Besser als medikamentöse Rhythmuskontrolle? – Interventionelle Therapie des Vorhofflimmerns

Die interventionelle Therapie des Vorhofflimmerns kann je nach Modalität bei der überwiegenden Mehrzahl der Fälle eine Verbesserung der Symptomatik erreichen. Dabei konkurrieren verschiedene Verfahren. Bei paroxysmalem VHF genügt oft die Pulmonalvenenisolation, bei permanentem VHF kommen meist komplexere Ablationsverfahren zur Anwendung und die Therapieerfolge sind bis dato weniger eindrücklich. Grenzen der Ablationstherapie sind schwer vernarbte Vorhöfe, da sich das Mapping aufgrund der fehlenden Signale erschwert und das Substrat für das Vorhofflimmern nicht mehr nur die Pulmonalvenen umfasst. Das ”Ablate and pace“-Verfahren stellt nach wie vor eine valide risikoarme Therapieoption zur Palliation des Tachy-Bradysyndroms und der schnellen Ventrikelantwort dar. Die Verbesserung der Überlebensrate, Verbesserung von Herzinsuffizienzfolgen, Langzeiterfolg der Pulmonalvenenisolation und vergleichbarer Methoden werden in andauernden Studien evaluiert.

Interventional therapy to treat atrial fibrillation (AF) achieves significant symptom improvement in the majority of patients. Different modalities compete. In paroxysmal AF, isolation of the pulmonary veins is oftentimes sufficient as compared to persistent or permanent AF, where substrate modification and a more complex ablation is often necessary, and results are often less satisfactory, particularly in scarred atria. Mapping is more difficult due to lack of signals and enlarged atria and the substrate initiating and maintaining atrial fibrillation is not confined to the pulmonary veins. When palliation is the main goal, 'ablate and pace' is still a valid low risk option to treat tachy- brady syndrome. Long term outcome of PVI, improvement of survival and amelioration of heart failure symptoms are being evaluated in ongoing clinical trials.

Key words

Atrial fibrillation - Imaging - Ablation

• Literatur

• 1 Fuster V et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation - Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol 2006; 48: 854-906
• 2 Ott A et al. Atrial fibrillation and dementia in a population-based study. The Rotterdam Study. Stroke 1997; 28: 316-321
• 3 Noheria A et al. Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation: A Systematic Review. Arch Intern Med 2008; 168: 581-586
• 4 Haissaguerre M et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998; 339: 659-666
• 5 Oral H et al. Catheter Ablation for Paroxysmal Atrial Fibrillation: Segmental Pulmonary Vein Ostial Ablation Versus Left Atrial Ablation. Circulation 2003; 108: 2355-2360
• 6 Terasawa T et al. Systematic review: comparative effectiveness of radiofrequency catheter ablation for atrial fibrillation. Ann Intern Med 2009; 151: 191-202
• 7 Jais P, Cauchamez B et al. Catheter Ablation versus Antiarrhythmic Drugs for Atrial Fibrillation: The A4 Study. Circulation 2008; 118: 2498-2505
• 8 Arentz T et al. Small or Large Isolation Areas Around the Pulmonary Veins for the Treatment of Atrial Fibrillation?: Results From a Prospective Randomized Study. Circulation 2007; 115: 3057-3063
• 9 Verma A et al. Substrate and Trigger Ablation for Reduction of Atrial Fibrillation (STAR AF): a randomized, multicentre, international trial. European Heart Journal 2010; 31: 1344-1356
• 10 Marrouche NF, Brachmann J. Catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation (CASTLE-AF) - study design. Pacing Clin Electrophysiol 2009; 32: 987-994
• 11 Akoum N et al. Atrial fibrosis helps select the appropriate patient and strategy in catheter ablation of atrial fibrillation: a DE-MRI guided approach. J Cardiovasc Electrophysiol 2011; 22: 16-22
• 12 Bertaglia E et al. Image integration increases efficacy of paroxysmal atrial fibrillation catheter ablation: results from the CartoMerge┢; Italian Registry. Europace 2009; 11: 1004-1010
• 13 Kistler PM et al. The impact of image integration on catheter ablation of atrial fibrillation using electroanatomic mapping: a prospective randomized study. Europ Heart J 2008; 29: 3029-3036
• 14 Martinez-Lopez JI. ECG of the month. Short circuit. Ventricular preexcitation. J La State Med Soc 2000; 152: 311-313
• 15 Moreira W et al. Long-term follow-up after cryothermic ostial pulmonary vein isolation in paroxysmal atrial fibrillation. J Am Coll Cardiol 2008; 51: 850-855
• 16 Beukema RP et al. Efficacy of multi-electrode duty-cycled radiofrequency ablation for pulmonary vein disconnection in patients with paroxysmal and persistent atrial fibrillation. Europace 502-507
• 17 Wieczorek M et al. Pulmonary vein isolation by duty-cycled bipolar and unipolar antrum ablation using a novel multielectrode ablation catheter system: first clinical results. J Interv Card Electrophysiol 2010; 27: 23-31
• 18 Wieczorek M et al. Results of short-term and long-term pulmonary vein isolation for paroxysmal atrial fibrillation using duty-cycled bipolar and unipolar radiofrequency energy. J Cardiovasc Electrophysiol 2010; 21: 399-405
• 19 Gaita F et al. Incidence of Silent Cerebral Thromboembolic Lesions After Atrial Fibrillation Ablation May Change According To Technology Used: Comparison of Irrigated Radiofrequency, Multipolar Nonirrigated Catheter and Cryoballoon. J Cardiovasc Electrophysiol DOI: 10.1111/j.1540-8167.2011.02050.x. 2011;
• 20 Neumann T et al. MEDAFI-Trial (Micro-embolization during ablation of atrial fibrillation): comparison of pulmonary vein isolation using cryoballoon technique vs. radiofrequency energy. Europace 2011; 13: 37-44
• 21 Haïssaguerre M et al. Catheter Ablation of Long-Lasting Persistent Atrial Fibrillation: Clinical Outcome and Mechanisms of Subsequent Arrhythmias. J Cardiovasc Electrophysiol 2005; 16: 1138-1147
• 22 Jais P et al. Mitral isthmus ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2005; 16: 1157-1159
• 23 Hocini M et al. Techniques, evaluation, and consequences of linear block at the left atrial roof in paroxysmal atrial fibrillation: a prospective randomized study. Circulation 2005; 112: 3688-3696
• 24 Khaykin Y et al. A Randomized Controlled Trial of the Efficacy and Safety of Electroanatomic Circumferential Pulmonary Vein Ablation Supplemented by Ablation of Complex Fractionated Atrial Electrograms Versus Potential-Guided Pulmonary Vein Antrum Isolation Guided by Intracardiac Ultrasound /Clinical Perspective. Circulation: Arrhythmia and Electrophysiology 2009; 2: 481-487
• 25 Knecht S et al. Left atrial linear lesions are required for successful treatment of persistent atrial fibrillation. Eur Heart J 2008; 29: 2359-2366
• 26 Nademanee K et al. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol 2004; 43: 2044-2053
• 27 Lemola K et al. Pulmonary Vein Region Ablation in Experimental Vagal Atrial Fibrillation: Role of Pulmonary Veins Versus Autonomic Ganglia. Circulation 2008; 117: 470-477
• 28 Scanavacca M et al. Selective Atrial Vagal Denervation Guided by Evoked Vagal Reflex to Treat Patients With Paroxysmal Atrial Fibrillation. Circulation 2006; 114: 876-885
• 29 Sahadevan J et al. Epicardial mapping of chronic atrial fibrillation in patients: preliminary observations. Circulation 2004; 110: 3293-3299
• 30 Cappato R et al. Worldwide Survey on the Methods, Efficacy, and Safety of Catheter Ablation for Human Atrial Fibrillation. Circulation 2005; 111: 1100-1105
• 31 Calkins H et al. HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures and Follow-Up: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and Approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society. Heart Rhythm 2007; 4: 816-861
• 32 Van Belle Y et al. Pulmonary vein isolation using an occluding cryoballoon for circumferential ablation: feasibility, complications, and short-term outcome. Europ Heart J 2007; 28: 2231-2237
• 33 Patel AM et al. Atrial Tachycardia After Ablation of Persistent Atrial Fibrillation/ Clinical Perspecive. Circulation: Arrhythmia and Electrophysiology 2008; 1: 14-22
• 34 Mainigi SK et al. Incidence and Predictors of Very Late Recurrence of Atrial Fibrillation After Ablation. Journ Cardiovasc Electrophys 2007; 18: 69-74
• 35 Sick PB et al. Initial Worldwide Experience With the WATCHMAN Left Atrial Appendage System for Stroke Prevention in Atrial Fibrillation. J Am Coll Cardiol 2007; 49: 1490-1495
• 36 Camm AJ et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace 2010; 12: 1360-1420