Atriale Tachykardien nach Vorhofflimmerablation: Fluch oder Segen?

Zusammenfassung

Nach Vorhofflimmerablation kann es neben Vorhofflimmerrezidiven auch zum Auftreten von verschiedenen atrialen Tachykardien kommen. Obwohl bei atrialen Tachykardien eine regelmäßige atriale Aktivierung vorliegt, sind diese Rhythmusstörungen für die Patienten häufig stark symptomatisch und teils kaum medikamentös zu kontrollieren. Für eine individualisierte Therapieplanung können anhand des Oberflächen-EKGs auch bei vielen vor-abladierten Patienten rechts- von links-atrialen Tachykardien recht zuverlässig unterschieden werden. Die Ablationsstrategie richtet sich nach dem Mechanismus der Tachykardie: Auffinden der frühesten elektrischen Aktivierung und lokale Ablation bei fokalen Tachykardien oder lineare Ablation zur Unterbindung des Reentry-Kreislaufs bei Makro-Reentry-Tachykardien. Speziell bei Patienten mit ausgeprägter Vorhoffibrose ist der optimale Therapieansatz aber noch Gegenstand klinischer Studien.

Abstract

Recurrences of atrial tachycardias can occur following ablation for atrial fibrillation. Despite regular atrial activation, atrial tachycardias can be highly symptomatic and difficult to control using antiarrhythmic medications. To guide therapeutic decisions, right- and left-atrial tachycardias can be distinguished with reasonable accuracy using the 12-lead surface ECG. The target of ablation depends on the mechanism of the tachycardia: identifying and ablating the earliest electrical acitivity for focal tachycardias, or linear ablation in macro-reentrant tachycardias. Particularily in patients with extensive fibrotic atrial myopathy, the most promising approach for ablation is still a matter of ongoing research.

Was ist wichtig?

Die Katheterablation ist mittlerweile in vielen Fällen von symptomatischem Vorhofflimmern Therapie der ersten Wahl. Nach Ablation kann es neben Vorhofflimmerrezidiven auch zum Auftreten von atrialen Tachykardien (AT) kommen, die sowohl in ihrer Pathogenese als auch der medikamentösen und interventionellen Therapie von Vorhofflimmern abzugrenzen sind.

Schlüsselwörter

Vorhofflimmern - atriale Tachykardie - Vorhofflattern - Ablation - fibrotische atriale Kardiomyopathie

Keywords

atrial tachycardia - atrial flutter - ablation - fibrotic atrial cardiomyopathy - atrial fibrillation

Publication History

Article published online:
14 June 2021

• Literatur

• 1 Hindricks G, Potpara T, Dagres N. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J 2021; 42: 373-498 DOI: 10.1093/eurheartj/ehaa612. (PMID: 32860505)
• 2 Raatikainen MJP, Arnar DO, Merkely B. A Decade of Information on the Use of Cardiac Implantable Electronic Devices and Interventional Electrophysiological Procedures in the European Society of Cardiology Countries: 2017 Report from the European Heart Rhythm Association. Europace 2017; 19: ii1-ii90 DOI: 10.1093/europace/eux258.
• 3 Haïssaguerre M, Jaïs P, Shah DC. Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins. N Engl J Med 1998; 339: 659-666 DOI: 10.1056/NEJM199809033391003. (PMID: 9725923)
• 4 Kirchhof P, Camm AJ, Goette A. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med 2020; 383: 1305-1316 DOI: 10.1056/nejmoa2019422. (PMID: 32865375)
• 5 Marrouche NF, Brachmann J, Andresen D. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med 2018; 378: 417-427 DOI: 10.1056/NEJMoa1707855. (PMID: 29385358)
• 6 Prabhu S, Taylor AJ, Costello BT. Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction: The CAMERA-MRI Study. J Am Coll Cardiol 2017; 70: 1949-1961 DOI: 10.1016/j.jacc.2017.08.041. (PMID: 28855115)
• 7 Müller-Edenborn B, Minners J, Allgeier J. Rapid improvement in left ventricular function after sinus rhythm restoration in patients with idiopathic cardiomyopathy and atrial fibrillation. Europace 2019; 21: 871-878 DOI: 10.1093/europace/euz013. (PMID: 31157388)
• 8 Phlips T, Taghji P, El Haddad M. Improving procedural and one-year outcome after contact force-guided pulmonary vein isolation: the role of interlesion distance, ablation index, and contact force variability in the ’CLOSE’-protocol. Europace 2018; 20: f419-f427 DOI: 10.1093/europace/eux376. (PMID: 29315411)
• 9 Kuck KH, Brugada J, Fürnkranz A. Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation. N Engl J Med 2016; 374: 2235-2245 DOI: 10.1056/NEJMoa1602014. (PMID: 27381589)
• 10 Verma A, Jiang C, Betts TR. Approaches to Catheter Ablation for Persistent Atrial Fibrillation. N Engl J Med 2015; 372: 1812-1822 DOI: 10.1056/NEJMoa1408288. (PMID: 25946280)
• 11 Deisenhofer I, Estner H, Zrenner B. Left atrial tachycardia after circumferential pulmonary vein ablation for atrial fibrillation: Incidence, electrophysiological characteristics, and results of radiofrequency ablation. Europace 2006; 8: 573-582 DOI: 10.1093/europace/eul077. (PMID: 16864612)
• 12 Shah D, Sunthorn H, Burri H. Narrow, slow-conducting isthmus dependent left atrial reentry developing after ablation for atrial fibrillation: ECG characterization and elimination by focal RF ablation. J Cardiovasc Electrophysiol 2006; 17: 508-515 DOI: 10.1111/j.1540-8167.2006.00413.x. (PMID: 16684024)
• 13 Duytschaever M, Vijgen J, De Potter T. Standardized pulmonary vein isolation workflow to enclose veins with contiguous lesions: The multicentre VISTAX trial. Europace 2020; 22: 1645-1652 DOI: 10.1093/europace/euaa157. (PMID: 32879974)
• 14 Fink T, Schlüter M, Heeger CH. Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation. Circ Arrhythmia Electrophysiol 2017; 10: e005114 DOI: 10.1161/CIRCEP.117.005114. (PMID: 28687670)
• 15 Saoudi N, Cosío F, Waldo A. A classification of atrial flutter and regular atrial tachycardia according to electrophysiological mechanisms and anatomical bases; a Statement from a Joint Expert Group from The Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Eur Heart J 2001; 22: 1162-1182 DOI: 10.1053/euhj.2001.2658. (PMID: 11440490)
• 16 Jaïs P, Matsuo S, Knecht S. A deductive mapping strategy for atrial tachycardia following atrial fibrillation ablation: Importance of localized reentry. J Cardiovasc Electrophysiol 2009; 20: 480-491 DOI: 10.1111/j.1540-8167.2008.01373.x. (PMID: 19207747)
• 17 Kistler PM, Roberts-Thomson KC, Haqqani HM. P-Wave Morphology in Focal Atrial Tachycardia. Development of an Algorithm to Predict the Anatomic Site of Origin. J Am Coll Cardiol 2006; 48: 1010-1017 DOI: 10.1016/j.jacc.2006.03.058. (PMID: 16949495)
• 18 Haissaguerre M, Shah AJ, Jadidi A. Atrial tachycardias arising from ablation of atrial fibrillation: A proarrhythmic bump or an antiarrhythmic turn?. Cardiol Res Pract 2010; 2010: 950763 DOI: 10.4061/2010/950763. (PMID: 20379387)
• 19 Jadidi A, Nothst M, Chen J. Specific Electrogram Characteristics Identify the Extra-Pulmonary Vein Arrhythmogenic Sources of Persistent Atrial Fibrillation – Characterization of the Arrhythmogenic Electrogram Patterns During Atrial Fibrillation and Sinus Rhythm. Nat Sci Reports 2020; 10: 1-12 DOI: 10.1038/s41598-020-65564-2.
• 20 Kottkamp H, Berg J, Bender R. Box isolation of fibrotic areas (BIFA): A patient-tailored substrate modification approach for ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2016; 27: 22-30 DOI: 10.1111/jce.12870. (PMID: 26511713)
• 21 Müller-Edenborn B, Chen J, Allgeier J. Amplified sinus-P-wave reveals localization and extent of left atrial low-voltage substrate : implications for arrhythmia freedom following pulmonary vein isolation. Europace 2020; 22: 240-249 DOI: 10.1093/europace/euz297. (PMID: 31782781)
• 22 Jadidi A, Müller-Edenborn B, Chen J. The Duration of the Amplified Sinus-P-Wave Identifies Presence of Left Atrial Low Voltage Substrate and Predicts Outcome After Pulmonary Vein Isolation in Patients With Persistent Atrial Fibrillation. JACC Clin Electrophysiol 2018; 4: 531-543 DOI: 10.1016/j.jacep.2017.12.001. (PMID: 30067494)
• 23 Comparison of regular atrial tachycardia incidence after circumferential radiofrequency versus cryoballoon pulmonary vein isolation in real-life practice. J Cardiovasc Electrophysiol 2014; 25: 948-952 DOI: 10.1111/jce.12423.
• 24 Pulmonary Vein Isolation Versus Defragmentation: The CHASE-AF Clinical Trial. J Am Coll Cardiol 2015; 66: 2743-2752 DOI: 10.1016/j.jacc.2015.09.088.