目的:探讨阵发性心房颤动(房颤)患者肺静脉前庭首次消融术中有或无肺静脉触发灶的复发原因。方法:共入选181例阵发性房颤患者,男性135例,女性46例,平均年龄(55.0±11.4)岁,平均病史为(64.6±68.5)个月。在三维标测系统指导下行肺静脉前庭隔离术达到肺静脉-左心房电学隔离;术后常规程序刺激诱发,若合并室上性心律失常或者非肺静脉触发灶,同时消融。根据术中记录到肺静脉电位翻转并触发房颤为肺静脉触发房颤组(61例),无明确肺静脉触发房颤为无肺静脉触发房颤组(120例)。出院前所有患者均做常规体表心电图和动态心电图检查,术后1~3个月,6个月分别再行上述随访检查。所有复发患者均接受二次消融。结果:所有患者术中均成功隔离肺静脉,但无肺静脉触发房颤组中明确有12例为非肺静脉触发灶,1例位于左心房顶部,11例起源于上腔静脉。两组间的临床资料比较差异无统计学意义。平均随访(36.1±16.4)个月,首次消融术后,与无肺静脉触发房颤组相比,肺静脉触发房颤组复发房颤率差异无统计学意义(22.9% vs 33.3%,P=0.15)。二次手术中,无肺静脉触发房颤组中12例患者均再次隔离肺静脉,其中1例术中发现同时存在上腔静脉触发灶。肺静脉触发房颤组中,36例接受再次隔离,静脉点滴异丙肾上腺素及“弹丸式”注射三磷酸腺苷时,16例患者共诱导出17处房颤触发灶,2例起源于肺静脉,15例为肺静脉之外(其中12例为上腔静脉起源,2例起源于冠状静脉窦,间隔处起源1例)。二次术后仍有15例复发,其中2例接受三次手术,触发灶分别位于左心房间隔与冠状静脉窦,1例患者四次手术,触发灶位于左心房后壁。二次消融术后,肺静脉触发房颤组的成功率明显高于无肺静脉触发房颤组(95.1% vs 84.1%,P=0.03)。但肺静脉触发房颤组的非肺静脉触发灶的比例明显低于无肺静脉触发房颤组,两组比较差异有统计学意义(1.98% vs 22.5%,P<0.001)。结论:明确肺静脉触发灶者,复发的主要原因是左心房肺静脉传导的恢复。无明确肺静脉触发者,主要原因是非肺静脉触发灶,常需要额外的消融。 Objective: To investigate the causes of recurrent or non-pulmonary venous trigger in the first ablation of pulmonary vein vestibular in patients with paroxysmal atrial fibrillation (AF). Methods: A total of 181 patients with paroxysmal atrial fibrillation were enrolled. There were 135 males and 46 females, with an average age of (55.0 ± 11.4) years and an average history of (64.6 ± 68.5) months. In the three-dimensional mapping system under the guidance of pulmonary vestibular veins to achieve pulmonary vein - left atrial electrical isolation; postoperative routine stimulation induced, if combined with supraventricular arrhythmias or non-pulmonary vein trigger, ablation. According to the intraoperative recording of pulmonary venous potential reversal and trigger atrial fibrillation for the pulmonary vein to trigger atrial fibrillation (61 cases), there is no clear pulmonary venous atrial fibrillation triggered by atrial fibrillation without pulmonary vein (120 cases). All patients before discharge were routine surface electrocardiogram and Holter monitoring, 1 to 3 months after surgery, 6 months, respectively, and then the above follow-up examination. All relapse patients underwent secondary ablation. Results: All the patients successfully isolated the pulmonary veins during operation. However, 12 patients without pulmonary veins were found to be non-pulmonary vein triggers in the atrial fibrillation group. One was located in the top of the left atrium and 11 in the superior vena cava. Clinical data between the two groups showed no significant difference. After a mean follow-up of (36.1 ± 16.4) months, there was no significant difference in the rate of atrial fibrillation between the two groups (22.9% vs 33.3%, P = 0.15) after the first ablation compared with those without atrial fibrillation . In the second operation, pulmonary vein was isolated again in 12 patients without atrial fibrillation triggered by pulmonary vein, of which 1 case was found to have the trigger of superior vena cava concurrently. In the pulmonary vein-triggered atrial fibrillation group, of the 36 patients who underwent isolation, intravenous isoproterenol, and “bolus” adenosine triphosphate, 17 of the 16 patients had atrial fibrillation triggering, two originated in the pulmonary veins, 15 Cases of pulmonary veins outside (of which 12 cases of origin of the superior vena cava, originated in 2 cases of coronary sinus, an interval of origin in 1 case). There were still 15 recurrences after the second operation, of which 2 patients underwent three surgeries. The triggering lesion was located in the left atrial septum and the coronary sinus, respectively. One patient underwent four surgeries and the triggering lesion was located at the posterior wall of the left atrium. After secondary ablation, the success rate of pulmonary vein atrial fibrillation was significantly higher than that of atrial fibrillation without pulmonary vein (95.1% vs 84.1%, P = 0.03). However, the proportion of non-pulmonary vein triggers in pulmonary vein-triggered atrial fibrillation group was significantly lower than that of non-pulmonary vein-triggered atrial fibrillation group (1.98% vs 22.5%, P <0.001). Conclusion: Clear pulmonary venous trigger, the main reason for recurrence of the left atrium pulmonary vein conduction recovery. No clear pulmonary vein triggers, the main reason is non-pulmonary vein trigger, often require additional ablation.