改进迷宫手术治疗慢性心房纤颤

目的:为减少外科治疗慢性心房纤颤并发症,对COX迷宫手术进行改进—增加冷冻代替部分手术切口,并应用于临床。方法:采用改进迷宫手术治疗风湿性心脏瓣膜病合并心房纤颤12例,同期行二尖瓣替换术12例,三法瓣环绕6例,左房血栓清除5例。结果:本组无手术死亡。无术后近期并发症。术后12例均恢复窦性心律,术后3个月窦性心律维持率100％(12/12),术后1年窦性心律维持率91％(11/12)。结论:改进迷宫手术治疗慢性心房纤颤手术效果确切,可有效防止并发症并简化手术操作。     

改良迷宫手术治疗风湿性心脏病所致心房纤颤

为减少外科治疗风湿性心脏病所致心房纤颤的并发症,对美国Cox设计的心房纤颤迷宫手术进行改良,并应用于临床。1995年9月至1997年9月采用二尖瓣置换加改良迷宫术治疗风湿性心脏病合并心房纤颤4例。本组病人无住院死亡,术后平静稳,无近期并发症。4例病人心脏复跳后均恢复窦性心律,术后3个月窦性心律维持率为100％(4/4),术后半年维持率为75.0％(3/4),术后1年维持率为75.0％(3/4),术后2年维持率为100％(1/1)。作者认为,改良迷宫手术对风湿性心脏病所致心房纤颤效果确实,精简手术操作,有效地防止严重并发症出现。     

心房纤维颤动的外科治疗

３例采用改良迷宫术探索进行心房纤颤外科治疗获成功。病人术前均为风湿性心脏病，心功能Ⅲ－Ⅳ级，心房纤颤病史３－１０年，左房直径５２－５８ｍｍ，心胸比率０．６４－０．７０。在进行改良迷宫术的同时，２例行二尖瓣替换，１例行双瓣替换及三尖瓣环缩。术后２例自动复跳，１例电击除颤复跳。３例术后早期均为窦性心律。２例术后３年恢复良好，正常心律，心功能Ｉ级；１例术后３个月死于脑血管意外。文中重点介绍了手术方法，提     

射频消融迷宫治疗心房纤颤

作者采用射频消融迷宫术治疗心房纤颤２０例,其中１９例合并风湿性二尖瓣病的患者,同时行瓣膜替换术,１例合并房间隔缺损患者进行修得。射频消融的路线采用小板井嘉夫的手术径路。术后１６例恢复窦性心律,占８０％,未恢复窦性心律的４例,２例为房颤,１例为房扑,另１例为结性心律。     

射频消融迷宫术治疗心房纤颤

作者采用射频消融迷宫术治疗心房纤颤２０例，其中１９例合并风湿性二尖瓣病的患者，同时行瓣膜替换术，１例合并房间隔缺损患者进行修复。射频消融的路线采用小板井嘉夫的手术径路。术后１６例恢复窦性心律，占８０％，未恢复窦性心律的４例，２例为房颤，１例为房扑，另１例为结性心律。射频消融迷宫术耗时短，仅增加钳闭主动脉时间平均２０．５分钟，无术后出血的潜在危险。但术后７～１０天之内，有１８例出现过房颤、房扑、房速等室上性心律失常，可能由于射频消融不均匀，干扰心房的心电活动所致。     

房顶及房间隔联合切口置换二尖瓣

目的报告１９９７年３～１２月用房顶及房间隔联合切口为１４例患者行二尖瓣置换术及术后心律随访结果。方法常规体外循环及心肌保护。首先做右心房斜切口，继而行房间隔切口，两切口汇于隔顶后向前切开左房顶３～４ｃｍ。带扣线置于左房顶切口下缘及房间隔作牵引，行二尖瓣置换。随访时复查心电图。结果无左房顶切口出血的病例，除１例术后死于急性肾功能衰竭和呼吸衰竭外，１３例患者恢复出院。随访结果：术前为窦性心律的３例患者术后仍为窦性心律，而术前为心房纤颤的１０例患者中除１例术后恢复窦性心律外，余９例仍为心房纤颤。结论在常规左心房直切口或经房间隔切口显露困难时，房顶及房间隔联合切口是一种较好的选择     

全胸腔镜改良迷宫手术治疗心房纤颤患者围术期护理

目的总结全胸腔镜改良迷宫术治疗心房纤颤患者围术期护理经验。方法对17例接受全胸腔镜改良迷宫手术的心房纤颤患者的围手术期护理资料进行回顾性分析。结果 17例手术患者中15例成功转为窦性心律,1例患者心房颤动复发,1例起搏心律。术后2例出现呼吸困难,4例引流管口渗液。结论对于全胸腔镜改良迷宫手术治疗心房纤颤患者,全面做好术前评估、心理疏导、术后并发症的观察和护理等措施。可提高手术效果,减少术后并发症的发生。     

改良迷宫术治疗心房纤颤的远期疗效

目的：评价改良迷宫术治疗心房纤颤的远期疗效。方法：１９９４年３月到１９９６年７月采用改良迷宫术－－按Ｃｏｘ经典迷宫手术原理用冷冻代替部分手术切割,治疗风湿性心脏膜瓣病合并心房纤颤１８例。同期行二尖瓣替换术１４例,又瓣膜替换术４例,三尖瓣成形术８例,左房血栓清除４例。结果：本组无手术死亡随访２５￣５２个月,平均３６．１个月,随访率１００％。远期死亡１例。生存１７例,心功能Ⅰ级８例,Ⅱ级９例;均持续窦     

右侧迷宫术治疗先天性心脏病合并心房纤颤的护理

采用改良的迷宫Ⅲ型手术（右侧迷宫术）治疗先天性心脏病合并心房纤颤１１例,９例术后即恢复窦必瓦律,１例１周后恢复,１例经口服胺碘胴２周恢复窦性心律;全部病例恢复过程无急性心功能衰竭、心脏压塞和恶性心律失常发生。护理要点：①术前注意观察心率、心律和脉搏变化,指导患者雾化吸入后进行深呼吸和有效咳嗽训练;②术后加强胸部引流管的护理,精确计算出入量,持续心电监护,及时发现心律失常。     

小剂量胺碘酮预防冠状动脉旁路移植术后心房纤颤

目的 评价小剂量胺碘酮对冠状动脉旁路移植术后心房纤颤的预防效果、耐受性和安全性。方法 对1998至1999年235例冠状动脉旁路移植术后病人进行回顾性研究分析，其中对照组155例予常规药物，试验组80例合用小剂量胺碘酮。结果 常规药物治疗组21．93％出现心房纤颤，而小剂量胺碘酮预防用药组10％出现心房纤颤(P=0．024)。小剂量胺碘酮致心律失常3例，无甲状腺及肺部并发症发生。结论 预防应用小剂量胺碘酮能明显降低术后心室率，减少心房纤颤发生率，延迟发作，缩短持续时间，促进心房纤颤转复，同时改善心功能。小剂量胺碘酮毒副作用低于大剂量胺碘酮，尤其适用于缺血性心脏病合并心肌梗死及左心功能不全者。     

The radiofrequency modified maze procedure. A less invasive surgical approach to atrial fibrillation during open-heart surgery.

OBJECTIVE: Patients with mitral valve disease and suffering of atrial fibrillation of more than 1 year's duration have a low probability of remaining in sinus rhythm after valve surgery alone. Intraoperative radiofrequency ablation was used as an alternative to simplify the surgical maze procedure. METHODS: Seventy-two patients with mitral valve disease, aged 63+/-11 years ranging from 31 to 80 years, underwent valve surgery and radiofrequency energy applied endocardially, based on the maze III procedure to eliminate the arrhythmia. The right-sided maze was performed on the beating heart and the left-sided maze during aorta cross-clamping. RESULTS: Surgical procedures included mitral valve repair (n=38) or replacement (n=34) and in addition tricuspid valve repair (n=42), closure of an atrial septal defect (n=2) and correction of cor triatriatum (n=1). The left-sided maze needed 14+/-3 min extra ischemic time. There were two in-hospital deaths (2.7%) and three patients (4.2%) died during follow-up of 20+/-15 months. Among 67 surviving patients, 51 patients (76%) were in sinus rhythm, two patients (3%) had an atrial rhythm and eight patients (12%) had persistent atrial fibrillation or atrial flutter. Four patients had a pacemaker implanted, in one patient because of sinus node dysfunction. Doppler echocardiography in 64 patients demonstrated right atrial contractility in 89% and left atrial transport in 91% of patients. CONCLUSIONS: Intraoperative radiofrequency ablation of atrial fibrillation is an effective and less invasive alternative for the original maze procedure to eliminate atrial fibrillation.     

The Cox maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures

BACKGROUND: For the last decade, the Cox maze III procedure has been available for the treatment of atrial fibrillation. It is unknown whether the operation has similar efficacy in patients with lone atrial fibrillation compared with that in patients with atrial fibrillation associated with coronary, valve, or congenital heart disease. This study examined the long-term outcome of patients who underwent this procedure either as a lone operation or as a concomitant procedure. METHODS: From 1988 to 2001, 198 patients underwent a Cox maze III procedure; 112 were lone operations, and 86 were concomitant procedures. Major complications included renal failure, reoperation for bleeding, mediastinitis, stroke, and balloon pump insertion. Follow-up was performed by means of mail and telephone questionnaires with both the patients and their cardiologists. All patients who had any history of arrhythmia or who were taking medication had their rhythm documented by means of electrocardiography. RESULTS: The lone operation group was significantly younger (51.3 +/- 10.5 vs 58.8 +/- 9.9 years) and had a higher male/female ratio (4:1 vs 2:1). There was no difference in operative mortality between groups (1.8% vs 1.2%). At a follow-up of 5.4 +/- 2.9 years, 96.6% (172/178) of all patients were free of atrial fibrillation. There was no difference between the lone operation and concomitant procedure groups (95.9% vs 97.5%). CONCLUSION: The Cox maze III procedure has equivalent operative risk and long-term efficacy in patients undergoing both lone operations and concomitant procedures. The Cox maze III procedure remains the standard against which alternative procedures for atrial fibrillation must be judged.     

Partial maze procedure is effective treatment for chronic atrial fibrillation associated with valve disease

The maze procedure may be performed in combination with valve operations to treat chronic atrial fibrillation associated with valve dysfunction. Although we initially used the modified Cox maze III procedure, a more limited partial maze procedure is now preferred because the left atrium might be considered as the electrical impetues for atrial fibrillation. In this study we compared the results of 30 patients (group I) who underwent the full biatrial modified Cox maze III and 20 (group II) patients the partial maze procedure. While the rates of restored sinus rhythm were the same in both groups at 6-month follow-up (I: 83.3%, vs II: 80%), the following advantages were noted in the patients undergoing the partial maze procedure: shorter operative times, lesser elevations of creatine phosphokinase, lower rate of blood transfusion, lower rate of junctional rhythm soon after the operation, and a higher P wave in those patients with restored sinus rhythm. The effectiveness of the partial maze procedure seems equal to that of the biatrial modified Cox maze III procedure for atrial fibrillation associated with valve disease. The partial maze procedure is simple and less invasive, and thus might be applied more frequently as an additional procedure to valve operations without additional risk.     

Radiofrequency modified maze in patients with atrial fibrillation undergoing concomitant cardiac surgery

OBJECTIVE: In the majority of patients with chronic atrial fibrillation the arrhythmia will persist after correction of the underlying structural abnormality. The maze procedure is an effective surgical method to eliminate atrial fibrillation and to restore atrial contractility. METHODS: In this study we used radiofrequency energy to create lines of conduction block in both atria during cardiac surgery as a modification of the maze III procedure. One hundred twenty-two patients with atrial fibrillation for at least 1 year and structural heart disease underwent open heart operation and a radiofrequency modified maze procedure. RESULTS: In 108 (89%) of 122 patients mitral valve surgery was performed, and in this group 86 patients (80%) underwent 121 concomitant procedures. Fourteen patients (11%) underwent cardiac surgery not involving the mitral valve. The additional crossclamp time required for the left atrial part of the radiofrequency modified maze procedure was 14 +/- 3 minutes. The in-hospital mortality rate was 4.1%. The overall 39-month survival was 90%, and freedom of atrial flutter or atrial fibrillation was 78.5% +/- 5.1%. Eighty-nine survivors with sinus, atrial rhythm, or atrioventricular sequential pacemaker had Doppler echocardiography, and right atrial transport function was documented in 83% and left atrial transport function in 77% of patients. CONCLUSION: We concluded that the radiofrequency modified maze procedure as an adjunctive procedure is safe, time-sparing, and effective in eliminating atrial fibrillation and restoring atrial transport function.     

改良线路心房直视迷宫式射频消融治疗心房颤动

目的：探讨风湿性心脏病合并心房颤动（房颤）病人,在瓣膜置换同时采用改良线路经心房直视迷品式射频消融治疗房颤的可行性及疗效。方法：66例风湿性心脏病二尖瓣病变合并房颤病人,在体外循环心内直视下经心房行迷宫式射频消融,同时行二尖瓣置换术,结果：无手术死亡,57例房颤消失,其中术后窦性心律54例（81．8％）,结性心律1例（1．5％）,心房扑动2例（3％）,9例（13．6％）仍为房颤,随访2－60个月,总随访率89．6％,窦性心律稳定,无远期死亡,结论：经心房内视改良线路迷宫式射频消融治疗房颤,方法简捷,安全有效,远期疗效稳定,值得进一步研究,推广。     

Long-term results of irrigated radiofrequency modified maze procedure in 200 patients with concomitant cardiac surgery: six years experience

BACKGROUND: The Cox maze procedure is considered an effective surgical treatment of atrial fibrillation in patients with and without organic heart disease. Radiofrequency energy offers an alternative to the complex surgical maze procedure. We used the radiofrequency modified maze III procedure in patients with atrial fibrillation undergoing elective concomitant cardiac surgery. This study evaluated the long-term results of the irrigated radiofrequency ablation to create linear lines of conduction block endocardially. METHODS: Between November 1995 and June 2001, 200 patients with mainly structural heart disease and chronic atrial fibrillation underwent intraoperative radiofrequency linear ablation in both atria with concomitant cardiac surgery. RESULTS: The in-hospital mortality rate was 3.5% (7 patients) and during the mean follow-up of 40 months (range, 12 to 80) 27 patients (13.5%) died. Eight patients (4%) were lost from follow-up and complete data were available in 158 survivors. Sinus or atrial rhythm was present in 116 patients (73.4%) and an atrial driven rhythm in 10 patients (6.3%) with an atrioventricular pacemaker. Atrial fibrillation or flutter was documented in 32 patients (20.3%). Antiarrhythmic drugs were used in 49% of survivors who were free of atrial fibrillation or flutter. CONCLUSIONS: Intraoperative radiofrequency endocardial ablation is an effective technique to eliminate atrial fibrillation with promising long-term results.     

The outcome and indications of the Cox maze III procedure for chronic atrial fibrillation with mitral valve disease

Objective: The efficacy of the Cox maze III procedure for chronic atrial fibrillation associated with mitral valve disease is unclear, and so was evaluated in this study. Methods: In 30 patients, we applied the maze III procedure (cut and suture), except for one modification in the case of a left posterior sinus node artery. After dividing the patients into sinus rhythm and atrial fibrillation groups more than 6 months after the operation, we compared various parameters. Results: Sinus rhythm was restored in 27 patients (90%). One patient had atrioventricular reentrant tachycardia and needed a pacemaker for sick sinus syndrome (3.3%). The f-wave voltage in lead V₁, the preoperative cardiothoracic ratio, the preoperative left atrial systolic dimension, and the duration of atrial fibrillation were 0.23 ± 0.10 mV, 60.4% ± 5.2%, 57.4 ± 8.2 mm, respectively, and 5.1 ± 4.6 years in the group with sinus rhythm, and were 0.06 ± 0.05 mV, 77.7% ± 10.3%, 95.3 ± 24.0 mm, respectively, and 11.8 ± 5.5 years in the group with atrial fibrillation. These parameters were all significantly different between the groups. Regarding atrial function, a transmitral flow A wave was detected in 66.7% and a transtricuspid flow A wave in 100%. Only the duration of atrial fibrillation had a significant influence on the restoration of left atrial function. Conclusion: The maze III procedure was effective for atrial fibrillation associated with mitral valve disease. This procedure should be applied to patients with a cardiothoracic ratio less than 70% and a left atrial systolic dimension less than 80 mm. (J Thorac Cardiovasc Surg 1998;116:220-7)     

Predictive factors for persistence of atrial fibrillation after mitral valve operation

BACKGROUND: The majority of patients operated on for mitral valve disease with chronic atrial fibrillation (AF) do not recover sinus rhythm with conventional postoperative treatment. The maze procedure may be used in these circumstances. To define the precise indications for the maze procedure, it would be necessary to identify those patients based on preoperative factors. METHODS: A retrospective study was undertaken on 100 consecutive patients operated on for mitral valve disease in chronic AF. The return to sinus rhythm was analyzed with relation to age, gender, AF duration, left atrial size, left ventricular ejection fraction, lesion type, valve procedure, associated procedures, and reoperation. RESULTS: At late follow-up (more than 1 year) 26 (26%) patients presented sinus rhythm and 74 (74%) remained in AF. Statistical single parametric analysis demonstrated that mitral stenosis was a risk factor for maintaining AF, whereas regurgitation was more associated to sinus rhythm recovery. There was no relation with the other parameters with return to sinus rhythm. It should be noted, however, that 96% of this series had AF for more than 6 months preoperatively. CONCLUSIONS: The majority of patients with mitral valve disease remain in AF and this may justify the association of maze procedure. Pure regurgitation may be a single predictor for return to sinus rhythm after mitral valve operation in chronic AF.     

Radiofrequency and Cryoablation of Atrial Fibrillation in Patients Undergoing Valvular Operations

Background. Previous studies have shown that the maze operation can restore sinus rhythm and atrial transport function in patients with chronic atrial fibrillation. The purpose of this study was to test the feasibility of the application of radiofrequency and cryoablation as an alternative to the classic maze operation.

Methods. Twelve patients undergoing mitral valve procedures were included in this study. Radiofrequency and cryoablation were applied to create lesions in both atria to simulate the classic maze operation.

Results. There were two surgical deaths. At the mean follow-up of 10.25 months for the remaining 10 patients; 6 were in sinus rhythm, 2 in atrial rhythm, 1 in paroxysmal atrial tachycardia, and 1 in atrial fibrillation. Doppler echocardiography at 6-month follow-up showed emergence of biatrial transport function in 3 patients and right atrial contractility in 8. At 12-month follow-up of 5 patients, Doppler echocardiography showed biatrial transport function in 3 and right atrial contractility in 4.

Conclusions. Our modified maze procedure during valvular operation is effective for achieving an acceptable success rate to restore sinus rhythm and atrial transport function in patients with chronic atrial fibrillation.