Download PDF
Kardiologie up2date 2020; 16(01): 19-37
DOI: 10.1055/a-0674-6738
Herzrhythmusstörungen
Georg Thieme Verlag KG Stuttgart · New York

Katheterablation von Vorhofflimmern

Korbinian Lackermair
,
Heidi L. Estner
Further Information

Publication History

Publication Date:
11 March 2020 (online)

Also available at
    Permissions and Reprints All articles of this category

Vorhofflimmern ist die häufigste supraventrikuläre Arrhythmie mit einer deutlichen Zunahme im Alter. Die Behandlung richtet sich nach der Dauer, dem klinischen Erscheinungsbild, hämodynamischen Auswirkungen, zugrunde liegenden kardialen Erkrankungen und Risikofaktoren für einen Schlaganfall. Dieser Beitrag gibt einen Überblick über die katheterablativen therapeutischen Optionen bei Vorhofflimmern.
Kernaussagen

  • Vorhofflimmern ist eine chronisch-progrediente Erkrankung und die häufigste supraventrikuläre Herzrhythmusstörung. Betroffen sind ca. 2% der Bevölkerung mit einer deutlichen Zunahme im Alter.

  • Die Therapie basiert auf der Thrombembolieprophylaxe, der Frequenzkontrolle und, bei bestehender Indikation, der rhythmuserhaltenden Therapie.

  • Rhythmuserhalt kann medikamentös oder durch interventionelle Therapie erreicht werden.

  • Mit unzweifelhafter Evidenz belegt ist bei der interventionellen Therapie die Isolation der Pulmonalvenen.

  • Verschiedene technische Varianten zum Erzielen dieser sind verfügbar. Einen klaren Vorteil weist keines der Verfahren auf.

  • Die Katheterablation ist die deutlich effektivste Therapie im Hinblick auf einen Rhythmuserhalt (bei geringer Evidenz für einen Einfluss auf harte klinische Endpunkte).

  • Da die Erfolgsaussichten, insbesondere bei persistierendem Vorhofflimmern, unbefriedigend sind, besteht Bedarf an der Entwicklung zusätzlicher Ablationsstrategien.

Schlüsselwörter

Vorhofflimmern - Katheterablation - Indikationsstellung - Ablationsstrategie - Ablationstechnologie
 

  • Literatur

  • 1 Haïssaguerre M, Jaïs P, Shah DC. et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998; 339: 659-666
    CrossrefPubMedGoogle Scholar
  • 2 Wijffels MC, Kirchhof CJ, Dorland R. et al. Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats. Circulation 1995; 92: 1954-1968
    CrossrefPubMedGoogle Scholar
  • 3 Kirchhof P, Benussi S, Kotecha D. et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37: 2893-2962
    CrossrefPubMedGoogle Scholar
  • 4 Olesen JB, Lip GY, Hansen ML. et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ 2011; 342: d124 doi:10.1136/bmj.d124
    CrossrefPubMedGoogle Scholar
  • 5 Camm AJ, Lip GY, De Caterina R. et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33: 2719-2747 doi:10.1093/eurheartj/ehs253
    CrossrefPubMedGoogle Scholar
  • 6 Kuck KB, Chun D, Deneke J. et al. Qualitätskriterien zur Durchführung der Katheterablation von Vorhofflimmern – Positionspapier der deutschen Gesellschaft für Kardiologie. Kardiologe 2017; 11: 161-182
    CrossrefPubMedGoogle Scholar
  • 7 Wilber DJ, Pappone C, Neuzil P. et al. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA 2010; 303: 333-340
    CrossrefPubMedGoogle Scholar
  • 8 Cappato R, Calkins H, Chen SA. et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 2010; 3: 32-38
    CrossrefPubMedGoogle Scholar
  • 9 Verma A, Jiang CY, Betts TR. et al. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med 2015; 372: 1812-1822
    CrossrefPubMedGoogle Scholar
  • 10 Packer DL, Mark DB, Robb RA. et al. Effect of Catheter Ablation vs. Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA 2019; 321: 1261-1274
    CrossrefPubMedGoogle Scholar
  • 11 Marrouche NF, Kheirkhahan M, Brachmann J. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med 2018; 378: 417-427
    CrossrefPubMedGoogle Scholar
  • 12 Herrera Siklody C, Deneke T, Hocini M. et al. Incidence of asymptomatic intracranial embolic events after pulmonary vein isolation: comparison of different atrial fibrillation ablation technologies in a multicenter study. J Am Coll Cardiol 2011; 58: 681-688
    CrossrefPubMedGoogle Scholar
  • 13 Dukkipati SR, Neuzil P, Kautzner J. et al. The durability of pulmonary vein isolation using the visually guided laser balloon catheter: multicenter results of pulmonary vein remapping studies. Heart Rhythm 2012; 9: 919-925
    CrossrefPubMedGoogle Scholar
  • 14 Dukkipati SR, Cuoco F, Kutinsky I. et al. Pulmonary Vein Isolation Using the Visually Guided Laser Balloon: A Prospective, Multicenter, and Randomized Comparison to Standard Radiofrequency Ablation. J Am Coll Cardiol 2015; 66: 1350-1360
    CrossrefPubMedGoogle Scholar
  • 15 Packer DL, Kowal RC, Wheelan KR. et al. Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the North American Arctic Front (STOP AF) pivotal trial. J Am Coll Cardiol 2013; 61: 1713-1723
    CrossrefPubMedGoogle Scholar
  • 16 Kuck KH, Brugada J, Fürnkranz A. et al. Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation. N Engl J Med 2016; 374: 2235-2245
    CrossrefPubMedGoogle Scholar
  • 17 Di Biase L, Burkhardt JD, Santangeli P. et al. Periprocedural stroke and bleeding complications in patients undergoing catheter ablation of atrial fibrillation with different anticoagulation management: results from the Role of Coumadin in Preventing Thromboembolism in Atrial Fibrillation (AF) Patients Undergoing Catheter Ablation (COMPARE) randomized trial. Circulation 2014; 129: 2638-2644
    CrossrefPubMedGoogle Scholar
  • 18 Macle L, Khairy P, Weerasooriya R. et al. Adenosine-guided pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation: an international, multicentre, randomised superiority trial. Lancet 2015; 386: 672-679
    CrossrefPubMedGoogle Scholar
  • 19 Platonov PG, Mitrofanova LB, Orshanskaya V. et al. Structural abnormalities in atrial walls are associated with presence and persistency of atrial fibrillation but not with age. J Am Coll Cardiol 2011; 58: 2225-2232
    CrossrefPubMedGoogle Scholar
  • 20 McGann C, Akoum N, Patel A. et al. Atrial fibrillation ablation outcome is predicted by left atrial remodeling on MRI. Circ Arrhythm Electrophysiol 2014; 7: 23-30
    CrossrefPubMedGoogle Scholar
  • 21 Kottkamp H. Human atrial fibrillation substrate: towards a specific fibrotic atrial cardiomyopathy. Eur Heart J 2013; 34: 2731-2738
    CrossrefPubMedGoogle Scholar
  • 22 Calkins H, Hindricks G, Cappato R. et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2018; 20: e1-e160
    CrossrefPubMedGoogle Scholar
  • 23 Ernst S, Ouyang F, Löber F. et al. Catheter-induced linear lesions in the left atrium in patients with atrial fibrillation: an electroanatomic study. J Am Coll Cardiol 2003; 42: 1271-1282
    CrossrefPubMedGoogle Scholar
  • 24 Sawhney N, Anousheh R, Chen W. et al. Circumferential pulmonary vein ablation with additional linear ablation results in an increased incidence of left atrial flutter compared with segmental pulmonary vein isolation as an initial approach to ablation of paroxysmal atrial fibrillation. Circ Arrhythm Electrophysiol 2010; 3: 243-248
    CrossrefPubMedGoogle Scholar
  • 25 Nademanee K, McKenzie J, Kosar E. et al. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol 2004; 43: 2044-2053
    CrossrefPubMedGoogle Scholar
  • 26 Narayan SM, Baykaner T, Clopton P. et al. Ablation of rotor and focal sources reduces late recurrence of atrial fibrillation compared with trigger ablation alone: extended follow-up of the CONFIRM trial (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation). J Am Coll Cardiol 2014; 63: 1761-1768
    CrossrefPubMedGoogle Scholar
  • 27 Cuculich PS, Wang Y, Lindsay BD. et al. Noninvasive characterization of epicardial activation in humans with diverse atrial fibrillation patterns. Circulation 2010; 122: 1364-1372
    CrossrefPubMedGoogle Scholar
  • 28 Di Biase L, Burkhardt JD, Mohanty P. et al. Left Atrial Appendage Isolation in Patients With Longstanding Persistent AF Undergoing Catheter Ablation: BELIEF Trial. J Am Coll Cardiol 2016; 68: 1929-1940
    CrossrefPubMedGoogle Scholar
  • 29 Marrouche NF, Wilber D, Hindricks G. et al. Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA 2014; 311: 498-506
    CrossrefPubMedGoogle Scholar
  • 30 Blandino A, Bianchi F, Grossi S. et al. Left Atrial Substrate Modification Targeting Low-Voltage Areas for Catheter Ablation of Atrial Fibrillation: A Systematic Review and Meta-Analysis. Pacing Clin Electrophysiol 2017; 40: 199-212
    CrossrefPubMedGoogle Scholar
  • 31 Brignole M, Pokushalov E, Pentimalli F. et al. A randomized controlled trial of atrioventricular junction ablation and cardiac resynchronization therapy in patients with permanent atrial fibrillation and narrow QRS. Eur Heart J 2018; 39: 3999-4008
    CrossrefPubMedGoogle Scholar
  • 32 Yousuf T, Keshmiri H, Bulwa Z. et al. Management of Atrio-Esophageal Fistula Following Left Atrial Ablation. Cardiol Res 2016; 7: 36-45
    CrossrefPubMedGoogle Scholar
  • 33 Schreiber D, Rostock T, Fröhlich M. et al. Five-year follow-up after catheter ablation of persistent atrial fibrillation using the stepwise approach and prognostic factors for success. Circ Arrhythm Electrophysiol 2015; 8: 308-317
    CrossrefPubMedGoogle Scholar
  • 34 Maury P, Champ-Rigot L, Rollin A. et al. Comparison between novel and standard high-density 3D electro-anatomical mapping systems for ablation of atrial tachycardia. Heart Vessels 2019; 34: 801-808
    CrossrefPubMedGoogle Scholar
  • 35 Cosedis Nielsen J, Johannessen A, Raatikainen P. et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med 2012; 367: 1587-1595
    CrossrefPubMedGoogle Scholar
  • 36 Wyse DG, Waldo AL, DiMarco JP. et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002; 347: 1825-1833
    CrossrefPubMedGoogle Scholar
  • 37 Van Gelder IC, Hagens VE, Bosker HA. et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002; 347: 1834-1840
    CrossrefPubMedGoogle Scholar
  • 38 Shoemaker MB, Muhammad R, Farrell M. et al. Relation of morbid obesity and female gender to risk of procedural complications in patients undergoing atrial fibrillation ablation. Am J Cardiol 2013; 111: 368-373
    CrossrefPubMedGoogle Scholar
  • 39 Sivasambu B, Balouch MA, Zghaib T. et al. Increased rates of atrial fibrillation recurrence following pulmonary vein isolation in overweight and obese patients. J Cardiovasc Electrophysiol 2018; 29: 239-245
    PubMedGoogle Scholar
  • 40 Pathak RK, Middeldorp ME, Lau DH. et al. Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: the ARREST-AF cohort study. J Am Coll Cardiol 2014; 64: 2222-2231
    CrossrefPubMedGoogle Scholar