背景:心脏神经消融(CNA)和无氟消融(FA)是电生理学当代新兴的手术和运动。由于副交感神经张力增加,心房中神经节丛(GP)输入的消融已成功靶向治疗有症状的缓慢性心律失常。由于这些病人大多是年轻人,避免电离辐射对于限制潜在的长期有害影响至关重要。随着3D电解剖标测系统和先进的心内回波(ICE)成像的广泛使用,无氟消融已被广泛采用。然而,无氟CNA尚未广泛进行。这项研究的目的是证明CNA可以安全有效地完成而无需透视。
方法:在单中心,描述了采用无氟法进行CNA的连续患者。在两个心房进行GP标测和消融。从右心房(RA)右心房-上腔静脉(RA-SVCGP),后内侧神经节丛(PMLGP),可以从右心房-冠状窦口进入,并对马歇尔静脉GP(VOM-GP)进行评估。从左心房(LA),左心房上神经节丛(LSGP),左下神经节丛(LIGP),右前神经节丛(RAGP),以右下神经节丛(RIGP)为目标。
结果:在研究期间,从2021年1月31日开始,30名年龄42.9±13.6岁的连续受试者(15名女性/15名男性)接受GP消融.消融前受试者平均有9.5(±9.2)次晕厥发作。平均CHADS2-VA2SC评分为零。平均LVEF为64.8%(±4.9)。其中两名受试者同时进行了消融,六个先前的药物治疗失败,其中一人之前放置了起搏器。所有手术均在没有透视的情况下进行。平均随访604(±366)天。有8例患者在第一次消融后症状没有改善。八个中的四个进行了重复消融,随后有所改善。26/30例患者在第一次或第二次消融后症状改善。没有发现并发症。
结论:与传统的透视CNA相比,这项概念验证研究表明,无氟GP消融可以安全进行。此外,耐久性和成功率与CNA的其他研究相当。考虑到队列的年龄较小和电离辐射的纵向风险,无氟CNA是该患者人群的可行方法。
BACKGROUND: Cardioneural ablation (CNA) and fluoroless ablation (FA) are emerging procedures and movements in contemporary in electrophysiology. Ablation of ganglionated plexus (GP) inputs in the atrium has been successfully targeted as a treatment for symptomatic bradyarrhythmias due to increased parasympathetic tone. As most of these patients are young, avoidance of ionizing radiation is of critical importance to limit potential long term deleterious effects. With widespread use of 3D electroanatomic mapping systems and advanced intracardiac echo (ICE) imaging, fluoroless ablation has become more widely adopted. However, fluoroless CNA has not been widely performed. The objective of this study is to demonstrate that CNA can be done safely and effectively without fluoroscopy.
METHODS: At a single-center, consecutive patients undergoing CNA with a fluoroless approach are described. GP mapping and ablation were performed in both atria. From the right atrium (RA), the right atrium-superior vena cava (RA-SVC GP), the posteromedial ganglionated plexus (PMLGP), which can be accessed from the right atrium-coronary sinus ostium, and the Vein of Marshall GP (VOM-GP) were evaluated. From the left atrium (LA), the superior left atrial ganglionated plexus (LSGP), the left inferior ganglionated plexus (LIGP), the right anterior ganglionated plexus (RAGP), and the right inferior ganglionated plexus (RIGP) were targeted.
RESULTS: Over the study period, beginning on January 31, 2021, 30 consecutive subjects (15 females/15 males) aged 42.9 ± 13.6 years underwent GP ablation. The average subject had 9.5 (± 9.2) episodes of
syncope prior to ablation. The average CHADS2-VA2SC score was zero. The average LVEF was 64.8% (± 4.9). Two of the subjects had concomitant ablations, six failed prior medical therapy, and one had a prior pacemaker placed. All of the procedures were done without fluoroscopy. The average follow-up was 604 (± 366) days. There were 8 patients that did not improve symptomatically postfirst ablation. Four of the eight underwent repeat ablation and have subsequently improved. 26/30 patients symptomatically improved after the 1st or 2nd ablation. There were no complications noted.
CONCLUSIONS: In comparison to the traditional CNA with fluoroscopy, this proof of concept study reveals fluoroless GP ablation can be performed safely. In addition, the durability and success rate are comparable to other studies of CNA. Given the young age of the cohort and the longitudinal risks of ionizing radiation, fluoroless CNA is a feasible procedure for this patient population.