心内直视下射频消融改良迷宫术治疗心房颤动

目的总结心内直视下射频消融改良迷宫手术治疗心房颤动的临床经验。方法2005年5月~2006年8月在心内直视手术同期采用射频消融改良迷宫手术治疗心房颤动30例,术前诊断风湿性心脏病26例,二尖瓣关闭不全3例,冠心病1例。手术采用CardioblateTM冲洗式射频消融系统,每例患者分别应用单极系统和双极系统,按照迷宫手术线路分别于左、右心房行心内膜射频消融手术,并切除左、右心耳,同期完成相应的心脏手术。结果手术均顺利完成,射频消融手术时间30.5±12.6min。术后死亡1例,其余29例顺利出院。术后当天21例患者(70.0%)转为窦性心律。29例患者出院后随访7.6±4.8个月,24例(82.8%)为窦性心律,5例(17.2%)为心房颤动或房室结性心律。结论心内直视下射频消融改良迷宫手术治疗心房颤动简单、有效,具有良好的临床应用前景。     

改良冲洗式双极射频消融手术治疗心房颤动

目的分析心瓣膜置换术中同期行改良冲洗式双极射频消融治疗心房颤动的临床效果。方法回顾性分析2009年4月至2011年6月安徽医科大学第二附属医院心瓣膜病合并心房颤动34例患者在体外循环下行心瓣膜置换术+改良冲洗式双极射频消融手术的临床资料,其中男21例,女13例;年龄41～76(50.5±11.3)岁。风湿性心脏瓣膜病31例,心瓣膜退行性病变3例;合并慢性持续性/永久性心房颤动27例,阵发性心房颤动7例。均采用Medtronic Cardioblate 68000冲洗式双极射频消融系统进行消融操作。消融手术包括双侧肺静脉的环形隔离、左心耳切除、左右心房消融(改良Cox-mazeⅢ手术路径)和Marshall韧带切除。术后常规予胺碘酮治疗。结果全组无死亡,除2例术后并发Ⅲ○房室传导阻滞、安装永久性心脏起搏器外,其余患者未发生与消融相关的并发症。术后31例转为非心房颤动心律(窦性心律25例,结性心律4例,起搏心律2例),3例维持心房颤动心律。随访3～20个月,29例维持窦性心律(85.3%),3例心房颤动心律,2例起搏心律。结论改良冲洗式双极射频消融治疗心房颤动安全、有效。     

心内直视手术同期行单极或双极射频消融治疗心房颤动的效果比较

目的探讨心内直视下同期行单极或双极射频消融治疗器质性心脏病合并心房颤动(房颤)的经验及疗效。方法回顾性分析2004年12月至2013年12月我院及上海交通大学医学院附属仁济医院心血管外科采用单极射频消融笔或双极射频消融笔为305例器质性心脏病合并房颤患者施行消融术的临床资料。其中男188例、女117例,年龄38~81岁。将患者分为3组:单极组,128例,行单极笔消融;双极组,165例,行双极笔消融;联合组,12例,行单极加双极笔联合消融。结果全组术后死亡2例。术后有249例患者转为窦性心律,总转复率为81.6%。其中单极组转复率为78.9%,双极组转复率为83.6%(P0.05)。术后随访3~85(38.2±15.4)个月。单极组、双极组术后半年(80.5%vs.83.9%,P0.05),1年(78.4%vs.83.3%,P0.05),2年(76.5%vs.81.1%,P0.05),5年(73.8%vs.77.1%,P0.05)窦性心律维持率差异均无统计学意义。结论心脏直视手术同期行单极或双极射频消融治疗房颤简易、安全、有效,其中长期效果值得肯定。单极和双极消融对于术后窦性心律的转复率无明显差异,但应用双极消融笔可以明显缩短消融手术时间。     

胸腔镜辅助下微创射频消融手术治疗心房颤动临床分析

目的 探讨胸腔镜辅助下微创射频消融手术治疗心房颤动的技术和早期疗效.方法 2006年12月至2007年10月,共有57例心房颤动患者接受了胸腔镜辅助下微创心脏手术,其中男性40例,女性17例,平均年龄56.4岁,术前心房颤动病史(5.7±4.5)年.本组阵发性心房颤动38例,持续性心房颤动7例,长期存在的持续性心房颤动12例;3例患者曾行导管消融治疗,2例已安置永久性起搏器.所有患者均在胸腔镜辅助下实施双侧肺静脉前庭射频消融隔离、心外膜部分去迷走神经化治疗、左心耳切闭(Wolf Mini-maze手术);并在消融前后行心外膜电生理标测.结果 本组患者平均手术时间3.5 h;术中发现左心房血栓1例,1例患者同期行心外膜的心脏同步化手术.无围手术期死亡;1例术后并发急性呼吸功能不全,1例并发急性心功能不全.共16例患者术后及随访期间行胸外直流电复律治疗;全组患者出院时、术后1、3及6个月窦性心律的比例分别为78.9%(45/57)、64.3%(36/56)、83.9%(47/56)和87.0%(20/23);术前阵发性心房颤动患者则为84.2%(32/38)、67.6%(25/37)、86.5%(32/37)和89.5%(17/19).全组随访1～10个月无血栓及栓塞事件发生.结论 胸腔镜辅助微创心脏外科手术主要适用于阵发性心房颤动患者,其早期疗效理想,创伤小,安全性高.     

心瓣膜置换术同期双极射频消融治疗心房颤动

目的总结心内直视下射频消融改良迷宫手术治疗心房颤动(AF)的临床经验,探讨该手术方法的效果。方法2007年12月至2008年2月在心内直视手术下同期采用射频消融改良迷宫手术治疗AF患者11例,男3例,女8例;年龄22～65岁,平均年龄40.36岁。术前诊断为风湿性心脏病二尖瓣狭窄11例,合并关闭不全5例,左心房血栓3例。采用Atricure双极射频消融系统,按照迷宫手术线路分别经房间沟路径行心内膜射频消融术,同期完成相应的心脏手术。结果手术均顺利完成,射频消融手术时间22～50min,平均30.55min。术后无死亡患者,术后当天有7例(63.64%)转为窦性心律。11例患者均顺利出院。出院后随访1个月以上,10例(90.91%)转为窦性心律。结论心内直视下射频消融改良迷宫手术治疗AF简单、有效,短期临床效果明显。     

非体外循环冠状动脉旁路移植术同期行房颤射频消融50例

2008年1月至2010年12月,我们收治50例冠心病(CHD)合并心房颤动(AF)患者,行非体外循环下冠状动脉旁路移植(OPCAB)手术,同期使用AtricureTM干式双极射频消融钳行AF射频消融术,现总结报道如下.     

141例心脏手术同期施行双极射频迷宫手术治疗心房颤动

目的 探讨心脏手术同期施行双极射频迷宫手术治疗心房颤动(AF)的效果及其影响因素.方法 2006年7月到2008年5月在心脏手术同期施行双极射频迷宫手术141例,回顾性分析和随访,比较手术前后心律、超声心动图等各项指标及心功能变化.结果 术后早期死亡6例.出院135例中,随访129例(95.56%),失访6例.随访3个月～2年,平均(16.79±7.91)个月.随访者中1例1O个月死于心衰,余128例生存.心功能(NYHA)Ⅰ级120例(93.75%),Ⅱ级8例(6.25%).被随访者3个月、6个月和1年以上稳定窦性心律(sSR)分别为69.77%、72.36%和87.14%.超声显示左心房比术前明显缩小,sSR者均出现明显 A 峰波,左心房功能良好.结论 心脏直视手术同期施行双极射频迷宫手术治疗AF安全有效.随着术后时间延长,sSR逐渐增加,AF复发率逐渐降低.老年、AF病程超过5年、左心房内径>60 mm以及中到重度的三尖瓣关闭不全是影响双极射频迷宫手术疗效的危险因素.     

风湿性心脏瓣膜病合并心房颤动单极和双极射频消融的疗效对比

目的对比风湿性心脏瓣膜病瓣膜置换同期单极和双极射频消融的疗效。方法回顾性分析2010~2015年上海市第一人民医院行瓣膜置换术和射频消融迷宫手术的261例风湿性心脏瓣膜病合并心房颤动(房颤)患者的临床资料,根据射频消融方式的不同分为单极消融组[(209例,其中男129例、女80例,年龄(59.6±9.7)岁]和双极消融组[52例,其中男36例、女16例,年龄(58.6±11.2)岁]。比较两组患者基础临床资料、围术期并发症发生率及死亡率、房颤消除率等指标。结果两组围术期死亡率及并发症发生率无明显差异,单极消融组射频消融时间长于双极消融组[(29.7±3.3)min vs.(22.3±7.8)min,P=0.035)],术后1年随访中,两组患者的左房内径均明显减小,双极消融组术后3个月和1年随访时房颤消除率分别为82.0%和80.0%,明显高于单极消融组的66.3%和59.6%(P=0.037和P=0.008)。结论风湿性心脏瓣膜病瓣膜置换同期行房颤消融术是安全有效的,与单极射频消融相比,双极射频消融房颤消除率高,射频消融时间和体外循环时间均有所缩短,具有更好的临床应用价值。     

心外科手术同期行双极射频消融术治疗房颤

目的 总结应用双极射频消融术在心外科手术同期治疗房颤的疗效,探讨房颤近期疗效的影响因素.方法 2007年6月至2010年2月,81例房颤患者被纳入研究.其中男45例,女36例;年龄(48.2±11.0)岁.合并先天性心脏病8例,冠心病16例,风湿性心脏病57例.房颤持续(7.56±7.47)年,其中永久性房颤26例,持续性房颤44例,阵发性房颤11例.左房直径36～ 72mm,其中小于60 mm者65例.术前心功能Ⅱ-Ⅳ级.应用Atricure双极消融系统49例,Metronic单双极消融系统32例.2009年6月至2010年2月期间22例患者进行房颤标测.所有患者均按照迷宫IV径路行双极房颤射频消融手术,同期行非体外循环冠状动脉旁路移植术(OPCAB) 16例,二尖瓣置换术(MVR)[或+三尖瓣成形术(TVP) ]33例,MVR+冠状动脉旁路移植术(CABG)1例,二尖瓣成形术(MVP)1例,主动脉瓣置换术(AVR)4例,二尖瓣主动脉瓣置换术(DVR)(或+TVP)18例,先心纠治8例.术后随访12 ～44个月.结果 住院期间死亡1例,无远期死亡.体外循环(105.0±26.9) min,主动脉阻断(64.1±21.4) min(OPCAB病例除外).术后即刻、出院时及平均随访(26.1±13.6)个月时房颤消融成功率分别为100％、82.5％及84.8％.左房内径小于60mm、房颤标测患者消融成功率显著提高(P＜0.05).结论 心外科手术同期行双极房颤射频消融术是安全有效的.左房内径小于60 mm、房颤标测为影响房颤近期疗效的独立影响因素,可能带来更佳的消融结果.     

阵发性心房颤动患者经导管射频消融治疗的护理

目的 探讨经导管射频消融治疗阵发性心房颤动患者的护理效果.方法 对12例接受介入治疗的阵发性心房颤动患者术前予以心理护理,术中严密观察、密切配合,术后严密监护、有效抗凝等措施.结果 12例患者一次射频消融治疗成功,随访4～8个月,10例无复发,2例术后第3、第29天复发,再次治疗好转.结论 科学的围术期护理是阵发性心房颤动患者经导管射频消融治疗顺利、预防或减少并发症的重要保障.     

Microwave surgical ablation for atrial fibrillation during off-pump coronary artery surgery using total arterial-Y-grafts: an early experience

This study demonstrates the efficacy and eligibility of concomitant epicardial microwave AF (MWAF) ablation during off-pump arterial revascularisation using the left internal mammary to radial 'Y' graft (OPCABy) in patients with permanent and paroxysmal atrial fibrillation. From June 2004 to December 2005, sixteen consecutive patients were offered MWAF ablation and OPCABy. AF was permanent in 11 cases and paroxysmal in five. The MWAF ablation protocol exploited the use of either the Flex 4 or Flex 10 probe (Afx- Guidant, Santa Clara, CA). Spontaneous cardioversion was used to demonstrate conduction block. Data were collected prospectively. Patients were followed-up in outpatient clinic at 6 weeks, 3 months and 6 months after discharge. Sinus rhythm was seen in 75%, 67% and 71% of patients at conclusion of surgery, and 3 and 6 months postoperatively. Cardioversion to sinus rhythm was seen in 67% of patients with permanent AF and 80% of patients with paroxysmal AF. Spontaneous cardioversion at operation occurred in 12 patients, all of whom were in sinus rhythm at six months. The use of MWAF ablation during concomitant OPCABy surgery is an effective therapy in the short- to medium-term. Spontaneous return to sinus rhythm is a reliable intraoperative indicator of long-term success.     

Biatrial radiofrequency ablation for atrial fibrillation: epicardial and endocardial surgical approach

Radiofrequency energy applied by means of surgical probes permits the ablation of atrial fibrillation (AF). This study presents our initial experience on 55 consecutive cardiac patients with permanent AF with radiofrequency ablation through biatrial epicardial and endocardial surgical approach. At discharge, 8.1% of the patients had persistent AF-atrial flutter. Hospital incidence of arrhythmias were, 9% of paroxysmal atrial fibrillation, 10.9% of atrial flutter, and 34.5% of persistent atrial fibrillation. After a mean follow-up of 7 months, 83.6% patients have recovered sinus rhythm, and echocardiographic biatrial contraction was re-established in 73%. Biatrial radiofrequency ablation applied from the endocardium and the epicardium has achieved satisfactory results, without increasing the surgical risk.     

Surgical treatment of permanent atrial fibrillation using microwave energy ablation: a prospective randomized clinical trial.

OBJECTIVE: Radiofrequency or the use of microwave energy in combination with atrial size reduction during open heart surgery have been reported to be effective in up to 75% in the treatment of permanent atrial fibrillation. However, no data from prospective randomized trials using microwave energy are available. METHODS: Forty-three patients with permanent atrial fibrillation undergoing open-heart surgery were randomly stratified into treatment group receiving microwave ablation and atrial size reduction (n=24) or control group (n=19). Patients in either group were treated with amiodarone or sotalol for 3 months if sinus rhythm or any atrioventricular rhythm was successfully restored. Follow-up time points were at 3, 6 and 12 month after surgery. RESULTS: In the treatment group 22 out of 24 patients (91,7%) were successfully converted to sinus rhythm by using intraoperative microwave ablation therapy whereas only six out of 19 (31.5%) patients converted to sinus rhythm directly after surgery. At 12-month follow-up there were still a significantly higher percentage of patients in the treatment group free from atrial fibrillation when compared to control (80 vs. 33.3%, P=0.036). CONCLUSION: The preliminary data from this first prospectively randomized trial indicate that microwave ablation combined with atrial size reduction is a safe and highly efficient treatment in permanent atrial fibrillation.     

Cryoablation of the left posterior atrial wall: 95 patients and 3 years of mean follow-up.

OBJECTIVE: Endocardial ablation of the left atrial posterior wall has been used to treat atrial fibrillation. Aim of the study was to evaluate its efficacy looking for the ablation pattern allowing a fast execution with limited interference on atrial contractility. Moreover a statistical analysis to identify predictors of long-term sinus rhythm recovery has been provided. METHODS: From April 1998 to May 2002, 95 patients with permanent (mean duration 65 months) or persistent (33%) atrial fibrillation have undergone three different ablation patterns, only 1 patient being affected by lone atrial fibrillation. Mean antero-posterior left atrial diameter was 76.2 mm. The prospective study collected information regarding variables related to patients' demographics, disease's characteristics and type of surgical ablation employed. Dependent variables were presence of sinus rhythm either at discharge and at 6 months. A logistic regression analysis was used to estimate the association between the collected variables and sinus rhythm restoration. RESULTS: In-hospital and late mortality rate were 3.2 and 6.3% respectively. At discharge 67 patients (72.8%) were in sinus rhythm while at a mean follow-up of 3 years, 81.4% of 86 surviving patients are in sinus rhythm. Major adverse events rate including cardiac reoperation, pace-maker implantation and cerebrovascular accident were 8.5, 6.3 and 4.2%, respectively. Pre-operative atrial fibrillation duration, left atrial dimension and type of mitral disease did not show any correlation with long term success while the lesion pattern and the rhythm at discharge were significant predictive factors. Survival is significantly higher in patients who converted to sinus rhythm at discharge (P=0.014) with respect to those who remained in atrial fibrillation. CONCLUSIONS: Permanent and persistent atrial fibrillation associated to a major cardiac disease can be safely treated with a linear ablation of the left atrial posterior wall. Satisfactory results in terms of rhythm restoration may be achieved regardless of the duration of the arrhythmia and its effects on atrial diameter. Any effort should be prompted to discharge patients in sinus rhythm. Life expectancy is longer if sinus rhythm is restored.     

Surgical ablation of atrial fibrillation with off-pump, epicardial, high-intensity focused ultrasound: results of a multicenter trial

BACKGROUND: A simplified alternative to the Cox maze procedure to treat atrial fibrillation with epicardial high-intensity focused ultrasound was evaluated clinically, and the initial clinical results were assessed at the 6-month follow-up visit. METHODS: From September 2002 through February 2004, 103 patients were prospectively enrolled in a multicenter study. Atrial fibrillation duration ranged from 6 to 240 months (mean, 44 months) and was permanent in 76 (74%) patients, paroxysmal in 22 (21%) patients, and persistent in 5 (5%) patients. All patients had concomitant operations, and ablation was performed epicardially on the beating heart before the concomitant procedure. The device automatically created a circumferential left atrial ablation around the pulmonary veins in an average of 10 minutes, and an additional mitral line was created epicardially in 35 (34%) patients with a handheld device by using the same technology. RESULTS: No complications or deaths were device or procedure related. There were 4 (3.8%) early deaths and 2 late extracardiac deaths. The 6-month follow-up was complete in all survivors. At the 6-month visit, freedom from atrial fibrillation was 85% in the entire study group (80% in patients with permanent atrial fibrillation, 88% in the 35 patients who had the additional mitral line, and 100% in patients with paroxysmal atrial fibrillation). A pacemaker was implanted in 8 patients. Only the duration and type of atrial fibrillation significantly increased the risk of recurrence. CONCLUSION: Epicardial, off-pump, beating-heart ablation with acoustic energy is safe and cures 80% of patients with permanent atrial fibrillation associated with long-standing structural heart disease.     

Surgical ablation of atrial fibrillation using the epicardial radiofrequency approach: mid-term results and risk analysis

BACKGROUND: The minor technical and time requirements with respect to the maze operation combined with a comparable efficacy has led to an increasing popularity of left atrial approaches to treat atrial fibrillation. We report our experience with a left atrial procedure based on extensive use of epicardial radiofrequency ablation in an effort to minimize cardiac arrest time. METHODS: A total of 132 consecutive patients with atrial fibrillation (121 chronic, 11 paroxysmal) undergoing open heart surgery had combined intraoperative ablation. An original set of left atrial lesions was performed using a radiofrequency linear catheter. Most of the ablations were performed epicardially before aortic cross-damping. Patients with contraindications to the epicardial approach had the whole lesion set performed endocardially. RESULTS: The mean cardiac arrest time spent for open heart ablations was significantly shorter (5.2 +/- 0.9 minutes with modem catheters) when the epicardial approach was used (107 of 132 patients, 81%). Hospital mortality was 0.8%. Freedom from atrial fibrillation was 77% 3 years after the operation. Of all the variables analyzed, only age at surgery and early postoperative arrhythmias increased the risk of recurrent atrial fibrillation. Overall 3-year survival was 94%. The 3-year actuarial freedom from stroke was 98%. No patient required implantation of a permanent pacemaker. Atrial contractility was recovered in all patients with stable sinus rhythm. CONCLUSIONS: Left atrial radiofrequency ablation allows recovery of sinus rhythm and atrial function in the great majority of patients with atrial fibrillation who undergo open heart surgery. The epicardial radiofrequency approach is a safe and effective means to cure atrial fibrillation with negligible technical and time requirements.     

外科射频消融术与经导管消融术治疗瓣膜病性房颤的疗效对比

目的 比较心内直视下射频迷宫术与介入导管消融术治疗合并心脏瓣膜病的心房颤动临床结果.方法 2004年1月到2006年3月因心脏瓣膜病合并心房颤动行瓣膜置换时加射频迷宫术60例,其中男34例,女26例;平均(57±11)岁.瓣膜置换术后在三维电解剖标测系统(CABTO)指导下进行经皮经导管环肺静脉消融治疗66例,其中男40例,女26例;平均(55±10)岁.结果 导管消融组随访(14±10)个月,窦性心律维持率64%.外科射频迷宫组随访(13±9)个月,窦性心律维持率75%,二者差异有统计学意义(P<0.05).对于病史小于1年、左房直径<50mm的阵发性房颤,导管消融组亦有较高的窦性心律维持率(分别为90%、82%).两组术后并发症无显著性差异.结论 射频迷宫术对瓣膜病合并心房颤动病人是简单、有效的治疗方法.若未行迷宫术,对于病史小于1年,左房直径小于50mm的阵发性心房颤动,瓣膜置换术后行经皮经导管消融术亦为一种有效的治疗方法.     

Surgical radiofrequency ablation of both atria for atrial fibrillation: results of a multicenter trial

BACKGROUND: The Cox maze procedure has shown to be effective in treating atrial fibrillation. Radiofrequency ablation, with a similar objective, has been used as an adjunct to conventional cardiac surgery for the treatment of atrial fibrillation in more than 20 centers in Australia and New Zealand since March 2000. This is a report of those results. METHODS: One hundred thirty-two patients in 20 centers underwent radiofrequency ablation as an adjunct to conventional cardiac surgery, with a standardized lesion set created with a flexible, 7-electrode, temperature-controlled probe (Cobra; EPTechnologies, San Jose, Calif). All data were entered into a central registry, with regular follow-up prompted by the registry cocoordinator. Each radiofrequency scar was made with standard parameters requiring 2 minutes of tissue coagulation at 80 degrees C to 85 degrees C. Patients undergoing mitral procedures had radiofrequency ablation performed in the left atrium endocardially. Patients undergoing aortic valve replacement or coronary artery bypass surgery underwent epicardial radiofrequency ablation of the left atrium. Epicardial radiofrequency ablation lesions on the right atrium were common to both groups of patients. Preoperatively, 75% of the patients had chronic atrial fibrillation, 21% had paroxysmal atrial fibrillation, and 4% had flutter. Surgical procedures performed included mitral valve procedure in 60%, coronary artery bypass grafting in 14%, aortic valve replacement in 7%, and coronary artery bypass grafting plus aortic valve replacement in 4%. RESULTS: There were no major complications related to the use of radiofrequency ablation. There were no soft tissue or cardiac perforations. Ten patients were defibrillated into sinus rhythm within 3 months postoperatively. The freedom from atrial fibrillation was 84% at 3 months, 90% at 6 months, and 100% at 12 months. All patients at 12 and 18 months' follow-up were in sinus rhythm. There were no thromboembolic complications. CONCLUSIONS: Surgical radiofrequency ablation can be performed safely as an adjunct to conventional cardiac surgery. A standardized lesion set created by using similar temperature settings can be adopted in multiple centers and might be effective in treating atrial fibrillation. Data collection through a central registry has helped in monitoring the effectiveness of this new technique in a scattered population.     

The biatrial cryo-maze procedure for treatment of atrial fibrillation: A single-center experience

Abstract

Objectives. The Cox-maze III procedure is the benchmark for atrial fibrillation (AF) surgery but has been replaced by surgical ablation. We evaluated our experience with biatrial cryoablation using the full Cox-maze III lesion pattern, and adhering follow-up to current guidelines. Design. Forty-three patients underwent the biatrial cryo-maze procedure as a concomitant (n = 37) or stand-alone procedure (n = 6). Mean age was 64.8 ± 9.5 years. Overall, AF was paroxysmal/persistent/permanent in 28/14/58%. Mean AF duration was 5.2 ± 6.5 years. Follow-up included prospective evaluation at 1, 3 and 12 months, long-term monitoring and transthoracic echocardiography. Results. No mortality and no complications related to the ablation procedure occurred. One patient suffered a stroke at 12 months. In the concomitant group, rhythm was sinus/pacing without AF/AF in 65/16/19% at three months, and 59/22/19% at 12 months. Five patients received new pacemakers (12%). In the stand-alone group, 5/6 (83%) patients had sinus rhythm with no AF at three and 12 months. Overall, 35/43 patients (81%) had sinus/paced rhythm at 12 months with no AF and no anti-arrhythmic drugs. Echocardiography showed satisfactory results in all patients. Conclusions. The biatrial cryo-maze procedure is safe and effective in surgical patients with concomitant AF, and could be considered for selected patients with lone AF.