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.     

超声心动图预测心房颤动患者左心房血栓形成

心房颤动(房颤)可促进左心房血栓形成,而血栓脱落后引起的血栓栓塞是其最严重的并发症之一。准确预测房颤患者左心房血栓的形成,对房颤术前风险评估及临床抗凝治疗方案的选择有重要价值。超声心动图具有无创、经济等优点,可为预测房颤患者左心房血栓的形成提供可靠信息。     

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。     

Congenital left atrial appendage aneurysm with unexpected course of left anterior descending coronary artery

The left atrial appendage (LAA) aneurysm is a rare condition that can produce local compressive effects and complications including supraventricular tachyarrhythmias, thromboembolic events and myocardial ischaemia. We present a rare case of a neonate with a congenital LAA aneurysm which resulted in local compressive effects on the left ventricle, severe mitral regurgitation and malposition of the left anterior descending (LAD) coronary artery. Intraoperatively, the LAD was found to be within the aneurysmal wall exterior to the left ventricular epicardium and was inadvertently injured during LAA aneurysm resection. Retrospective review of the preoperative computed tomography and echocardiography scans demonstrated the LAD lying within the wall of the LAA aneurysm, although this had not been well appreciated at that time. This highlights the importance of thorough multimodal preoperative imaging and intraoperative assessment for recognition of this rare association between the LAA aneurysm and LAD malposition, and prevention of inadvertent LAD injury during aneurysm resection.     

Systolic anterior motion of the mitral valve despite the sliding leaflet technique for repair of the mitral valve

We report a systolic anterior motion of the anterior mitral leaflet despite employing the sliding leaflet technique for repair of mitral valve regurgitation. A 65-year-old man with chronic, symptomatic mitral regurgitation due to ruptured chordae tendineae underwent mitral valve repair by quadrangular resection of the posterior leaflet and sliding leaflet technique with ring annuloplasty. After weaning from cardiopulmonary bypass, left ventricular outflow obstruction developed and transesophageal echocardiography demonstrated systolic anterior motion of the mitral valve and severe mitral regurgitation. Non-operative treatment resolved the outflow tract obstruction, systolic anterior motion and mitral regurgitation. We conclude that post-repair systolic anterior motion can still occur after the sliding plasty procedure and that medical treatment can successfully resolve systolic anterior motion and outflow tract obstruction in most patients.     

Role of left atrial appendage occlusion in patients with HeartMate 3

Open in a separate window OBJECTIVESLeft atrial appendage occlusion (LAAO) at the time of implantation may reduce thromboembolic events (TEs) during continuous-flow left ventricular assist device support. The HeartMate 3 (HM3) reduces TEs overall, but the efficacy of LAAO in HM3 is unknown.METHODSAdults receiving first HM3 implantation from November 2014 through December 2019 at a single, large medical centre were retrospectively reviewed. TEs included device thrombosis and ischaemic stroke. Patients were classified by whether they received LAAO or not. Incidence of TEs was compared between groups using cumulative incidence curves with competing risks (death and heart transplant) and risk factors for TEs were assessed with Fine and Gray competing risk regression.RESULTSA total of 182 patients received HM3, of whom 99 (54%) received LAAO versus 83 (46%) who did not. There were 14 TEs, including 13 strokes (7%) and 1 pump thrombosis (0.5%). No significant difference in the incidence of TEs in each group was found (Gray’s test: P = 0.35). LAAO was not associated with TEs in multivariable Fine–Gray analysis (P = 0.10) and no significant risk factors for TEs were found. There were zero disabling strokes in those who received LAAO compared to 6 (7%) in those who did not receive LAAO (P = 0.008).CONCLUSIONSA low number of TEs was observed in HM3 recipients. LAAO did not further reduce the overall rate of TEs in this patient population, though its use may be beneficial in preventing disabling ischaemic strokes after HM3 implantation.     

快速起搏犬左心耳致自主神经功能改变和神经重构的研究

目的 观察快速起搏(RAP)犬左心耳对自主神经功能及神经密度的影响,探讨自主神经系统(ANS)在心房颤动(AF)发生和维持中的作用.方法 成年健康Beagle犬14条,体质量(8.67±0.75) kg,雌雄不拘.随机分为快速起搏组(RAP组,n=7)和对照组(CTL组,n=7).RAP 组犬以400次/min连续起搏8周,诱导AF,CTL组不起搏.起搏8周后,应用短程心率变异指标观察犬自主神经功能变化;并用免疫组织化学染色技术检测犬心脏神经生长相关蛋白( GAP-43)、酪氨酸羟化酶(TH)的表达.结果 心率变异分析显示RAP组心率变异性(HRV)时域指标均较CTL组降低,频域指标RAP组的低频功率(LF)、高频功率(HF)较CTL组明显降低,LF/HF较CTL组明显增高;免疫组织化学结果显示,与CTL组比较,RAP组犬左心耳可见GAP-43、TH的阳性表达,其神经密度与CTL组比较显著升高;显微镜下显示取样部位心脏神经呈不均一性分布.结论 长期快速起搏左心耳致犬的慢性房颤模型中心脏自主神经功能失衡,神经纤维分布及密度改变,引起神经重构导致AF的发生和维持.     

双源CT评估心房颤动患者左心房及左心耳结构及功能重构

目的探讨应用双源CT评估心房颤动(AF)患者左心房及左心耳结构及功能改变,分析其与左心耳血栓形成的关系。方法回顾性分析84例AF患者(AF组)及对照组32例的心脏CT资料,以图像后处理软件测量左心房最大、最小容积(LAVmax、LAVmin)及左心耳最大、最小容积(LAAVmax、LAAVmin),计算左心房射血分数(LAEF)及左心耳射血分数(LAAEF)。根据临床症状将AF组患者分为阵发性AF亚组及持续性AF亚组,又根据是否存在左心耳血栓或"血栓前状态"分为AF左心耳血栓阳性亚组及阴性亚组,对左心房及左心耳容积及心功能指标进行统计学分析。结果 AF左心耳血栓两亚组LAVmax、LAVmin、LAAVmax及LAAVmin均明显高于对照组(P均0.05),且AF左心耳阳性亚组LAVmax、LAVmin、LAAVmax及LAAVmin均高于阴性亚组(P均0.01);AF左心耳血栓两亚组LAEF及LAAEF均明显低于对照组(P均0.001),且AF左心耳阳性亚组LAEF及LAAEF均低于阴性亚组(P均0.001)。持续性AF亚组LAEF及LAAEF均明显低于阵发性AF亚组(P均0.01),阵发性AF亚组与持续性AF亚组间LAVmax、LAVmin、LAAVmax及LAAVmin差异均无统计学意义(P均0.05)。持续性AF亚组左心耳血栓及"血栓前状态"发生率明显高于阵发性AF亚组[72.41%(21/29)vs 14.55%(8/55),χ2=113.46,P0.001]。结论当AF患者存在左心耳血栓或"血栓前状态"时,左心房及心耳结构及功能重构更明显。     

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...     

Early and late results of mitral valve repair with anterior leaflet patch augmentation

OBJECTIVESThe aim of this study was to determine the long-term results of mitral valve (MV) repair with anterior leaflet patch augmentation.Open in a separate windowMETHODSBetween 2012 and 2015, 45 patients underwent MV repair using the anterior leaflet patch augmentation technique at our institution. The mean age of the patients was 65.9 ± 13.0 years (16 males). We reviewed the MV pathology and the surgical techniques used and assessed the early and late results.RESULTSIn terms of MV pathology, 43 patients (95.6%) had pure mitral regurgitation (MR) and 2 patients (4.4%) had mixed mitral stenosis and MR. Rheumatic changes were seen in 18 patients (40.0%). Postoperative echocardiography showed that 95.6% of patients had none to mild MR. During a median follow-up period of 5.5 years (range 0.1–8.3 years), there were 8 late deaths. Nine patients (20%) required reoperation. The mean interval between the initial operation and redo operation was 3.7 ± 3.1 years (range: 0.4–7.8 years). The causes of reoperation included patch dehiscence (n = 4), progression of mitral stenosis (n = 2), band dehiscence (n = 1), patch enlargement (n = 1) and unknown (n = 1). Eight patients underwent MV replacement and 1 underwent repeat MV repair. The freedom from reoperation at 3 and 5 years was 85.7 ± 6.7% and 81.2 ± 7.7%, respectively.CONCLUSIONSAnterior leaflet patch augmentation can provide excellent early results in the majority of the patients even in the presence of rheumatic pathology; however, we observed late reoperation in 20% of patients. Thus, this technique should be used with caution and careful follow-up with serial echocardiography is essential.     

Successful repair of atrial fibrillation by surgical ablation in a patient with persistent left superior vena cava and mitral stenosis

We recently cared for a woman who had mitral stenosis, atrial fibrillation, absent right superior vena cava, and persistent left superior vena cava. She underwent mitral valve replacement and surgical ablation of the pulmonary vein, and conjunction of the coronary sinus and left superior vena cava. Her atrial fibrillation was cured and successfully restored to sinus rhythm postoperatively.     

Cor triatriatum in adulthood with mitral valve regurgitation and atrial fibrillation

Cor triatriatum is a rare congenital heart disease. A 57‐year‐old woman had cor triatriatum with severe mitral valve regurgitation (MR) and atrial fibrillation (AF). We performed mitral valve repair, left atrial appendage resection, and maze procedure by resection of the anomalous septum in the left atrium. As a result, MR was controllable and AF disappeared after the operation. Although there is no established maze procedure with cor triatriatum, removing the septum was effective to complete it.     

超声心动图新技术评价房颤患者左心房结构和功能的研究进展

心房颤动(简称房颤)可导致卒中、心力衰竭等严重并发症,评估左心房的结构和功能对监测房颤病情及评估预后有重要价值。实时三维超声心动图、斑点追踪成像等超声新技术可为临床评价房颤患者左心房结构和功能提供详细、准确的信息。     

胺碘酮与普罗帕酮转复心房颤动临床比较

目的胺碘酮与普罗帕酮转复心房颤动临床比较。方法我院入选的74例患者按随机数字表法分为胺碘酮组和普罗帕酮组。胺碘酮组（37例）：将胺碘酮150mg加入葡萄糖20mL,15min左右缓慢静脉推注,继之胺碘酮300mg加入葡萄糖500mL,以0.5-1mg/min静滴维持。复律成功后,口服胺碘酮维持。普罗帕酮组（37例）：70mg普罗帕酮静脉注射,于15min左右完成。推注完毕尚未转复者,继之140mg以0.5-1mg/min静滴。复律成功后,口服胺碘酮维持。所有患者均予持续24h心电监护,记录房颤转复的时间,比较两组患者转复率。结果胺碘酮组37例转复成功27例（72.97%）;普罗帕酮组37例转复成功19例（51.35%）;转复成功率胺碘酮组高于普罗帕酮组,差异有显著性（P〈0.05）。两组均未出现明显不良反应。结论胺碘酮治疗心房颤动比普罗帕酮效果好且安全可靠。     

风湿性二尖瓣狭窄患者左心房流体力学观察

目的探讨风湿性二尖瓣狭窄(MS)患者发生心房颤动(AF)与左心房流体力学环境的关系.方法根据术前心律情况不同,将49例合并AF的MS患者分为2组,A组(n＝25):合并慢性AF,B组(n＝24):均为窦性心律;对照组:29例正常人作为对照.采用超声心动图检测3组左心房流体力学指标,术后6～8个月复查.结果术后A组左心房机械应力(LAS)、左心房面积(LAA)和左心房容积(LAV)均较术前降低或减少,B组LAS亦较术前明显降低(P＜0.01).术前A组LAS明显低于B组,LAA、LAV明显大于B组;术后A组LAA、LAV仍大于B组(P＜0.01).术前、术后A组、B组LAS、LAA、LAV均高于或大于对照组.结论 MS患者术后左心房流体力学环境远未恢复正常,LAS可能是导致MS患者发生AF的重要因素.     

Survival and sinus rhythm maintenance after modified Cox/maze procedure and mitral valve operation in patients with chronic atrial fibrillation

OBJECTIVE: Sinus rhythm gained after the Cox/maze procedure concomitant with mitral valve operation has demonstrated long-term attrition during the follow-up, no information exists on whether the type of mitral valve operation--(repair vs. replacement)--affects this sinus rhythm maintenance rate. We retrospectively studied patients undergoing concomitant mitral valve operation and Cox/maze procedure to answer this question. METHODS: Between April 1993 and August 1995, 87 consecutive patients--35 men and 52 women (mean age: 59.3 years)--with chronic atrial fibrillation and mitral valve disease underwent the modified Cox/maze procedure and concomitant mitral valve operation, with 56 having mitral valve repair (repair group) and 31 mitral valve replacement (replacement group). Patients were followed up and changes in rhythm studied retrospectively. RESULTS: Follow-up for a mean 51.3 +/- 11.6 months was completed in 82 of 83 long-term survivors (99%). Repair group surgery survival was 98.1 +/- 1.9% at 1 year and 94.2 +/- 3.2% at 5 based on the Kaplan-Meier method. Replacement group surgery survival was 85.7 +/- 5.9% at 1 year and 82.9 +/- 6.4% at 5. Probability in sinus rhythm maintenance for the repair group at 1 year was 88.6 +/- 5.4% and at 5 years was 67.6 +/- 9.1%. Probability in sinus rhythm maintenance for the replacement group at 1 year was 95.7 +/- 4.3% and at 5 years was 65.0 +/- 11.1%. CONCLUSIONS: Medium-term results after the Cox/maze III procedure concomitant with mitral valve operation are good. The attrition of sinus rhythm maintenance appears similar by the completion of 5-year follow-up.     

改良Mini-Maze手术患者左心耳组织PITX2及KCNQ1蛋白表达特点分析及其临床相关性分析

目的 通过检测改良Mini-Maze手术心房颤动(房颤)患者左心耳组织PITX2及KCNQ1蛋白表达水平,结合临床数据对不同类型房颤的临床危险因素进行分析.方法 收集2017年2月至2018年8月因房颤于本中心行手术患者共59例的左心耳组织,其中58例行改良Mini-Maze手术,即双侧微创切口下行双极射频消融术、双侧...