背景:非肺静脉(PV)触发因素对房颤(AF)的启动/复发的重要性已得到充分证实。
目的:本研究旨在评估挑衅性动作对识别非PV触发因素的增量益处。
方法:我们纳入了2020年至2022年连续接受首次房颤消融术的患者。激发方案包括步骤1,在房颤复律后和/或窦性心律期间确定自发性非肺静脉触发因素;步骤2,输注异丙肾上腺素(3、6、12和20-30μg/min);步骤3,在残余或低剂量异丙肾上腺素输注或诱发局灶性心动过速期间进行心房猝发起搏以诱发房颤,随后进行复律。非肺静脉触发定义为非肺静脉异位搏动触发AF或持续局灶性房性心动过速。
结果:包括1,372例患者,883(64.4%)接受了完整的逐步激发方案,包括异丙肾上腺素输注和爆发性起搏,334(24.3%)仅输注异丙肾上腺素,仅77(5.6%)阵发起搏,和78(5.7%)没有挑衅性演习(只有步骤1)。总的来说,在135例(9.8%)患者中发现161例非PV触发因素。其中,51(31.7%)非PV触发自发发生,其余110人(68.3%)需要挑衅动作进行诱导。在那些接受完整的逐步挑衅协议的人中,异丙肾上腺素输注后非肺静脉触发因素的患者数量增加了2.2倍,在完整的逐步激发方案中,异丙肾上腺素输注后增加了猝发起搏,导致总共增加了3.6倍。
结论:大多数非PV触发因素需要进行挑衅性的诱导操作。由异丙肾上腺素输注和突发起搏组成的逐步激发方案可识别出非PV触发的患者数量增加3.6倍。
BACKGROUND: The importance of nonpulmonary vein (PV) triggers for the initiation/recurrence of atrial fibrillation (AF) is well established.
OBJECTIVE: This study sought to assess the incremental benefit of provocative maneuvers for identifying non-PV triggers.
METHODS: We included consecutive patients undergoing first-time AF ablation between 2020 and 2022. The provocation protocol included step 1, identification of spontaneous non-PV triggers after cardioversion of AF and/or during sinus rhythm; step 2, isoproterenol infusion (3, 6, 12, and 20-30 μg/min); and step 3, atrial burst pacing to induce AF followed by cardioversion during residual or low-dose
isoproterenol infusion or induce focal atrial tachycardia. Non-PV triggers were defined as non-PV ectopic beats triggering AF or sustained focal atrial tachycardia.
RESULTS: Of 1,372 patients included, 883 (64.4%) underwent the complete stepwise provocation protocol with
isoproterenol infusion and burst pacing, 334 (24.3%)
isoproterenol infusion only, 77 (5.6%) burst pacing only, and 78 (5.7%) no provocative maneuvers (only step 1). Overall, 161 non-PV triggers were found in 135 (9.8%) patients. Of these, 51 (31.7%) non-PV triggers occurred spontaneously, and the remaining 110 (68.3%) required provocative maneuvers for induction. Among those receiving the complete stepwise provocation protocol, there was a 2.2-fold increase in the number of patients with non-PV triggers after isoproterenol infusion, and the addition of burst pacing after
isoproterenol infusion led to a total increase of 3.6-fold with the complete stepwise provocation protocol.
CONCLUSIONS: The majority of non-PV triggers require provocative maneuvers for induction. A stepwise provocation protocol consisting of
isoproterenol infusion followed by burst pacing identifies a 3.6-fold higher number of patients with non-PV triggers.