胸腔镜辅助下双极射频消融治疗房颤

目的 探讨微创双极射频消融对房颤治疗的效果.方法 10例阵发性房颤患者,房颤时间均在1年以上,平均年龄53岁,尢器质性心脏病,心肺肝肾功能正常,气管插管麻醉,非体外循环胸腔镜辅助下双极射频先行右肺静脉环状消融,然后行左肺静脉环状消融,最后切割缝合器切除左心耳.结果 全组无死亡,术后随访1至3个月.房颤转复率90%.复发1例,为房颤6年的患者.结论 微创双极射频消融是一种操作简单、安全有效的外科治疗房颤方法.     

Left atrial radiofrequency ablation during cardiac surgery in patients with atrial fibrillation

Introduction: Intraoperative left atrial radiofrequency (RF) ablation recently has been suggested as an effective surgical treatment for atrial fibrillation (AF). The aim of this study was to verify the outcome of this technique in a controlled multicenter trial. Methods and Results: One hundred three consecutive patients (39 men and 65 women; age 62 ± 11 years) affected by AF underwent cardiac surgery and RF ablation in the left atrium (RF group). The control group consisted of 27 patients (6 men and 21 women; age 64 ± 7 years) with AF who underwent cardiac surgery during the same period and refused RF ablation. Mitral valve disease was present in 89 (86%) and 25 (92%) patients, respectively (P = NS). RF endocardial ablation was performed in order to obtain isolation of both right and left pulmonary veins, a lesion connecting the previous lines, and a lesion connecting the line encircling the left veins to the mitral annulus. Upon discharge from the hospital, sinus rhythm was present in 65 patients (63%) versus 5 patients (18%) in the control group (P < 0.0001). Mean time of cardiopulmonary bypass was longer in the RF group (148 ± 50 min vs 117 ± 30 min, P = 0.013). The complication rate was similar in both groups, but RF ablation‐related complications occurred in 4 RF group patients (3.9%). After a mean follow‐up of 12.5 ± 5 months (range 4–24), 83 (81%) of 102 RF group patients were in stable sinus rhythm versus 3 (11%) of 27 in the control group (P < 0.0001). The success rate was similar among the four surgical centers. Atrial contraction was present in 66 (79.5%) of 83 patients in the RF group in sinus rhythm. Conclusion: Endocardial RF left atrial compartmentalization during cardiac surgery is effective in restoring sinus rhythm in many patients. This technique is easy to perform and reproducible. Rare RF ablation‐related complications can occur. During follow‐up, sinus rhythm persistence is good, and biatrial contraction is preserved in most patients. (J Cardiovasc Electrophysiol, Vol. 14, pp. 1289‐1295, December 2003)     

Left atrial flutter after radiofrequency catheter ablation of focal atrial fibrillation

We report an arrhythmic complication in two patients in whom a procedure directed at isolating one or two pulmonary veins had been performed. The complication was related to pulmonary vein disconnection scars after ablation. Both patients developed new clinical tachycardia (atypical atrial flutter) secondary to a reentrant phenomena in the vicinity of a previously ablated pulmonary vein.     

阵发性心房颤动射频消融术后左房大小和机械功能变化

目的探讨经导管射频消融术对阵发性心房颤动（房颤）患者左房功能的影响,并比较肺静脉口节段性电隔离（SPVI）和环肺静脉消融（CPVA）两种术式在此方面的异同。方法66例阵发性房颤患者接受射频消融手术治疗。应用经胸心脏超声检查测量患者术前、术后1天、1个月和3个月时的左房前后径、左房面积、舒张晚期跨二尖瓣血流峰速（A峰）和舒张晚期心肌组织运动峰速（A’峰）。结果66例患者中,30例接受SPVI术,36例接受CPVA术。两组患者一般临床情况及术前超声参数相似。术后随访（315±153）d,SPVI组和CPVA组无房性心律失常复发率相似（70％与75％,P=0．650）。两组在手术后左房面积均较术前缩小,SPVI组发生于术后1个月,而CPVA组于术后3个月。SPVI组左房直径也显示出明显缩小（P〈0．05）,而CPVA组术前和术后则差异无统计学意义。左房机械功能方面,CPVA组于术后1天A峰和A’峰明显降低（P〈0．05）,两者均于3个月后较术后1天明显回升,A峰恢复至术前水平,A’峰较术前有明显升高。SPVI组术后1天没有出现A峰和A’峰明显降低;其A峰于术后1个月升高,并保持至3个月;A’峰于术后3个月时升高。结论阵发性房颤经导管SPVI术和CPVA术治疗后3个月,可以出现左房面积缩小和收缩功能改善。CPVA术比SPVI术造成了更多的左房损伤,表现为术后1天左房功能的下降以及术后左房大小、功能参数改善的延迟。     

Left atrial-esophageal fistula following radiofrequency catheter ablation of atrial fibrillation

This report describes a fatal case of left atrial-esophageal fistula occurring in a 72-year-old man after a radiofrequency catheter ablation of paroxysmal atrial fibrillation. Catheter ablation was performed around the pulmonary vein using an 8-mm-tip electrode (60 W or 55 degrees C) guided by a 25-mm circular catheter. On day 22 of follow-up, the patient presented with seizures followed by hematemesis due to left atrial-esophageal fistula. His clinical condition deteriorated, and he died of speticemia. Thus, left atrial-esophageal fistula is a sever complication of radiofrequency catheter ablation of the left atrial posterior wall.     

改良双极射频消融治疗房颤合并二尖瓣疾病之经验

目的：探讨胸骨下端切口改良双极射频消融治疗心房颤动同期行二尖瓣手术的手术方法以及临床疗效。方法：回顾分析2017年1月至2018年1月武汉亚洲心脏病医院44例同期接受胸骨下端切口改良双极射频消融及二尖瓣手术患者的基线资料,术式及手术相关参数。记录手术即刻,术后第一天,术后3个月,术后6个月,术后12个月心电图。结果：44例患者均在全麻体外循环下行改良双极射频消融手术,同期接受二尖瓣置换者41例、二尖瓣成形者3例。其中男性24例,女性20例;年龄49.33±12.1岁;体重：57.53±9.54 kg,身高：161.62±6.83 cm,体表面积：1.59±0.19 m2。术前左房前后径为6.20±1.33（极值4.5~9.5）cm。术前左室射血分数（LVEF）为54.18±3.48 %。临床心功能（NYHA分级）为III级或IV级者16名。患者AF病史为5,14±1.76 年。所有患者中,二尖瓣狭窄者5例,二尖瓣关闭不全者11例,二尖瓣狭窄伴关闭不全者28例。CHA2DS2-VASc评分为1.45±0.76 分。术中电除颤复律者11例。复跳时结性心律6例,均于术后1周内恢复为窦性心律。手术术毕转复窦性心律者43例（97.7%）,返监护室后窦性心律43例（97.7%）。二次开胸止血2例（4.5%）,所有患者均顺利出院。术后均常规服用胺碘酮200 mg 每日1次（QD）。术后3月维持窦性心律者31例（70.5%）,术后6月为33例（75%）,术后12月为32例（72.7%）。左房前后径≥5.5cm者其术后3、6及12个月的复律率与＜5.5cm组无明显统计学差异。结论 胸骨下端切口改良双极射频消融同期行二尖瓣手术安全可行,疗效确切,并发症相对较少,对于左房前后径≥5.5cm 的患者仍有确切的转复效果,具有较好的研究及发展前景。     

房颤治疗:外科射频消融术与内科导管射频消融术孰优?

诸学时:2006年10月13日,中国第一家房颤研究治疗中心——北京安贞医院房颤中心,在北京召开的第四届五洲国际心血管病研讨会上正式宣告成立。该中心集医疗、科研、教学、培训和咨询五位一体,整合了安贞医院心脏内科和外科两支房颤研究治疗团队的力量,优势互补。其学科带头人均是我国著名心脏病学专家。心脏内科马长生教授于1998年率先在国内开展房颤的经导管射频消融治疗,截至目前已累计完成近千例,为国内最大系列。在心脏外科孟旭教授带领下,2002年安贞医院开始外科直视下的房颤射频消融术,至今累计完成420例,为国内最大系列,也是亚洲范围内…     

体外循环下心脏瓣膜置换术同期双极射频消融治疗心房颤动

目的:评估体外循环下心脏瓣膜置换术同期行双极射频消融治疗心房颤动(房颤)。方法:纳入2015年1月至2019年10月丹阳市人民医院及镇江市第一人民医院连续58例瓣膜置换同期行双极射频消融术的房颤患者,其中非风湿性瓣膜病16例,风湿性心脏瓣膜病42例。术中房颤消融路线均一致,常规结扎切除左心耳。同期行体外循环下二尖瓣置换56例,行主动脉瓣置换25例,行三尖瓣成形38例,行血栓清除术10例。术后常规口服胺碘酮3~6个月,所有患者均随访12个月,记录患者术后房颤转复情况。结果:术后恢复为窦性心律44例(75.8%),发生心房扑动8例(10.3%),消融后仍为房颤9例(15.5%),出院前恢复为窦性心律47例(81.0%)。结论:在体外循环下心脏瓣膜置换术同期行双极射频消融治疗房颤的临床效果满意,并具有安全性高、容易操作的特点。     

Cryoballoon ablation versus radiofrequency ablation for atrial fibrillation

Catheter ablation (CA) provides the most effective treatment option for patients suffering from symptomatic atrial fibrillation (AF). The procedural cornerstone of all ablation strategies and for all entities of AF is the electrical isolation of the pulmonary veins (PV). CA with the use of radiofrequency (RF) in conjunction with a 3-dimensional electroanatomical mapping system is the most established ablation approach, but it demands a long learning curve and recurrences of AF are commonly the result of recovered PV conduction. As a consequence, novel ablation systems such as the Cryoballoon (CB) have been evolved aiming at facilitation and increased efficacy of pulmonary vein isolation (PVI). CB ablation is characterized by a short learning curve as well as short procedure times and demonstrated non-inferiority with regard to safety and efficacy when being directly compared to RF ablation for treatment of paroxysmal AF. However, RF ablation is first choice for treatment of persistent AF, in particular when expanded ablation strategies beyond PVI are intended in order to improve clinical outcomes.     

Left atrial appendage size is a marker of atrial fibrillation recurrence after radiofrequency catheter ablation in patients with persistent atrial fibrillation

IntroductionThere are no consistently confirmed predictors of atrial fibrillation (AF) recurrence after catheter ablation. Therefore, we aimed to study whether left atrial appendage volume (LAAV) and function influence the long‐term recurrence of AF after catheter ablation, depending on AF type.MethodsAF patients who underwent point‐by‐point radiofrequency catheter ablation after cardiac computed tomography (CT) were included in this analysis. LAAV and LAA orifice area were measured by CT. Uni‐ and multivariable Cox proportional hazard regression models were performed to determine the predictors of AF recurrence.ResultsIn total, 561 AF patients (61.9 ± 10.2 years, 34.9% females) were included in the study. Recurrence of AF was detected in 40.8% of the cases (34.6% in patients with paroxysmal and 53.5% in those with persistent AF) with a median recurrence‐free time of 22.7 (9.3–43.1) months. Patients with persistent AF had significantly higher body surface area‐indexed LAV, LAAV, and LAA orifice area and lower LAA flow velocity, than those with paroxysmal AF. After adjustment left ventricular ejection fraction (LVEF) <50% (HR = 2.17; 95% CI = 1.38–3.43; p < .001) and LAAV (HR = 1.06; 95% CI = 1.01–1.12; p = .029) were independently associated with AF recurrence in persistent AF, while no independent predictors could be identified in paroxysmal AF.ConclusionThe current study demonstrates that beyond left ventricular systolic dysfunction, LAA enlargement is associated with higher rate of AF recurrence after catheter ablation in persistent AF, but not in patients with paroxysmal AF.     

微创射频消融治疗心房颤动

心房颤动（简称房颤）是最常见的快速型心律失常之一,可增加心血管疾病死亡率和发病率,我国流行病学研究显示房颤发病率为0.73％[1].房颤治疗原则包括：控制心室率、抗凝治疗、缓解症状、治疗基础心脏病和诱发因素、恢复并维持窦性心律.房颤的药物疗效差,不能预防血栓栓塞和心力衰竭,抗凝药物的应用虽然减少血栓栓塞风险但同时也增加了出血风险.导管及外科的射频消融治疗房颤效果明显好于单纯药物治疗12-4].内、外科微创射频消融治疗房颤各有优缺点,可结合其优点联合治疗房颤.     

Minimally invasive surgical ablation of atrial fibrillation: The thoracoscopic box lesion approach

Background Atrial fibrillation is the most common cardiac rhythm disturbance and is associated with increased morbidity and mortality. It is often found in association with structural heart disease; however, lone atrial fibrillation is not uncommon. Potentially, these patients are ideal candidates for a minimally invasive thoracoscopic approach for the surgical treatment of atrial fibrillation. Methods From August 2003 through February 2006, 100 drug-resistant symptomatic patients with lone atrial fibrillation underwent thoracoscopic off-pump closed-chest epicardial ablation using the FLEX 10 AFx Microwave Ablation System (Guidant, Indianapolis, IN, USA). There were 66 men (66.0%) and 34 women (34.0%), with a mean age of 60.9 ± 9.8 (range 37–81) years. Mean duration of atrial fibrillation was 72.4 ± 79.5 (range 6–480) months. Sixty-four patients (64.0% had paroxysmal, 11 (11.0%) had persistent and 25 (25.0%) had permanent atrial fibrillation. Results There were no hospital deaths. Postoperative in-hospital complications were minimal. Mean postoperative length of stay was 3.4 ± 1.7 days. Cumulative follow-up was 2,106.3 (mean 23.1) patient months, with a maximum follow-up of 39.8 months. There were three late deaths (3.0%). In nine patients (9.0%), the thoracoscopic box lesion pulmonary vein isolation operation and subsequent electrophysiological intervention failed, and a Cox-Maze operation was performed. Follow-up was 100% complete, with 42.0% (37 of 88) patients in normal sinus rhythm. Two patients (2.3%) experienced a transient ischemic attack and two (2.3%) a cerebral vascular accident. Twenty-seven patients (30.7%) required electrophysiological intervention post procedure. Ten patients (11.4%) were on amiodarone and 48 (54.5%) were on coumadin at follow-up. Conclusion Totally thoracoscopic surgical ablation for the treatment of atrial fibrillation is technically feasible and presents minimal risk to the patient. Clinical results with the application of microwave energy have been less than satisfactory, with no demonstrated electrical isolation of the pulmonary veins. Moreover, long-term relief from atrial fibrillation has not been achieved.     

Midterm results of left atrial bipolar radiofrequency ablation combined with a mitral valve procedure in persistent atrial fibrillation

Introduction

The aim of the study was to assess the midterm results of left atrial bipolar radiofrequency ablation combined with a mitral valve procedure in patients with mitral valve disease and persistent atrial fibrillation.

Methods

Between October 2006 and July 2009, 95 patients with mitral valve disease and persistent atrial fibrillation underwent a mitral valve procedure and left atrial bipolar radiofrequency ablation. The postoperative data of the combined procedure were collected at the time of discharge and at one, three, six and 12 months after the operation.

Results

Hospital mortality rate was 6.3% (six patients). Normal sinus rhythm was achieved in 77.2% of patients during the early postoperative period in hospital, and in 73.3, 72.0 and 75% of patients at three, six and 12 months postoperatively, respectively. Patients were followed up for a mean duration of 14.02 ± 5.71 months (range: 6–19 months). During this midterm follow-up period, nine patients had late recurrence of atrial fibrillation. No risk factor was identified for late recurrence of atrial fibrillation.

Conclusion

Our midterm follow-up results suggest that the addition of left atrial bipolar radiofrequency ablation to mitral valve surgery is an effective and safe procedure to restore sinus rhythm in patients with chronic atrial fibrillation.     

Thoracoscopic radiofrequency ablation for lone atrial fibrillation: Box-lesion technique

BackgroundWe report the feasibility and outcomes of box-lesion ablation technique to treat stand-alone atrial fibrillation (AF).MethodsThere were 31 patients with a mean age of 63.3 ± 8.4 years who underwent bilateral totally thoracoscopic ablation of symptomatic paroxysmal AF (n = 8; 25.8%) and long-standing persistent AF (n = 23; 75.2%). The box-lesion procedure included bilateral pulmonary vein and left atrial posterior wall ablation using irrigated bipolar radiofrequency with documentation of conduction block.ResultsThere were no intra- or perioperative ablation-related complications. There was no operative mortality, no myocardial infarction, and no stroke. Skin-to-skin procedure time was 152.1 ± 36.7 min and the postoperative average length of stay was 6.26 ± 1.24 days. At discharge, 29 patients (93.5%) were in sinus rhythm. Median follow-up time was 20.4 ± 8.3 months. At three months postsurgery, 20 patients of 30 (66.6%) were free from AF without the need of antiarrhythmic drugs. Six patients (20%) underwent catheter reablation. Twenty-three patients (76.6%) were in sinus rhythm at one year after the last performed ablation (surgical ablation or catheter reablation).ConclusionThe thoracoscopic box-lesion ablation procedure is a safe, effective, and minimally invasive method for the treatment of isolated (lone) AF. This procedure provided excellent short-term freedom from AF.     

Left atrial thrombus associated with ablation for atrial fibrillation: identification with intracardiac echocardiography

OBJECTIVES: This study reports the incidence of, risk factors for, and management of left atrial (LA) thrombus documented by intracardiac echocardiography (ICE) during LA ablation for atrial fibrillation (AF). BACKGROUND: Thrombus formation is a risk associated with LA ablation procedures. METHODS: Intracardiac echocardiography imaging was performed in 232 patients (184 men, average age 55 +/- 11 years) with AF undergoing pulmonary vein ostial ablation. RESULTS: Anticoagulation (activated clotting time >250 s) was maintained after dual transseptal catheterization. Left atrial thrombus (n = 30) was observed in 24 of 232 patients (10.3%). Thrombi measured 12.9 +/- 11.1 mm (length) and 2.2 +/- 1.3 mm (width) and were attached to a sheath or mapping catheter. Most thrombi (27 of 30, 90%) were eliminated from the LA by withdrawal of the sheath and catheter into the right atrium (RA). Two thrombi became wedged in the interatrial septum and incompletely withdrawn into the RA, and one was recognized only on post-procedure review of ICE images. Patients with LA thrombus had an increased LA diameter (4.8 +/- 0.5 vs. 4.5 +/- 0.6 cm, p < 0.02), spontaneous echo contrast (67% vs. 3%, p < 0.0001) and a history of persistent AF (29% vs. 6%, p < 0.0002). Multivariate discriminant analysis showed that spontaneous echo contrast (f = 97.9, p < 0.0001) was the most important determinant of LA thrombus formation. No patient with LA thrombus suffered a clinical thromboembolic complication. CONCLUSIONS: Left atrial thrombus identified on ICE may occur during LA catheter ablation procedures despite aggressive anticoagulation. Spontaneous echo contrast may predict risk for LA thrombus formation. Left atrial thrombus may be successfully withdrawn into the RA under ICE imaging with no overt complications.