心脏瓣膜手术同期行射频消融术后血栓和出血事件发生率的研究

目的:研究心脏瓣膜手术同期行射频消融术治疗永久性心房纤颤(房颤)术后脑血管事件的发生。方法:回顾2003年1月至2006年12月758例瓣膜病合并房颤病例,其中行瓣膜手术+房颤射频消融374例(射频消融组),仅行瓣膜手术384例(对照组)。术后随访6～54个月,平均(32±6.23)个月,对比分析2组病例术后脑血管事件随访数据。结果:术后随访证实消融组在术后脑血管事件发生率、生存率、窦性心律转复率等均优于对照组。结论:心脏瓣膜置换术同期行射频消融术治疗永久性房颤的远期疗效确切,可降低脑血管事件的发生,并提高远期生存率、窦性心律转复率。     

心脏瓣膜置换术同期直视下射频消融治疗风湿性瓣膜病合并慢性房颤效果观察

目的观察心脏瓣膜置换术同期直视下射频消融治疗对慢性风湿性瓣膜病合并心房纤颤的疗效。方法选择80例有瓣膜置换手术指征并伴有慢性心房纤颤的患者,随机分成治疗组和对照组各40例。治疗组在心脏瓣膜置换同期行冲洗式射频消融,对照组则未给予射频消融治疗。结果随访（8.6±3.1）个月,治疗组中34例术后恢复窦性心律,转复率为85%;对照组术后11例恢复了窦性心律,转复率为27.5%;两组房颤转复率相比,P〈0.05。两组均无明显并发症出现。结论心脏瓣膜置换术同期直视下射频消融治疗能安全有效地治疗风湿性瓣膜性心脏病伴慢性房颤。     

瓣膜置换同期直视下射频消融治疗房颤

目的 探讨瓣膜置换手术同期行双极射频消融治疗心房纤颤(AF)的效果.方法 选择40例有瓣膜置换手术指征的患者,随机分成2组,瓣膜置换合并房颤同期行双极射频消融组20例(治疗组)和同期行经典迷宫组20例(对照组),比较两种手术方法的早期治疗效果.结果 治疗组16例术后恢复窦性心律,转复率为80%.对照组12例术后恢复窦性心律,转复率为60%,两组相比房颤转复率差异有统计学意义(P<0.01).结论 瓣膜置换手术期间使用双极射频消融治疗心房纤颤是安全有效的,能使绝大部分患者恢复窦性心律及心房正常收缩功能.     

二尖瓣机械瓣膜置换同期行房颤双极射频消融术对左心功能的影响

目的探讨二尖瓣机械瓣膜置换+同期双极射频消融术对左心功能的影响。方法 80例采用二尖瓣机械瓣膜置换同期施行房颤双极射频消融术的患者为观察组,同期收治的仅采用二尖瓣机械瓣膜置换治疗的患者为对照组,比较两组患者手术情况、术后恢复情况及心脏功能。结果两组患者术中出血量、术后24 h胸液量、呼吸机辅助时间、ICU停留时间、术后住院时间、死亡率均无统计学差异(P>0.05)。观察组的体外循环时间、主动脉阻断时间均长于对照组(P<0.05)。观察组随访时的左室射血分数(LVEF)、左房内径(LA)大于对照组,左室短轴缩短率小于对照组(P<0.05)。观察组的术毕、1年门诊随访时的窦性心律均高于对照组,复发率低于对照组(P<0.05)。结论房颤双极射频消融术在二尖瓣机械瓣膜置换中应用是安全有效的,能提高患者术后心功能和心房纤颤的转复率,且不会影响患者的术后恢复。     

瓣膜置换术同期射频消融治疗风湿性心瓣膜病伴慢性心房纤颤（附30例报告）

目的观察心脏瓣膜置换术同期射频消融对慢性心房纤颤（AF）的治疗效果。方法将60例有心脏瓣膜置换手术指征并伴有慢性AF患者随机分成A、B组,各30例。A组行心脏瓣膜置换术＋冲洗式射频消融术,B组仅常规行心脏瓣膜置换术。结果术后平均随访11个月,A组25例恢复窦性心律,转复率为83.3%;B组分别为9例和30%（P〈0.01）。结论心脏瓣膜置换术同期行冲洗式射频消融治疗慢性AF安全、有效。     

二尖瓣手术同期射频消融治疗慢性持续性房颤

目的:观察评价二尖瓣手术同期行射频消融治疗慢性心房纤颤的疗效.方法:以具有二尖瓣置换手术指征并合并慢性心房纤颤的风湿性心脏病患者150例为研究对象.据不同疗法分为两组,瓣膜置换并行消融治疗68例为消融组,瓣膜置换后药物治疗82例为对照组.术后随访2年,比较两种方法对房颤的治疗效果及预后.结果:术后随访2年,治疗组窦性心律恢复率(63.2%)明显高于时照组(13.1%).消融组心脏功能恢复情况.左房内径41.6mm±7.5mm,左室射血分数(57.3±9.6)%,肺动脉收缩压(35.7士5.1)mmHg,心功能≤Ⅱ级94.1%.对照组分别为46.7mm±11.4mm;(53.2±7.1)%;(39.1±6.8)mmHg;86.4%,两组比较有统计学意义(P<0.05).两组在术后病死率、二次开胸率等其他严重并发症发生率比较无统计学意义(P>0.05).结论:风湿性心脏病二尖瓣手术同期行射频消融治疗慢性持续性心房纤颤转复率较高,严重并发症发生少,心功能恢复佳.     

心脏瓣膜置换同期双极射频消融术治疗心房纤颤的短期疗效观察

目的 探讨瓣膜置换同期双极消融治疗心房纤颤(AF)的短期疗效. 方法对14例瓣膜置换同期双极消融治疗心房纤颤的患者进行回顾性分析,观察其早期治疗效果. 结果 全组患者术前房颤时间(28.6±13.5)个月,转机时间(88.7±10.4)min,主动脉阻断时间(41.7±8.2)min,无围手术期死亡,患者出院时全部恢复窦性心律,无一例安置永久起搏器,随访3～6(4.7±1.2)个月,13例保持窦性心律,晚期死亡1例.结论 心脏瓣膜置换手术同期行双极射频消融术与传统的Cox迷宫治疗AF相比,能简化手术操作并缩短主动脉阻断时间,是一种简便、安全、有效的治疗方法,值得在临床推广应用.     

改良MazeⅢ术治疗心房纤颤（附30例报告）

目的观察改良MazeⅢ术治疗心房纤颤的疗效。方法 60例风湿性心脏瓣膜病伴心房纤颤患者,随机分为观察组和对照组,各30例。观察组患者在行瓣膜置换（成形）术治疗心脏瓣膜病的同期以行改良MazeⅢ手术治疗心房纤颤;对照组仅施行瓣膜置换（成形）手术。结果观察组全组病例无死亡,未发生任何与改良M azeⅢ手术相关的并发症。观察组术后当日、1周、1个月、3个月的房颤转复率分别为93.3%、86.6%、83.3%、96.6%,明显高于对照组的23.3%、6.66%、6.66%、6.66%,P均〈0.05。观察组术后6个月窦性心律者20例,转复率为90.9%（20/22）;术后12个月窦性心律者8例,转复率为100.0%（8/8）。结论 改良MazeⅢ手术治疗心房纤疗效满意。     

瓣膜置换同期行双极射频消融治疗心脏瓣膜病合并心房颤动的疗效观察

目的分析瓣膜置换同期行双极射频消融术(MazeⅣ)治疗心脏瓣膜病变合并心房颤动的临床效果。方法 2011年1月至2013年12月,共92例心脏瓣膜病合并心房颤动患者在全身麻醉中低温下接受瓣膜置换同期行双极射频消融术,术后给予胺碘酮。出院后常规口服强心、利尿药物,监测凝血酶原时间/国际标准化比率调整华法林用量,定期复查超声心动和心电图。结果随访6~30(18.4±8.8)个月,围术期死亡1例,有效随访87例,失访4例。术后窦性心律69例(79.3%),房颤心律10例(11.5%),房扑心律4例(4.6%),交界性心律3例(3.4%),Ⅲ度房室传导阻滞1例(1.2%)给予安放永久性心脏起搏器。结论心脏瓣膜病合并心房颤动患者接受瓣膜置换同期行双极射频消融术是安全有效的。     

外科双极射频消融术治疗心房颤动406例疗效及影响因素分析

目的:探讨体外循环瓣膜置换手术同期行双极射频消融治疗心房颤动(房颤)的疗效,并分析影响疗效的因素。方法:总结分析2010年8月-2019年4月在我院行体外循环瓣膜置换手术同期行双极射频消融并存活的406例病例,其中男145例,女261例,采用Atricure双极射频消融或Medtronic双极消融系统行房颤外科双极射频消融。术后门诊随访0～5年,记录患者12导联心电图、心脏彩超资料、抗心律失常药物使用情况及射频相关并发症。结果:消融成功组与房颤复发组在术前房颤持续时间、房颤类型、左房大小、右房大小上有显著差异(均P0.05),左室大小与射血分数(EF)差异无统计学意义。窦性心律维持组与房颤复发组EF、左房大小、右房大小比较有统计学差异(均P0.05),左室大小无统计学差异。结论:需行心内手术合并房颤患者行同期双极射频消融术简单易行、远期效果较好。术前房颤持续时间、房颤类型、左房大小会影响房颤消融手术的治疗效果。术后左房大小、右房大小对窦性心律的维持有积极意义。     

微波消融治疗心房颤动在风湿性心脏病二尖瓣置换术中的应用

目的研究风湿性心脏病二尖瓣手术同期行心内膜微波消融术治疗持续性心房颤动(简称房颤)的效果。方法66例患者随机分为两组,33例在二尖瓣手术中行心内膜微波消融治疗,另外33例设为对照组,单独行瓣膜手术。结果微波组主动脉阻断时间、体外循环时间长于对照组(63.818±17.738 min vs 47.545±18.018 min;108.879±32.191 min vs 85.333±22.885 min。P均<0.05)。术后两组均未出现严重并发症。随访2.3±1.4年,微波组中24例(72.7%)维持窦性心律,对照组中5例(15.2%)为窦性心律,两组比较,P<0.05。术后6个月、2年,微波组左房内径明显小于对照组(P<0.05);术后2年,微波组三尖瓣返流量明显低于对照组(P<0.05)。结论微波消融治疗房颤安全、效果确切,可延缓术后左房内径变大及三尖瓣返流的进展。     

Efficacy of intra-operative radiofrequency ablation in patients with permanent atrial fibrillation undergoing concomitant mitral valve replacement

BACKGROUND: Permanent atrial fibrillation (AF) is present before operation and persists after surgery in 30-40% of patients undergoing mitral valve surgery. Using the maze procedure, 75-82% of patients can be cured of AF, but the procedure is difficult and long lasting. Percutaneous radiofrequency (RF) ablation has emerged as an effective therapy for AF in recent years. AIM: To assess the efficacy of intra-operative RF ablation of AF in patients undergoing mitral valve surgery. METHODS: 100 adults with permanent AF underwent mitral valve replacement. Patients were divided into two groups: the RF group--50 patients qualified for mitral valve replacement and RF ablation; and the control group--50 patients selected for mitral valve replacement without ablation. Odds ratio and 95% confidence interval were examined to assess the influence of several factors on the outcome (free from AF during one-year follow-up based on symptoms and serial Holter ECG recordings). RESULTS: Baseline clinical, demographic and echocardiographic characteristics were similar in both groups. Electrical cardioversion following surgery was required in 76% of patients from the RF group compared with 94% from the control group (p<0.002). In those who underwent cardioversion, sinus rhythm was restored more frequently in RF than control patients (32 vs. 16%, p<0.002). Sinus rhythm at hospital discharge was present in 56% of RF patients compared with 22% of controls (p=0.0001), and after one-year follow-up in 54 vs. 16% (p<0.001), respectively. The use of amiodarone was significantly lower in RF patients compared with controls (32 vs. 70%, p<0.05). NYHA class III (OR 8.5, CI 1.0-394) or IV (OR 36, CI 1.2-1958) and left atrial diameter >6 cm (OR 9.3, CI 0.5-5230) were identified as predictors of AF. CONCLUSIONS: Intra-operative RF ablation performed in the left atrium in patients with chronic AF undergoing mitral valve replacement significantly improves sinus rhythm restoration rate. Advanced heart failure (NYHA class IV) and left atrial diameter >6 cm are negative prognostic factors for sinus rhythm maintenance.     

Intra-operative cooled-tip radiofrequency linear atrial ablation to treat permanent atrial fibrillation.

AIMS: To demonstrate the safety and efficacy of saline irrigated cooled-tip atrial linear endocardial radiofrequency ablation (SICTRA) concomitant to open-heart surgical procedures in the treatment of permanent atrial fibrillation (AF). METHODS AND RESULTS: Two hundred and twenty-two patients presenting with permanent AF and the need for cardiac surgery were included. In addition to the cardio-surgical procedure [mitral valve (MV) surgery (n = 94), aortic valve replacement (n = 29), bypass surgery (n = 76 including 24 patients with additional MV surgery), and combined procedures (n = 23)] concomitant SICTRA was performed. In 116 patients, the ablation pattern was restricted to the left atrium alone. During the mean follow-up of 29 months, 174 patients (78%) converted to sinusrhythm (SR). In patients with SICTRA restricted to the left atrium conversion rates were not different compared to a biatrial approach (83 vs. 74%, P = 0.47). Thirty-days mortality was found to be 4% (9/222). Post-mortem evaluation revealed 23% of all lesions to be histologically non-transmural. In the overall group, only 4% of patients developed sustained secondary regular atrial arrhythmia. CONCLUSIONS: SICTRA safely and effectively restores stable SR in 78% of patients with permanent AF undergoing open-heart surgery. Rhythm outcome is not influenced by treatment of the right atrium. Sustained regular atrial arrhythmia with the need for invasive treatment strategies occurs in 4% although intra-operative ablation lesions are often non-transmural.     

瓣膜置换术中双极射频消融治疗风湿性心脏病合并心房颤动

目的 探讨风湿性心脏瓣膜病合并心房颤动（AF）患者同期行瓣膜替换术及双极射频消融迷宫术的近期手术效果.方法 选取风湿性心脏瓣膜病合并心房颤动患者18例（消融组）,同期行瓣膜替换术及双极射频消融迷宫术治疗心房颤动.18例配对仅行心脏瓣膜替换术而未行双极射频消融迷宫术的患者作为对照组.患者年龄36～65岁,平均53.5岁,房颤持续时间1～10年,平均5年,左心房内径为44～67 mm.比较两组患者的手术治疗结果.结果 消融组18例患者术后窦性心律16例,房颤心律1例,结性心律1例;随访8个月,15例维持窦性心律,3例阵发性房颤心律.对照组13例术中心脏复跳后即为房颤心律,5例心脏复跳后为窦性心律,术后24 h内均转为房颤心律,应用胺碘酮不能持续恢复窦性心律.两组术后左房内径均较术前显著降低（P＜0.01）,消融组术后左房内径小于对照组[（33.06±2.88）mm比（36.16±2.43）mm,P＜0.05].结论 风湿性心脏瓣膜病合并慢性心房颤动患者在行瓣膜替换术的同时行附加的双极射频消融手术疗效良好,安全简便.     

Factors related to sinus rhythm at discharge after radiofrequency ablation of permanent atrial fibrillation in patients undergoing mitral valve surgery

Late recovery of sinus rhythm is unusual in patients with permanent AF treated by (radiofrequency) RF maze procedure during mitral valve surgery. Identification of clinical and instrumental preoperative factors predictive of early success of RF ablation in patients with permanent AF undergoing mitral valve surgery may improve selection of subjects to obtain long-term results. Hundred and thirty consecutive patients with permanent AF and mitral valve disease underwent modified RF maze procedure during concomitant mitral valve surgery. Rheumatic valve disease (61 pts) and mitral valve prolapse (41 pts) were the more common aetiology of valve abnormalities. Mitral valve replacement was performed in 54 % of patients and mitral valve repair in the remaining 46 %. Four patients died after surgery. At discharge, 87 patients (69 %) were in sinus rhythm (group 1) and 43 patients in AF persisted (group 2). At an average 24-month follow-up, sinus rhythm was present in 67 % of patients, and 33 % were in atrial fibrillation. In this period, late recovery of sinus rhythm was observed only in five patients, while eight discharged in sinus rhythm developed again atrial fibrillation. Among preoperative parameters at univariate analysis female sex, atrial fibrillation >24 months, left atrial diameter >54 mm, left atrial area >24 cm², rheumatic valve disease and NYHA class were associated with persistence of AF. At Cox regression multivariate analysis, increased left atrial area (OR 1.07 per unit increase—95 % CI 1.01–1.131) and rheumatic aetiology of valve disease (OR 4.52, 95 % CI 1.65–12.4) were associated with persistence of AF at hospital discharge. Persistence of AF after RF ablation in patients undergoing mitral valve surgery is related to aetiology, e.g. rheumatic valve disease, and to increasing left atrial diameter. Due to low rate of late recovery of sinus rhythm, indication to RF ablation associated with MV surgery should be carefully considered in patients with large atria and rheumatic mitral valve disease.     

瓣膜手术同期行射频消融迷宫手术治疗心房颤动的疗效观察

目的观察瓣膜手术同期行射频消融迷宫手术治疗心房颤动的疗效,探讨外科手术治疗瓣膜病合并心房颤动的临床价值。方法2003年1月至2011年12月,149例心脏瓣膜病合并心房颤动患者接受瓣膜手术同期行射频消融迷宫手术。记录心电图变化,比较术前与术后心脏超声心动图指标（LAD、LVDS、EF）的变化及心脏功能的恢复情况。随访6～90个月。结果二尖瓣成形术21例,二尖瓣置换术89例（其中生物瓣置换术35例）,主动脉瓣置换术32例（其中生物瓣置换术11例）,三尖瓣成形术46例,三尖瓣置换术3例,左房血栓清除术48例。体外循环时间（82．1±17．8）min,主动脉阻断时间（37．8±25.3）min。双极射频消融121例,单、双极联合射频消融28例,射频消融时间12-38（17．4±5．1）min。手术后即刻,心房颤动全部消失,窦性心律133例,节性心律14例,Ⅲ度房室传导阻滞2例。围术期死亡3例,死亡率2．0％（3／149）,其中2例为严重低心排综合征,1例多器官功能衰竭。术后1个月,窦性心律121例（82．9％）,结性心律8例（5．5％）,心房扑动5例（3．4％）,房颤心律12例（8．2％）,Ⅲ度房室传导阻滞1例（0．6％）,安置永久起搏器。随访时间3～90个月,随访率78．8％（115／146）。随访期间死亡9例（4例心源性死亡,2例脑梗塞死亡,3例脑出血死亡）。106例随访到的存活病例,93例恢复窦性心律,转复率87．7％。随访超声心动图可见左心房及左心室舒张末内径均较术前减小,而左心室射血分数较术前无明显变化。结论瓣膜病合并心房颤动同期行瓣膜手术及射频消融迷宫手术,手术安全性高,远期疗效确切。抗凝并发症仍是瓣膜置换手术远期的主要并发症及致死原因之一,瓣膜成形或生物瓣置换联合射频迷宫手术可能降低此风险。     

Antiarrhythmic Surgery to Cure Atrial Fibrillation—Subgroups and Postoperative Management

Antiarrhythmic surgical procedures to cure atrial fibrillation (AF) are widely used in cardiac surgery. Whereas the Cox maze procedure remains the highly effective gold-standard a variety of different antiarrhythmic procedures aim at reducing the extent and duration of the procedure. Antiarrhythmic procedures are especially effective in patients undergoing mitral valve surgery. In 110 patients with permanent AF undergoing various surgical procedures sinus rhythm was re-established in 75%. Subgroup analyses revealed no significant differences in rhythm or survival after antiarrhythmic intraoperative ablation indicating the usefulness and feasibility of this procedure in patients with a wide range of characteristics. Because conversion usually occurs spontaneously within the first 6 months and antiarrhythmic medication does not increase the incidence of conversion it seems reasonable to wait for spontaneous occurrence of sinus rhythm after antiarrhythmic intraoperative ablation. In patients with permanent AF undergoing open heart surgery additional antiarrhythmic procedures have been shown to be safe and effective.     

心房颤动导管射频消融术逆转功能性三尖瓣反流的超声研究

目的 研究导管射频消融术对非瓣膜病性房颤患者中重度功能性三尖瓣反流的影响及逆转右心重构的作用.方法 采用前瞻性的研究方法,连续入选2010年12月至2012年6月632例非瓣膜病性房颤首次行导管射频消融手术的患者,于手术前（72 h内）进行二维超声心动检查,将伴有中重度功能性三尖瓣反流的患者作为研究对象（12例）,于手术后3个月及6个月复查二维超声心动图,对比分析手术前后超声心动图数据,从而评判导管射频消融术后维持窦性心律对功能性三尖瓣反流的影响及逆转右心重构的作用.结果 导管射频消融术后3个月和6个月右心房上下径[（54.13±6.06）mm比（49.72±5.96）mm,P=0.001;（54.13±6.06）mm比（48.37±5.53）mm,P=0.001]、右心房左右径[（39.29±6.38）mm比（35.09±3.15）mm,P=-0.023;（39.29±6.38）mm比（33.86±2.97）mm,P=0.014]、右心室基底部横径[（34.65±4.51）mm比（32.58±3.93）mm,P=0.033;（34.65±4.51）mm比（31.40±3.59）mm,P=0.043]、三尖瓣反流面积[（7.30±1.37）mm^2比（3.18±2.10）mm^2,P=0.001;（7.30±1.37）mm^2比（1.52±1.92）mm^2,P=0.001]均有所减少,差异有统计学意义.结论 导管射频消融术可以改善非瓣膜病性房颤患者功能性三尖瓣反流的程度,逆转右心重构,疗效确切.     

Impact of left atrial size reduction and endocardial radiofrequency ablation on continuous atrial fibrillation in patients undergoing concomitant cardiac surgery: three-year results

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the efficacy of left atrial (LA) size reduction combined with radiofrequency (RF) ablation in the treatment of continuous atrial fibrillation (AF), by comparative analysis of the outcomes of patients undergoing RF ablation with and without LA size reduction. METHODS: A total of 46 patients with continuous AF and cardiac disease underwent cardiac surgery and RF ablation alone (group I, n = 20) or combined with LA size reduction (group II, n = 26). Patients were followed for three years postoperatively, with evaluation of cardiac rhythm, neurological complications, LA size (by echocardiography) and atrial contractility. RESULTS: At three years after surgery, sinus rhythm (SR) was restored in 61.1% and 70% of patients in groups I and II, respectively. Mean LA diameter was reduced from 60 +/- 15 mm to 57 +/- 5 mm in group I, and from 69 +/- 19 mm to 55 +/- 6 mm in group II. The overall three-year survival was 90% in group I, and 88.5% in group II. Three-year freedom from stroke was 88.9% and 86.2% in groups I and II, respectively. Two patients in each group received transvenous permanent pacemaker implantation. Atrial contractility was recovered in all patients with stable SR. CONCLUSION: LA size reduction improves SR conversion rate after RF ablation for continuous AF in patients undergoing concomitant cardiac surgery.