmia Club, member of the Hubei Alliance of the China Green Electrophysiology Alliance, and editorial board member of the Chinese Journal of Cardiac Pacing and Electrophysiology. Mainly engaged in the basic and clinical research of autonomic nerve and arrhythmia, good at radiofrequency ablation of arrhythmia and cardiac pacemaker implantation. He has won 1 first prize of the Huaxia Medical Science and Technology Award, presided over 1 National Natural Science Foundation of China Youth Fund Project, 1 Hubei Provincial Health and Family Planning Commission Youth Talent Project, participated in many National Natural Science Foundation of China, and published papers in domestic and foreign professional journals More than 20 articles, participated in the compilation and translation of 5 works.
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