风湿性二尖瓣病变伴房颤的外科治疗

目的　回顾性分析二尖瓣置换术 (MVR)同期Cox迷宫III型手术治疗风湿性二尖瓣病变伴房颤 (Af)的效果。方法　 1994年 3月至 1999年 2月间采用上述方法治疗病人 5 4例。其中男 30例 ,女2 4例 ;年龄 (45 32± 6 37)岁。风湿病史 15年以上 ,房颤病史 2～ 7年。术前心功能III～IV级。均行MVR +Cox迷宫III型手术 ,三尖瓣中度以上关闭不全者附加三尖瓣成形术 (TVP) 34例 ,清除左房血栓 4例。结果　本组无手术死亡 ,主动脉阻断和体外循环时间分别为 (75± 2 0 )min和 (12 4± 36 )min。复跳后出血 2例 ,止血治疗均有效。随访 2 4～ 5 0个月 ,术后Af均消失。有 1例为结性心律 ;窦性心律者占98 11% (5 2 / 5 3例 ) ,最大体力活动时均无窦性迟钝现象 ,无需安装起搏器 ,均有心房收缩功能 ;术后 1年心功能Ⅰ级者占 98 11% (5 2 / 5 3例 ) ,II级 1 88% (1/ 5 3例 ) ;无抗凝严重出血 ,亦无血栓栓塞并发症。术后早期死亡 1例 (1 85 % ) ,术后 1周死于多脏器功能衰竭。术后第 3年晚期死亡 1例 (1 88% )。结论　MVR同期行迷宫III型手术治疗风湿性二尖瓣病变伴房颤安全有效 ,能消除Af,恢复心房收缩功能 ,可避免术后血栓栓塞并发症 ,远期疗效确切。     

Concomitant ablation of atrial fibrillation in rheumatic mitral valve surgery

Objective

Efficacy of atrial fibrillation ablation in rheumatic mitral valve disease has been regarded inferior to that in nonrheumatic diseases. This study aimed to evaluate net clinical benefits by the addition of concomitant atrial fibrillation ablation in rheumatic mitral valve surgery.

Results of endocardial radiofrequency ablation of atrial fibrillation during mitral valve surgery

AIM: The aim of the study is to evaluate the efficacy of thermocontrolled endocardial radiofrequency (RF) ablation for the patients with mitral valve disorder and associated chronic atrial fibrillation during mitral valve replacement operation. METHODS: Between February 2002 and January 2004, 43 patients with mitral valve disease and associated chronic atrial fibrillation underwent mitral valve replacement and thermocontrolled endocardial RF ablation with Cobra RF system flexible probe at Gulhane Military Academy of Medicine, Department of Cardiovascular Surgery. Eighteen of the patients (41.8%) were males, while the remaining 25 (58.2%) were females. The average age of the patients was 44+/-14.21 (18-66) years. Functional capacity of the patients was class II in 15 (34. 9%), class III in 24 (55.8%), class IV in 4 (9.3%) according to the NYHA classification. At the preoperative period all of the patients were evaluated routinely by twelve-lead ECG, chest film and transthoracic echocardiography (TTE). For the patients over 40 years of age, we performed additional coronary angiography to delineate any coronary lesions. The patients were evaluated at months 1, 3, 6 and annually by twelve-lead ECG, TTE and holter monitoring after discharge. RESULTS: There were not any complications related to the performed technique. No operative and hospital mortality were recorded. At the follow-up period for 35 of 43 patients (81.4%) sinus rhythm was restored. The mean follow-up time was 24.3+/-11.2 (12-35) months. CONCLUSION: Endocardial RF ablation especially during mitral valve surgery is a simple technique to be performed. Early and midterm results of the cohort are satisfying.     

慢性心房颤动合并二尖瓣病的迷宫手术

作者自１９９５年至１９９６年１０月共作２０例慢性心房颤动的迷宫手术和二尖瓣替换或修复术。术吣外膜标测结果左房多为扑（１４／２０）,右房则往往是颤动（１８／２０）。无早期死亡。２０例随访３个月以上,其中１４例随访在１年以上,经电生理检查均为窦性心率,房室同步活动,不能诱发房颤;经多普勒超声心动图检查,左和右心房输出功能正常。晚期死亡１例,手术后４年半月死于急性坏死性肝炎,对迷宫手术作了一些改进,术后     

Cryomaze procedure simultaneously with surgery of rheumatic mitral valve disease for permanent atrial fibrillation

Objective  

Atrial Fibrillation is a well known phenomenon in patients suffering from Rheumatic Mitral Valve Disease. Cox Maze procedure is an effective way to treat Atrial Fibrillation in such cases. Cryoablation has been substituted for cut and sew lines of Cox Maze operation from last several years so as to decrease the invasiveness. However, there has been no study from India indicating its efficacy in rheumatic patients. Therefore we evaluated efficacy of Cryomaze procedure in patients undergoing surgery for Rheumatic Mitral Valve disease.     

Microwave ablation of atrial fibrillation during mitral valve operations

Although the Cox-Maze III procedure cures atrial fibrillation in the majority of patients, it has not had widespread application. Development of new operations that use alternate energy sources and different lesion sets have caused resurgence in the surgical treatment of atrial fibrillation. Microwave creates lines of conduction block by thermal damage and subsequent scar formation. We describe a rapid and simple technique for microwave ablation of atrial fibrillation in patients having mitral valve operations.     

Radiofrequency ablation of atrial fibrillation during mitral valve surgery

Twenty-three patients underwent endocardial radiofrequency ablation of atrial fibrillation (AF) during mitral valve procedures with a previously described left atrial lesion pattern. A temperature-controlled 7-coil surgical probe delivered 60-second lesions at 80 degrees C. The left atrial appendage was oversewn after ablation. Ages ranged from 28 to 88 years. Nineteen patients had chronic AF that was present for over 1 year in 74%; 12 patients had rheumatic mitral stenosis. Mean left atrial diameter was 5.4 +/- 0.7 cm. There was 1 operative death unrelated to the ablation, and no strokes or ablation-related complications were observed. At mean follow-up of 32.5 weeks, 86% of the 22 survivors were in sinus rhythm. All 18 patients with left atrial diameter <6 cm are in sinus rhythm. All postoperative atrial flutter was transient, and no patients required subsequent transcatheter ablation. This lesion pattern is safe and effective when applied in the method described here. It appears to be a reasonable alternative to the complete Maze 3 lesion pattern in patients with mitral valve disease.     

Barriers to atrial fibrillation ablation during mitral valve surgery

BackgroundNearly 40% of patients with atrial fibrillation (AF) undergoing mitral valve surgery do not receive concomitant ablation despite societal guidelines. We assessed barriers to implementation of this evidence-based practice through a survey of cardiac surgeons in 2 statewide quality collaboratives.MethodsAdult cardiac surgeons across 2 statewide collaboratives were surveyed on their knowledge and practice regarding AF ablation. Questions concerning experience, clinical practice, case scenarios, and barriers to implementation were included.ResultsAmong 66 respondents (66 of 135; 48.9%), the majority reported “very comfortable/frequently use” cryoablation (53 of 66; 80.3%) and radiofrequency (55 of 66; 83.3%). Only 12.1% (8/66) were not aware of the recommendations. Approximately one-half of the respondents reported learning AF ablation in fellowship (50.0%; 33 of 66) or attending courses (47.0%; 31 of 66). Responses to clinical scenarios demonstrated wide variability in practice patterns. One-half of the respondents reported no barriers; others cited increased cross-clamp time, excessive patient risk, and arrhythmia incidence as obstacles. Desired interventions included cardiology/electrophysiology support, protocols, pacemaker rate information, and education in the form of site visits, videos and proctors.ConclusionsKnowledge of evidence-based recommendations and practice patterns vary widely. These data identify several barriers to implementation of concomitant AF ablation and suggest specific interventions (mentorship/support, protocols, research, and education) to overcome these barriers.     

Combined atrial fibrillation and mitral valve surgery using radiofrequency technology

Recently, intraoperative radiofrequency ablation of the left atrium combined with mitral valve surgery has become widely used. In our center, 30 patients underwent this combined procedure; median sternotomy was used in 16 patients, and port access was used in 14 patients. At hospital discharge, 18 patients (60%) were no longer in atrial fibrillation, and at 6 months, 19 patients (65%) remained in sinus rhythm. All sinus rhythm patients had a well-defined transmitral A wave detectable by echocardiography. One patient sustained a major stroke. Two patients required pacemaker implantation. Such encouraging preliminary results have triggered worldwide interest in the percutaneous and surgical treatment of atrial fibrillation. However, the excellent long-term results with the classic Cox-Maze III operation have not yet been achieved with these newer approaches. Further basic and clinical research is required before a predictable simple and safe technique can be introduced as a new standard for the surgical treatment of atrial fibrillation in patients with or without structural heart disease.     

Long-term results of the Cox-Maze III procedure for persistent atrial fibrillation associated with rheumatic mitral valve disease: 10-year experience.

OBJECTIVE: We evaluated the long-term results of the Cox-Maze III procedure (CM-III) for persistent atrial fibrillation (AF) associated with rheumatic mitral valve (MV) disease. METHODS: We analyzed 127 patients who underwent the CM-III combined with a rheumatic MV procedure between 1994 and 2004. In-hospital mortalities were excluded from the study. RESULTS: There were 10 late deaths and the mean follow-up duration was 7.1+/-2.8 years (range, 13 months to 11.5 years). Normal sinus rhythm was restored in 88.2% (112/127) after the CM-III. Right atrial contractility was demonstrable in 100% (112/112) and left atrial contractility in 68.8% (77/112) of the patients restored to sinus rhythm. Fifteen patients never regained sinus rhythm after the CM-III (AF treatment failure). Permanent pacemakers were implanted in 4.7% (6/127) of the patients during the follow-up. Late recurrence of AF developed in 34 of 112 patients at 44+/-27 months postoperatively, and sinus rhythm was restored in 29 of 34 patients by administration of an antiarrhythmic medication. Independent risk factors for late AF recurrence were longer duration of AF (>60 months) (odds ratio (OR)=2.758, p=0.025), increased left atrial size (OR=1.113, p=0.004). Freedom from AF recurrence was 93% at 1-year, 82% at 3 years, 71% at 5 years, and 63% at 7 years. Risk factors for AF treatment failure were longer duration of AF (>60 months) (p<0.001) and increased patient age (p=0.030). A higher prevalence of significant late tricuspid regurgitation was observed in patients with AF treatment failure and those with late AF recurrence. CONCLUSIONS: The CM-III for persistent AF associated with rheumatic MV disease demonstrated a progressively decreased cure rate during the follow-up period. Early surgical therapy, aggressive left atrial reduction, and correction of tricuspid regurgitation at the time of surgery may increase the long-term success rate.     

Outcome of the modified maze procedure for atrial fibrillation combined with rheumatic mitral valve disease using cryoablation

This study evaluated the mid-term results of the modified maze procedure using cryoablation for treating atrial fibrillation associated with rheumatic mitral valve disease. Between March 2000 and February 2004, 177 consecutive patients underwent the modified maze procedure using cryoablation concomitant with mitral valve surgery, were divided into the modified Cox-Maze III (group CM, n=88), modified Kosakai-Maze (group KM, n=63) and left atrial maze (group LA, n=26) procedures. Postoperative and follow-up results were analyzed and compared between the groups, with a mean follow-up time of 22.4+/-15.1 months. There were three hospital deaths (1.7%). The operative time was significantly longer in the group CM than the KM or LA groups, respectively. One late death developed in the CM group. At last follow-up, 139 patients had sinus rhythm (79.9%), which was regained in 67 CM (77.9%), 50 KM (80.7%) and 22 (84.6%) LA group (P=0.743) patients. Freedom from stroke at 4 years was 84.6% in the CM, 95.0% in the KM, and 92.9% in the LA (P=0.916) groups. There were no significant differences in the sinus conversion or stroke rate between patients with the left atrial appendage preserved and those with it excised or obliterated. The modified maze procedure using cryoablation is safe and effective, with an acceptable sinus conversion rate and clinical improvement.     

Pulmonary vein isolation for chronic atrial fibrillation associated with mitral valve disease: the midterm results.

OBJECTIVE: The Cox Maze procedure is widely performed for the surgical treatment of atrial fibrillation. However it requires numerous incision lines and therefore is a time-consuming operation. We report a simplified operation for chronic atrial fibrillation associated with mitral valve disease. METHODS: Pulmonary vein isolation procedure was performed on atrial fibrillation associated with mitral valve disease in thirteen patients. This simple procedure consisted of isolation of the four pulmonary veins only. Combined mitral valve surgery involved mitral valve plasty, mitral valve replacement with or without aortic valve replacement and tricuspid annuloplasty. RESULTS: Eleven patients returned to sinus rhythm (84.6%). Mean follow-up time is 32.7 +/- 11.7 months. Three patients required a DDD pacemaker implant for sick sinus syndrome but two out of these three resumed sinus rhythm most of the time recently. Left atrial contraction was detected in eight cases by trans-esophageal echo. One patient died of liver failure two months postoperatively. Eight patients had no blood transfusion. Twelve patients are classified as New York Heart Association class I. CONCLUSION: Compared with the Maze procedure, this operation was less invasive and preserved the atrial appendage and was thought to have a normal level of secretion of atrial natriuretic peptide. This study suggests that the pulmonary vein isolation procedure may be an effective and simple maneuver for atrial fibrillation associated with mitral valvular disease.