实时三维经食管超声心动图定量评价心房颤动患者左心耳形态及功能

目的探讨实时三维经食管超声心动图(RT-3D-TEE)定量评估心房颤动(AF)患者左心耳(LAA)形态和功能的可行性。方法选取56例拟接受射频消融术的阵发性AF患者(阵发组)、26例持续性AF患者(持续组)及同期11名健康人(对照组),采用RT-3D-TEE测量3组LAA各参数。结果与对照组比较,阵发组LAA舒张末期容积(LAA-EDV)、收缩末期容积(LAA-ESV)、开口最大面积(A_(max))及最小面积(A_(min))均增大,射血分数(LAA-EF)、最大排空速度(Vep)、面积变化率(A%)及直径变化率(D%)均减小(P均0.05);持续组LAA-EDV、LAA-ESV、A_(max)、A_(min)增大,LAA-EF、Vep、A%、D%减小(P均0.05);阵发组与持续组间各参数差异均无统计学意义(P均0.05)。LAA-EF与ESV (r=-0.73,P0.01)、EDV(r=-0.64,P0.01)、A_(max)(r=-0.36,P0.01)及年龄(r=-0.27,P=0.02)呈负相关,与A%、D%、Vep呈正相关(r=0.86、0.74、0.55,P均0.01),与D_(max)无明显相关(P0.05)。结论 RT-3D-TEE能定量分析AF患者LAA形态及功能变化,对于评估AF患者病情具有一定临床意义。     

Left atrial appendage perforation with Watchman device implantation: Strategies for surgical repair

Percutaneous occlusion of the left atrial appendage is increasingly being used as an alternative for stroke prevention in patients with non‐valvular atrial fibrillation at high risk of complications from long term anticoagulation. We describe a case of left atrial appendage perforation during Watchman device implantation requiring emergency repair of the left atrium using sternotomy and cardiopulmonary bypass. Technical considerations for surgical decision making are discussed; in hemodynamically unstable patients as well as those at high risk for embolization.     

Standalone epicardial left atrial appendage exclusion for thromboembolism prevention in atrial fibrillation

Open in a separate window OBJECTIVESMost strokes associated with atrial fibrillation (AF) result from left atrial appendage thrombi. Oral anticoagulation can reduce stroke risk but is limited by complication risk and non-compliance. Left atrial appendage exclusion (LAAE) is a new surgical option to reduce stroke risk in AF. The study objective was to evaluate the safety and feasibility of standalone thoracoscopic LAAE in high stroke risk AF patients.METHODSThis was a retrospective, multicentre study of high stroke risk AF patients who had oral anticoagulation contraindications and were not candidates for ablation nor other cardiac surgery. Standalone thoracoscopic LAAE was performed using 3 unilateral ports access and epicardial clip. Periprocedural adverse events, long-term observational clinical outcomes and stroke rate were evaluated.RESULTSProcedural success was 99.4% (174/175 patients). Pleural effusion occurred in 4 (2.3%) patients; other periprocedural complications were <1% each. One perioperative haemorrhagic stroke occurred (0.6%). No phrenic nerve palsy or cardiac tamponade occurred. Predicted annual ischaemic stroke rate of 4.8/100 patient-years (based on median CHA₂DS₂-VASc score of 4.0) was significantly higher than stroke risk observed in follow-up after LAAE. No ischaemic strokes occurred (median follow-up: 12.5 months), resulting in observed rate of 0 (95% CI 0–2.0)/100 patient-years (P < 0.001 versus predicted). Six all-cause (non-device-related) deaths occurred during follow-up.CONCLUSIONSStudy proved that a new surgical option, standalone thoracoscopic LAAE, is feasible and safe. With this method, long-term stroke rate may be reduced compared to predicted for high-risk AF population.     

对比盘式封堵器LAmbre与LAcbes封堵左心耳治疗心房颤动

目的 对比以盘式封堵器LAmbre与LAcbes行左心耳封堵(LAAC)治疗心房颤动(AF)的有效性和安全性。方法 分析99例接受以LAcbes封堵器(LAcbes组)、130例以LAmbre封堵器(LAmbre组)行LAAC的AF患者,对比治疗效果、安全性及预后。结果 LAcbes组左心耳完全封堵率66.67%(66/99),LAmbre组57.69%(75/130),组间差异无统计学意义(P>0.05)。LAcbes组密封盘直径、固定盘直径及封堵术后周边漏(特别是1~3 mm周边漏)发生率均低于LAmbre组(P均<0.01)。2组围术期均无急性心脏压塞及死亡病例。术后(中位复查时间为术后72天)复查经食管超声心动图,组间器械相关血栓发生率差异无统计学意义(P>0.05)。术后平均随访(12±6)个月,随访期间LAcbes组5例(5/99,5.05%)、LAmbre组1例(1/130,0.77%)发生延迟性心脏压塞,LAcbes组发生脑梗死、短暂性缺血发作各1例,LAmbre组发生脑梗死2例、脑出血1例、死于心力衰竭1例,2组差异均无统计学意义(P均>0.05)。结论 盘式封堵器LAmbre与LAcbes封堵左心耳治疗AF的效果及安全性均相当。     

左心耳封堵术后影响封堵器不完全内皮化的危险因素

目的 分析心房颤动（AF）患者左心耳封堵（LAAO）术后封堵器不完全内皮化的影响因素。方法 回顾性分析53例接受LAAO（封堵装置均为Watchman）治疗的AF患者。于术后3个月以双源CT评估封堵器是否完全内皮化;采用单因素及多因素logistic回归分析观察封堵器不完全内皮化的影响因素。结果 术后随访77~134天,中位随访时间100天。术后3个月,双源CT诊断不完全内皮化32例（不完全组）、完全内皮化21例（完全组）;组间左心室射血分数（LVEF）和二尖瓣反流（MR）差异有统计学意义（P均<0.05）,性别、年龄、AF类型等指标差异均无统计学意义（P均>0.05）。以LVEF和MR为自变量、完全内皮化与否为因变量行logistic回归分析,结果显示LVEF和MR均为封堵器不完全内皮化的独立影响因素（P均<0.05）。结论 二尖瓣轻度及以上反流及低射血分数可在一定程度上影响LAAO治疗AF术后封堵器内皮化,导致封堵器延迟内皮化或内皮化不完全。     

高龄冠心病合并心房颤动患者行非体外循环冠状动脉旁路移植术中左心耳处理的回顾性队列研究

目的 本文旨在探讨左室射血分数(LVEF)降低的高龄冠心病合并心房颤动(房颤)患者在非体外循环冠状动脉旁路移植术(OPCABG)中同期处理左心耳的手术技巧及效果评价.方法 纳入2013～ 2018年,84例OPCABGLVEF降低(＜50％)的高龄(年龄≥70岁)冠心病合并房颤患者在我科行非体外循环冠脉搭桥术.男54例...     

Impact of preoperative atrial fibrillation in patients with left ventricular assist device: A systematic review and meta‐analysis

Atrial fibrillation (AF) is a common finding in patients evaluated for left ventricular assist device (LVAD). There is conflicting data regarding the mortality risk as well as the thromboembolic risk in patients with preoperative AF who undergo LVAD implantation. We examined these risks by performing a meta‐analysis. We performed a literature search of Pubmed, EMBASE, SCOPUS, and Cochrane from inception to February 2018. The eligible studies were used to compare mortality rate and thromboembolic risk between AF and Non‐AF (NAF) groups after LVAD implantation. We obtained 391 articles from our search strategy. Seven retrospective studies were included and accounted for 5823 LVAD patients (AF 1589; NAF 4234). The median follow‐up duration ranged from 7–24 months. The pooled analysis revealed a significantly increased risk of mortality in preoperative AF patients who underwent LVAD operation compared to those with NAF (Risk Ratio [RR] 1.16, 95% CI 1.05‐1.28, I2 = 0%). Five studies reported thromboembolism events involving 1359 preoperative AF and 3893 NAF patients. The pooled analysis did not show a statistically significant association between risk of thromboembolic event and preoperative AF (Risk Ratio [RR] 1.08, 95% CI 0.86‐1.36, I2 = 76.2%). Our study shows that preoperative AF may be associated with a higher mortality rate. This study is limited by the fact that the data are pooled from retrospective studies. Further prospective studies are warranted in order to validate these results.     

心脏CT血管造影三维重建定量左心耳口部周长选择封堵器型号

目的 观察心脏CT血管造影(CTA)三维重建定量左心耳(LAA)口部周长对选择左心耳封堵术(LAAC)治疗房颤(AF)所用封堵器型号的价值。方法 基于术前心脏CTA三维重建、经食管超声心动图(TEE)及术中LAA造影测量94例接受LAAC AF患者LAA口部最大长径,基于心脏CTA三维重建测量LAA口部周长、计算周长衍生直径(PDD)。分析LAA口部参数与植入封堵器型号的相关性及一致性,评估以各种方法所获LAA口部参数预测与实际植入封堵器型号的一致性;以LAA PDD为预测变量、植入封堵器型号为因变量建立线性回归方程。结果 实际植入封堵器型号(真实直径)为(28.95±3.13)mm,周长为(90.90±9.82)mm。心脏CTA、TEE及术中LAA造影所测LAA口部最大长径分别为(24.63±3.17)mm、(24.07±3.19)mm及(23.17±3.25)mm,均与封堵器型号呈正相关(r=0.814、0.691、0.790,P均<0.001);基于心脏CTA所测LAA口部周长为(78.48±10.69)mm, PDD为(24.98±3.40)mm; LAA口部周长与封堵器...     

Mechanical properties of currently available left atrial appendage occlusion devices: A bench‐testing analysis

Endoluminal left atrial appendage occlusion is an emerging therapy to treat patients suffering from atrial fibrillation with contraindications against oral anticoagulation. Different occlusion devices have been introduced into the clinical setting while comparative studies between the devices are sparse. This in vitro study compares several endoluminal left atrial appendage occlusion systems regarding 2 mechanical properties: radial (RF) and tug force (TF). Seven different occluder systems of various sizes (24 in total) underwent testing throughout their recommended sizing range. RF was measured in a commercial RF tester. TF was assessed according to a recently published bench test. RF increased with compression of the devices: The LAmbre 2228 device exerted the highest RF (8.6 N) at maximum compression of 16 mm. The lowest RF of 0.1 N was exhibited by the 27 mm Occlutech occluder at minimal compression. The highest TFs were exerted by the WaveCrest devices at maximum compression with 4.6 and 3.6 N for the 22 mm and the 27 mm device, respectively. The lowest TFs were measured for the first‐generation Occlutech devices, particularly for the 24 mm device with 1.1 N at maximum compression and 0.4 N at minimum compression. A strong positive correlation was found between the number of hooks per millimeter circumference of an occluder and its tug force (r = 0.87, P < 0.01). The analysis revealed device stability to be more dependent on anchoring structures than on RF. The wide range of mechanical properties makes comparison of current LAA occluders difficult and emphasizes the need for standardized preclinical testing to prompt clinical compatibility.     

A modified maze procedure performed only on the left atrium for chronic atrial fibrillation associated with mitral valve disease: Report of a case

We describe herein the successful treatment of a patient with chronic atrial fibrillation (AF) associated with mitral valve stenosis and regurgitation, achieved by performing a modified maze procedure on the left atrium alone. The patient was a 51-year-old man who had suffered from intractable AF for 17 years, causing multiple cerebral emboli and palpitations. He had undergone open mitral commissurotomy and balloon commissurotomy 15 and 7 years ago, respectively. On admission, an echocardiogram revealed mitral valve restenosis and thrombosis in the left atrial appendage. Prosthetic valvular replacement was performed following isolation of all pulmonary veins with cryoablation to the posterior wall of the left atrium and excision of the left atrial appendage. Postoperatively, the AF disappeared and echocardiogram demonstrated a left atrial kick in the mitral valvular inflow without any evidence of thrombosis in the left atrium. Thus, we believe that our modified left side only maze procedure is a simple and efficient method for the treatment of chronic AF with mitral valve disease.