迷宫手术对二尖瓣病合并的慢性心房颤动电生理的…

对２１例二尖瓣疾患伴心房颤动（简称房颤）施行了迷宫手术和二尖瓣手术的患者，采用１２导联心电图，心内电生理、动态心电图、踏车运动试验方法进行检查，探讨迷宫手术对慢性房颤患者心脏围手术和远期电生理的影响。平均随访１７．９±７．９个月。结果如下：①术后３个月９０％（１８／２０）恢复窦性心律，随访１年以上者（１４例）房颤均未见复发。②术后除１例房结恢复时间延长外余均正常，无窦性起搏或房室结传导功能障碍。③     

心房纤颤迷宫手术及其电生理评价

本研究为评价迷宫手术的电生理效果及对窦房结心房激动顺序和房室传导功能的影响。１０例风湿性心脏病二尖瓣疾患伴心房纤颤病人施行迷宫手术和二尖瓣替换或修复术。女５例，男５例，平均年龄４１岁。持续房颤病史３个月至３年。电生理检查标测房颤心外膜电图，同步电击复制后测定ＳＮＲＴ和房室结传导功能。     

射频迷宫术治疗心房颤动

为探讨射频迷宫术治疗心房颤动（简称房颤）的效果，比较１８例二尖瓣置换术中加做迷宫术（治疗组）和１８例单纯二尖瓣置换术（对照组）的慢性房颤治疗结果。治疗组前２例采用切割冷冻法完成迷宫术，后１６例采用改良的射频法。其中１６例（８８．９％）于术后当日至２２日转为窦性心律。切割冷冻法有１例因术后出血给予大量输血引起急性肾功能衰竭而死亡，余未见明显并发症。随访２～１２个月未见房颤复发。对照组中５例曾于术后恢复短暂窦性心律，但出院时又转为房颤。结果表明迷宫术能有效地治愈慢性房颤，改良的射频法比切割冷冻法操作简单，无出血并发症，心房肌损伤小。提示心房的大小、ｆ波的粗细、心功能的好坏等是影响迷宫术成功的因素     

风湿性二尖瓣狭窄伴心房纤颤患者在经皮球囊二尖瓣成形术后的心房纤颤电复律治疗(附538例报告)

探讨风湿性二尖瓣狭窄伴心房纤颤（房颤）球囊二尖瓣成形术（PBMV）后房颤复律治疗的方法及复律后影响维持窦性心律的因素。方法：PBMV术后4～6周仍不能转复为窦性心律的房颤患者538例进行电复律治疗，转复后随诊3～6个月，动态观察房颤复发情况。结果：538例行体表电复律者，恢复窦性心律。     

风心病房颤患者心房纤维化程度与房颤复律后窦性心律维持的关系

41例风湿性心脏病（风心病）二尖瓣病变患者（房颤29例，窦性心律12例）行心脏外科手术时取右心耳组织，用V—G染色法和VIDAS-21图像分析系统测量其心房组织胶原容积分数（CVF）。结果房颤患者的心房组织CVF明显高于窦性心律患者（P〈0．05）。房颤患者均转复为窦性心律，随访12个月后，维持窦性心律20例，转为房颤9例；房颤复发患者的心房组织CVF、房颤持续时间和左房内径均明显大于维持窦性心律患者（P〈0．05）。提示心房纤维化程度可能是影响风心病房颤患者复律后窦性心律维持的因素之一。     

二尖瓣替换术后房颤转复为窦性心律的临床分析

在风湿性心脏病二尖瓣病变中，慢性心房纤颤（简称房颤）是一种常见的并发症。房颤会给病人带来许多问题，如左房血栓形成、体循环栓塞、心房扩大和心输出量减少等并发症，从而增加了死亡率，影响了生活质量的提高。因此，人们一直采用各种方法使之转复为窦性心律。风湿性心脏病二尖瓣替换术同时给予电除颤，可使部分病人恢复窦性心律。本组对89例患风湿性心脏病二尖瓣替换术后房颤转复情况进行了回顾性研究，根据手术后病人出院时的心律情况将病人分为两组，A组为出院时仍为房颤者，B组为出院时为窦性心律者。分析结果表明，风湿性心脏病二尖瓣替换术后，解除了机械梗阻，部分术前伴有房颤的病人术后可以转复为窦性心律，但能维持至1个月以上者较少，仅占手术病人的15．7％。病人手术时的年龄、房颤病史长短及左房径对房颤转复情况有显著影响，且可以预见其短期效果，根据本组病例分析的结果表明，年龄小于40岁、房颤病史不超过一年、左房径小于55mm的病人，窦性心律可维持在1个月以上。     

改良迷宫Ⅲ式手术治疗心房纤颤

对伴心房纤颤的１１例风湿性心脏病和１例左心房粘液瘤患者采用改良迷宫Ⅲ式手术，前者同时行二尖瓣替换，后者同时行粘液瘤摘除；５例合并左房血栓者予以清除。结果：１例重度二尖瓣狭窄、小左室及左室纤维化患者术后死于低心排综合征；９例于术后３８小时至７３天恢复窦性心律（恢复前均为结性心律），以３￣１８个月随访、心律均正常；１例复跳后即为窦性心律，１例术后为结性心律。认为此种术式可缩短主动脉阻断时间，对心房电位     

心房颤动时心室率与房室结电生理性质的关系

影响心房颤动（房颤）时心室率的因素有心房率、房室结的传导性质、隐匿传导等。本研究旨在探讨房室结的传导性质,即房室结前传文氏点和有效不应期与房颤时心室率的关系。资料与方法：９例阵发性房颤患者接受心内电生理检查,男７例,女２例,年龄３８～７２岁。７例行导管射频改良房室结慢径治疗。电生理检查前停用抗心律失常药物５个半衰期以上,窦性心律下测房室结前传文氏点（ａＷＣＬ）和前传有效不应期（ａＥＲＰ）。房颤时的心室率是在患者清醒、休息时测量的,最快心室率（ＭａＶＲ）＝６００００／最短Ｒ－Ｒ间期（ｍｓ）;最慢心…     

经食管心房调搏术的临床应用

预激综合征预激综合征常引起多种快速性心律失常，对其进行食管法心脏电生理检查具有重要临床价值。一、隐性（潜在性）预激综合征当部分旁道不应期偏长或位于离窦房结较远时，窦性心律无法显示出预激图形、在食管心脏电生理检查时，通过心房刺激频率的增快或期前刺激偶联间期的缩短，使激动落入房室结不应期中，     

右侧迷宫术治疗先天性心脏病合并心房颤动的初步经验

目的评价采用右侧迷宫术治疗先天性心脏病合并心房颤动(房颤)的近、远期疗效。方法26例先天性心脏病(21例继发孔型房间隔缺损,5例Ebstein畸形)合并房颤患者,根据心内直视矫正术中有无同期接受右侧迷宫术分成迷宫组(n=15)和对照组(n=11)。房颤病程1~8年,19例为慢性房颤,7例为阵发性房颤。所有患者均有明显的右心房扩大,但均排除二尖瓣病变。结果迷宫组有12例患者于心脏复跳后转为窦性心律,2例术后出现一过性的交界区心律,1例术后仍有间歇性房颤,经口服胺碘酮2周后恢复窦性心律;出院时14例(93·3%)维持窦性心律。对照组有1例患者在心脏复跳后转为窦性心律,另1例应用胺碘酮于术后24h内转为窦性心律,但出院时仅1例维持窦性心律;9例(81·8%)仍维持房颤心律。术后平均随访27·5个月。迷宫组93·3%患者维持窦性心律;对照组81·8%患者维持房颤心律并需口服抗凝药物,其中6例(54·5%)为持续性,包括1例因合并高度房室阻滞安装了永久性心脏起搏器;另2例(18·2%)维持交界区心律;超声心动图检查显示,迷宫组术后1个月三尖瓣和二尖瓣血流频谱呈现E、A双峰;术后1年其左、右心房每搏排出量占心排出量比率分别是术前的(271·44±30·55)%和(363·50±44·22)%,73·3%患者心功能恢复Ⅰ级(NYHA分级),而对照组45·4%心功能恢复Ⅰ级。结论同期施行右侧迷宫术和心内畸形矫正术,能有效地治疗先天性心脏病合并的房颤,并能改善术后左、右心房的传输功能,近、远期疗效较为满意。     

心脏不停跳下改良迷宫术加左房折叠治疗房颤瓣膜病的临床观察

目的 评价心脏不停跳心内直视下行二尖瓣置换术与改良迷宫术同时行左房折叠术（LAP）的安全性和疗效.方法 对33例二尖瓣病变合并巨大左心房与慢性心房颤动患者,在体外循环心脏不停跳下行二尖瓣置换术的同时,采用射频消融方式实施改良迷宫术,加行左房折叠术.结果 全组无院内死亡,术后心房颤动全部消失,无房室传导阻滞、出血.随访12～36个月,其中30例维持窦性心律,心房颤动复发3例,转复率为90.9%.复查心脏超声心动图提示,左心房、左心室较术前明显缩小,心功能明显改善.无血栓复发.结论 应用心脏不停跳下改良迷宫术加左房折叠在二尖瓣病变合并巨大左心房瓣膜置换术中治疗慢性房颤,能有效消除房颤并长期维持窦律,改善左心房、室主动收缩功能,并发症少,安全简便且疗效确切,值得推广应用.     

Sinus node function after cardiac surgery: is impairment specific for the maze procedure?

BACKGROUND: Maze surgery is a final solution for intractable atrial fibrillation (AF), but an adverse effect on postoperative sinus node function has been reported. Whether this also applies to other types of cardiac surgery is unclear. METHODS: We assessed postoperative rhythm by means of repeated exercise tolerance testing, ambulatory electrocardiography, and non-invasive testing of autonomic function between 1 and 12 months after four types of cardiac surgery. Fourteen patients without structural cardiac disease and medically refractory AF underwent the maze III procedure, 11 patients with mitral valve disease and preoperative AF underwent valvar surgery combined with a (simplified) maze III procedure, and 8 patients with mitral valve disease in sinus rhythm (SR) underwent isolated valvar surgery. The control group consisted of eight patients with sinus rhythm who underwent coronary artery bypass surgery (CABG). RESULTS: One month after surgery, the chronotropic response to exercise was depressed, mean heart rate was high, and heart rate variability (HRV) was low, especially after maze III, combined surgery, and isolated valvar surgery. Twelve months after surgery, moderate improvements were observed. After CABG, considerably fewer abnormalities were observed, and HRV parameters recovered to a large extent. Non-invasive testing of autonomic function indicated disturbed vagal modulation of heart rate in all three groups with atrial incision. CONCLUSION: Thus, attenuation of HRV and vagal modulation of sinus node function are not confined to maze surgery but also apply to isolated mitral valve surgery. Atrial incision therefore appears to be crucial and presumably produces autonomic nervous damage followed by partial reinnervation. Nevertheless, cardiac surgery in general seems initially to impair sinus node function with partial recovery in the consecutive 12 months.     

Preoperative atrial size predicts the success of radiofrequency maze procedure for permanent atrial fibrillation in patients undergoing concomitant valvular surgery

BACKGROUND: The radiofrequency (RF) maze procedure can effectively restore sinus rhythm and atrial transport function in the majority of patients with permanent atrial fibrillation (AF) and mitral valve disease. No previous study has described a cutoff value of preoperative atrial size determined by the discriminant analysis in predicting the success of sinus conversion by the RF maze procedure for permanent AF in patients with mitral valve disease. METHODS AND RESULTS: This study included 81 patients with permanent AF and mitral valve disease who underwent the RF maze IV procedure while undergoing concomitant valvular operations. There was one surgical death (1.2%). Another patient died of acute necrotizing pancreatitis 13 months later. Two patients (2.5%) developed sick sinus syndrome and received transvenous permanent pacemaker implantation. In the remaining 77 patients, there were 38 men and 39 women, with a mean (+/- SD) age of 51 +/- 11 years. At a mean follow-up time of 38 months, 65 patients (84.4%) had persistent sinus conversion that had been accomplished by the RF maze procedure (group 1), and 12 patients (15.6%) did not regain sinus rhythm (group 2). We evaluated the preoperative variables between the two groups. Univariate analysis demonstrated that the preoperative left atrial area and the left atrial diameter of group 1 patients were significantly smaller than those of group 2 patients. Group 1 had significantly fewer patients associated with tricuspid valve disease than did group 2. By multiple stepwise logistic regression analysis, only the preoperative left atrial area was an independent determinant of sinus conversion by the RF maze procedure (odds ratio, 0.961; 95% confidence interval, 0.935 to 0.988; p < 0.005). Linear discriminant analysis demonstrated that the sensitivity and specificity of the cutoff value of 56.25 cm(2) of the preoperative left atrial area in predicting the sinus conversion by the RF maze procedure were 50.0% and 86.2%, respectively, and the positive and negative predictive values were 40.0% and 90.3%, respectively. CONCLUSION: The preoperative left atrial area is an independent determinant of sinus conversion by the RF maze procedure for patients with permanent AF and mitral valve disease.     

Long-term results of the maze procedure on left ventricular function for persistent atrial fibrillation associated with mitral valve disease

Although the maze procedure is often performed as a surgical treatment for atrial fibrillation (AF) combined with mitral valve surgery, the long-term efficacy of the maze procedure concerning cardiac function has not been determined. The aim of this study was to assess long-term results of the maze procedure for left ventricular function in patients with persistent AF associated with mitral valve disease. We analyzed 38 patients who underwent the maze procedure for persistent AF and mitral valve surgery. The cardiothoracic ratio on chest X-ray and the left atrial dimension, left ventricular end-diastolic dimension, left ventricular end-systolic dimension and left ventricular ejection fraction on transthoracic echocardiography were evaluated before and 6 years after the maze procedure. Twenty-two patients maintained sinus rhythm (SR group) and 16 patients had recurrence of permanent AF (AF group) after the maze procedure. Preoperative cardiac function and the methods of mitral surgery were similar between the two groups. At the latest follow-up, left ventricular function tended to be better in the SR group than in the AF group. Cardiovascular events occurred more often in the AF group during follow-up (50 vs. 18%, p < 0.05). This retrospective study revealed that maintaining the sinus rhythm after the maze procedure for patients who underwent mitral valve surgery might be important for preserving better long-term left ventricular function and result in fewer cardiovascular events.     

Atrial pacemaker complex preserved radiofrequency maze procedure reducing the incidence of sick sinus syndrome in patients with atrial fibrillation

BACKGROUND: The Cox maze III procedure can effectively restore sinus rhythm in most patients with permanent atrial fibrillation (AF). However, previous studies have shown that the maze procedure results in significant sinus node dysfunction, and, consequently, a considerable number of patients required postoperative pacemaker implantation. HYPOTHESIS: This study investigates the hypothesis that the modification of the Cox III maze procedure, to avoid injuring the sinus node and the atrial physiologic pacemaker complex, will reduce the incidence of sick sinus syndrome following surgery. METHODS AND RESULTS: This study investigated 71 patients with permanent AF and mitral valve disease who were undergoing concomitant open-heart surgery. Most atrial incisions in the Cox maze III procedure were replaced with radiofrequency ablation, and the intercaval counterablation was moved posterolaterally to avoid injury to the sinus node and atrial pacemaker complex. At a mean (+/- SD) follow-up time of 46.5 +/- 24 months, 59 patients (83.1%) regained sinus rhythm without receiving antiarrhythmic drug therapy or undergoing electrical cardioversion. The transmitral atrial wave was observed in 44 patients (62%), and the transtricuspid atrial wave was also observed in 53 patients (74.6%). Late sinus node dysfunction developed in only two patients (2.8%), who received permanent pacemaker implantation. CONCLUSION: This modified radiofrequency maze procedure produces few patients with sick sinus syndrome and effectively restores sinus rhythm and atrial transport function in most patients with permanent AF undergoing concomitant open-heart surgery.     

二尖瓣置换加Cox手术对心房颤动转复、心电活动及心功能的影响

目的探讨二尖瓣置换加迷宫手术（ＭＶＲ－ＭＰ）对二尖瓣病变伴心房颤动（房颤）患者的心律转复作用及对心电活动和心功能的影响。方法应用心电图、动态心电图、运动负荷心电图及超声心动图观察２８例ＭＶＲ－ＭＰ患者手术前后心电活动、心功能及运动耐量变化,并与９８例单纯二尖瓣置换术（ＭＶＲ）患者的相应指标比较。术前两组均为二尖瓣病变伴长期房颤患者。结果在随访中ＭＶＲ－ＭＰ组和ＭＶＲ组恢复并维持窦性心律分别为９２．９％和２．０％（Ｐ＜０．０１）;ＭＶＲ－ＭＰ组心律转复后Ｐ波矮小、时限较长,动态及运动心电图未见严重心律失常;两组手术后心功能改善级别分别为２．３７±０．６９和１．４３±０．６７（Ｐ＜０．０１）,所能完成的做功量分别为１０．６７±１．５６和５．２８±０．５９ＭＥＴｓ（Ｐ＜０．０１）,左室射血分数分别为（６５．０±９．２）％及（５１．４±１０．４）％（Ｐ＜０．０１）。结论ＭＶＲ－ＭＰ可使二尖瓣病变伴长期房颤患者恢复窦性心律,可显著提高运动耐量、改善心功能。     

Outcomes and predictors of success of a radiofrequency- or cryothermy-simplified left-sided maze procedure in patients undergoing mitral valve surgery

BACKGROUND AND AIM OF THE STUDY: Restoration of sinus rhythm with a maze procedure after concomitant mitral valve (MV) surgery has been shown to reduce the rate of stroke and improve cardiac function and quality of life compared to MV surgery alone. Unlike the classical Cox-Maze III operation, a simplified left-sided maze procedure can be performed without any significant increase in operative complexity. METHODS: Outcomes were compared retrospectively between radiofrequency (RF) and cryothermy as an energy source and analyzed predictors of outcome in 73 consecutive patients undergoing MV surgery with a concomitant simplified left-sided maze procedure. Clinical characteristics as well as rhythm and complication rate at follow up were assessed by review of medical records and patient and physician interview. RESULTS: There were no complications associated directly with the maze procedure. At an average follow up of 342 days, 69% of patients were in normal sinus rhythm. Of the remainder, 30% had recurrent atrial fibrillation (AF) and 1% atrial flutter. In addition, 7% of patients required cardioversion and 14% required anti-arrhythmic therapy to maintain sinus rhythm. Patients with recurrent AF were more likely to have an enlarged right atrium or Carpentier Type IIIa mitral regurgitation on preoperative echocardiography, and more likely to have undergone concomitant aortic or tricuspid valve surgery. There was no difference in outcome between RF and cryothermy as an energy source in unadjusted or adjusted analyses. CONCLUSION: The results of the study helped to establish RF- or cryothermy-simplified left-sided maze procedure as being efficacious and without associated complications in patients having MV surgery and a history of AF. Further investigations are warranted to better define the clinical predictors of recurrent AF to improve patient selection and potentially to modify current maze techniques.     

Carto系统指导下左房电解剖隔离治疗心房颤动

对 3例阵发性和 2例持续性心房颤动 (简称房颤 )进行左房线性消融。采用Carto标测构建左房三维电解剖图 ,并标识出肺静脉和二尖瓣环 ,在距肺静脉口外 1～ 2cm处进行绕左右肺静脉和左房峡部的环状线性隔离消融 ,后 2例增加一条左房后壁的消融线 ,消融的终点为 :①环状隔离区内的双极电压≤ 0 .1mV ,②跨消融线相邻两点的传导时间延迟 30ms以上。结果 :整个手术时间为 2 2 9± 18min ,X线曝光时间为 2 5± 3min。消融线环绕的左房面积占整个被标测左房面积的 36 %± 3.2 % ,消融线环绕的左房区域内的电压较消融前明显降低 ,绕消融线以外的部分心房组织的电压亦降低。 3例阵发性房颤有 2例在术后 1～ 2天有房颤发作 ,1例持续性房颤于术后 1周转为持续性心房扑动 ,3周时电复律为窦性心律 ,术中和术后随访期内无并发症发生 ,5例在 5 .3± 1.85个月的随访中无有症状的房颤发作。结论 :左房线性电隔离治疗房颤是安全有效的方法。     

左心房内径大于60 mm心房颤动患者行改良迷宫射频消融术的疗效

目的 评价改良迷宫双极射频消融术在左心房内径＞60 mm患者中治疗心房颤动（房颤）的临床疗效.方法 对同一术者在瓣膜置换同期行改良迷宫双极射频消融术并随访9个月以上的患者106例,按左心房内径大小分为两组：观察组左心房内径＞60 mm（27例）,对照组左心房内径＜60 mm（79例）.对所有患者进行随访分析,比较两组手术疗效.结果 两组手术并发症发生率比较,差异无统计学意义（P＞0.05）.观察组术后当日恢复窦性心律23例,心房扑动1例,房颤2例,交界性心律1例,房颤消除率为88.9％.出院时窦性心律22例,心房扑动2例,房颤消除率为88.9％.术后9～12个月窦性心律21例,房颤6例,房颤消除率为77.8％.对照组术后当日恢复窦性心律71例,心房扑动1例,房颤5例,交界性心律2例,房颤消除率为91.1％.术后9～12个月窦性心律70例,房颤9例,房颤消除率为88.6％.随访至术后9～12个月观察组房颤消除率与对照组相比,差异无统计学意义[77.8％（21/27）vs.88.6％（70/79）,P＞0.05].结论 左心房内径＞60 mm的患者行改良迷宫双极射频消融术治疗房颤安全、简便,仍可获得较好的近期疗效.对左心房显著增大的患者,增加左心房后壁消融线路,术后注意避免过高的中心静脉压、维持钾离子浓度在正常高值,有利于提高手术疗效.     

Effect of maze procedure in patients with atrial fibrillation undergoing valve replacement

BACKGROUND AND AIMS OF THE STUDY: The study aim was to elucidate the impact of the maze procedure on late outcome after valve replacement. METHODS: Between 1992 and 2000, 241 patients underwent the maze procedure combined with valve replacement. Patients were allocated to three groups: aortic valve replacement (AVR/maze, n = 16); mitral valve replacement (MVR/maze, n = 148); and combined aortic and mitral valve replacement (DVR/maze, n = 77). RESULTS: Mean follow up was 3.9 +/- 2.3 years. Hospital mortality was 0% in the AVR/maze group, 2.0% (n = 3) in the MVR/maze group, and 3.9% (n = 3) in the DVR/maze group. Elimination of atrial fibrillation (AF) at discharge was achieved in 74.3-75.9% of cases. Freedom from recurrence of AF/atrial flutter was 71.2% in the AVR/maze group, 68.2% in the MVR/maze group, and 64.0% in the DVR/maze group at five-year follow up. By multivariate analysis, risk factors for recurrence of AF/atrial flutter included preoperative enlarged left atrial dimension >70 mm, decreased postoperative fractional shortening <30%, and absence of postoperative left atrial contraction. Freedom from stroke was 93.6% in patients who achieved regular rhythm (normal sinus rhythm or junctional rhythm), and 80.9% in those with recurrence of AF at five years after surgery (p = 0.03). CONCLUSION: The combined maze procedure and valve replacement is safe and effective in selected patients. Restoration of regular rhythm significantly reduced the incidence of late stroke.