| 二尖瓣手术同期房颤外科射频消融手术的安全性和中长期疗效分析 |
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| 引用本文： | 张科,陈鑫. 二尖瓣手术同期房颤外科射频消融手术的安全性和中长期疗效分析[J]. 四川大学学报(医学版), 2021, 52(6): 1022-1027. DOI: 10.12182/20211160503 |
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| 作者姓名： | 张科 陈鑫 |
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| 作者单位： | 南京医科大学附属南京医院 南京市第一医院 心胸外科 南京 210006 |
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| 摘 要： | 目的 观察并分析二尖瓣手术同期行房颤外科射频消融的安全性和中长期疗效。 方法 2014年1月?2018年12月，共选取280例合并房颤的器质性二尖瓣疾病患者入组研究，其中130例患者接受单纯的二尖瓣手术（未消融组），150例患者接受二尖瓣手术同期进行房颤外科射频消融手术（消融组）。150例消融组患者中有80例行双心房消融，70例行左心房消融。所有患者全麻后通过胸骨正中切口，升主动脉-上下腔静脉建立体外循环，主动脉阻断后，消融组患者参照Maze Ⅲ路线采用Atricure双极消融钳完成消融，同时切除左心耳，电灼Marshall韧带和Waterston沟。消融完成后，再进行二尖瓣手术。所有患者术后第一天予以口服胺碘酮200 mg，先3次/d×7 d，再2次/d×7 d，然后口服胺碘酮200 mg/d维持至术后3个月（消融组）或12个月（未消融组）。所有患者在出院后3个月、6个月、12个月、2年、3年、5年进行随访，随访内容包括胸前标准12导联心电图和24 h动态心电图等，研究主要终点为术后出现晚期房颤事件的时间点；次要终点为:主要心脑血管事件、死亡、心衰再次入院。 结果 入组患者均顺利完成手术，共有30例患者在术后5年内失访（失访率10.7%），其中消融组有11例患者失访，未消融组有19例患者失访。消融组和未消融组在术后6个月、12个月、2年、3年、5年的无房颤发生比例分别为83.3%和27.7%、72.7%和20.8%、66.0%和15.4%、61.3%和13.1%、43.3%和10.8%，两组数据差异有统计学意义（P<0.001）；双房消融组和左心房消融组在术后6个月、12个月、2年、3年、5年的无房颤发生比例分别为87.3%和87.5%、92.4%和82.8%、90.5%和85.7%、94.8%和88.1%、75.5%和69.4%，两组数据差异无统计学意义（P>0.05），但是两组的累积房颤发生差异有统计学意义（P<0.001）；两组均无术后30 d死亡病例，术后1年内两组病例在脑血管意外、心衰再次入院、肺部感染、纵膈感染方面差异无统计学意义（P>0.05），而消融组在因III度房室传导阻滞行永久起搏器安装较未消融组增多（P<0.05）。消融组术后迟发型心包积液需要再引流的情况高于未消融组（P<0.05）。 结论 心脏瓣膜手术同期使用双极射频消融装置行改良Maze手术治疗房颤的窦性心律转复维持率显著高于未消融组，手术安全性好，中长期疗效明显优于未消融组。左心房和双心房消融都是安全、有效的房颤外科治疗方法。相对于左心房消融组，双心房消融组在恢复和保持窦性心律上更有效。
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| 关 键 词： | 二尖瓣手术 房颤 外科射频消融 中长期疗效 |
| 收稿时间： | 2020-12-09 |
Safety and Medium- and Long-Term Efficacy of Treating Atrial Fibrillation with Surgical Radiofrequency Ablation during Concomitant Mitral Valve Surgery |
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| ZHANG Ke,CHEN Xin. Safety and Medium- and Long-Term Efficacy of Treating Atrial Fibrillation with Surgical Radiofrequency Ablation during Concomitant Mitral Valve Surgery[J]. Journal of Sichuan University. Medical science edition, 2021, 52(6): 1022-1027. DOI: 10.12182/20211160503 |
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| Authors: | ZHANG Ke CHEN Xin |
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| Affiliation: | Department of Cardiothoracic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China |
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| Abstract: | Objective To investigate the safety and medium- and long-term efficacy of surgical radiofrequency ablation to treat atrial fibrillation during concomitant mitral valve surgery. Methods From January 2014 to December 2018, 280 patients with mitral valve disease and the comorbidity of preoperative atrial fibrillation were recruited for the study. Among them, 130 patients received only mitral valve surgery (non-ablation group), and 150 patients were underwent surgical radiofrequency ablation for the atrial fibrillation during concomitant mitral valve surgery (ablation group). Among the 150 patients of the ablation group, 80 had biatrial ablation, and 70 had left atrial ablation. Under general anesthesia, median sternotomy was done on all patients and cardiopulmonary bypass was established through the ascending aorta and superior and inferior venae cavae. After aortic occlusion, patients in the ablation group underwent the ablation procedure with the Atricure? bipolar ablation device, using the Cox Maze Ⅲ procedure as a reference. In addition, the left atrial appendage was removed and electrocautery of the ligament of Marshall and Waterston’s groove were performed in all Cox Maze cases. Following ablation, mitral valve replacement or repair was performed. All patients were given 200 mg oral amiodarone on the first day after surgery, for three times/d×7 d, which was followed by twice/d×7 d, and then oral amiodarone 200 mg/d was maintained till the end of 3 months after surgery (ablation group) or 12 months after surgery (non-ablation group). Patients were followed up at the intervals of 3 months, 6 months, 12 months, 2 years, 3 years, and 5 years after discharge. The follow-up service included standard 12-lead chest electrocardiogram (ECG) and 24-h dynamic ECG. The primary end point of the study was the time point of postoperative atrial fibrillation and the secondary endpoints were major cardiovascular events, death, and readmission due to heart failure. Results The surgeries were successfully performed in all subjects of the study. A total of 30 patients were lost to follow-up within 5 years after operation (10.7% losses to follow-up), including 11 patients in the ablation group and 19 patients in the non-ablation group. The proportion of patients who did not have atrial fibrillation in the ablation group and the non-ablation group at 6 months, 12 months, 2 years, 3 years and 5 years after surgery was 83.3% and 27.7%, 72.7% and 20.8%, 66.0% and 15.4% 61.3% and 13.1%, and 43.3% and 10.8%, respectively, with the data from the two groups showing statistically significant difference (P<0.001). The proportion of patients who did not have atrial fibrillation in the biatrial ablation and the left atrial ablation group at 6 months, 12 months, 2 years, 3 years and 5 years after surgery was 87.3% and 87.5%, 92.4% and 82.8%, 90.5% and 85.7%, 94.8% and 88.1%, and 75.5% and 69.4%%, respectively, with the data from the two groups showing no statistically significant difference (P>0.05). However, the cumulative incidence of atrial fibrillation in the two groups showed statistically significant difference (P<0.001). There were no deaths within 30 days after operation in either group. There was no significant difference in cerebrovascular accident, readmission for heart failure, pulmonary infection and mediastinal infection between the two groups within one year after operation (P>0.05). However, the proportion of patients who had permanent pacemaker installed due to Ⅲ-degree atrioventricular block in the ablation group was higher than that in the non-ablation group (P<0.05). The proportion of patients who required re-drainage due to delayed pericardial effusion in the ablation group was higher than that in the non-ablation group (P<0.05). Conclusion In the group of patients who had modified Cox Maze procedure with bipolar ablation device to treat atrial fibrillation during concomitant mitral valve surgery, the maintenance rate of sinus rhythm after cardioversion was significantly higher than that in the non-ablation group. The surgery showed better safety and significantly better medium- and long-term outcomes. Left atrial ablation and biatrial ablation were both considered safe and effective surgical treatment for atrial fibrillation. Compared with the left atrial ablation group, the biatrial ablation group achieved better effects in restoring and maintaining sinus rhythm without an increase the incidence of perioperative complications. |
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