心脏瓣膜手术同期微波消融治疗心房纤颤

心房纤颤（AF）是心脏瓣膜疾病最常合并的心律失常之一,在风湿性心脏病二尖瓣病变的病人中,AF的发生率可达40%～60%,且术后仍为AF的发生率可高达80.09%.心内直视手术病例,药物、冷冻、手术前后介入及附加迷宫手术（MAZE手术）治疗AF疗效差别较大.心内直视手术同期采用微波消融治疗AF,具有创伤小、并发症少、疗效确切等优点.2003年5月至2005年5月,我们在心脏瓣膜手术同期微波消融治疗合并的AF 82例,早期效果满意.     

瓣膜置换术中直视双极射频消融治疗风湿性心脏病心房纤颤70例

心房纤颤(atrial fibrillation,AF)是常见的快速性室上型心律失常.风湿性心脏病(RHD)合并AF病程长,多为持续性AF和慢性AF,是内科治疗容易复发原因之一.目前AF的微创外科治疗较引人注目,射频消融(radiofrquency ablation,RFA)是其中研究热点之一[1].我们在瓣膜置换术中心内直视应用美国Atricure公司产双极射频消融系统行改良迷宫术射频消融治疗RHD合并AF,取得了较好的效果,现总结报道如下.     

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。     

心瓣膜置换时采用盐水冲洗射频改良迷宫手术治疗心房颤动

目的介绍心瓣膜置换时采用盐水冲洗射频改良迷宫手术治疗心房颤动(AF)的技术要点。方法对74例心瓣膜疾病合并AF患者行心瓣膜置换时采用盐水冲洗射频改良迷宫手术治疗AF,射频能量25~30W,盐水冲洗速度180~240m l/h。首先完成右心房主要的切口和消融,在心脏停搏后进行左心房消融,继后处理心瓣膜。心脏复跳后再完成右心房剩余的消融和缝合切口。结果本组患者体外循环时间102±26m in,主动脉阻断时间58±22m in,射频消融时间12±5m in。住院死亡2例,其中死于机械瓣膜故障1例,多器官功能衰竭1例。术后随访70例,随访时间1.0~3.5年,随访过程中突然死亡2例。60例患者恢复窦性心律(85.7%,60/70)。结论心瓣膜疾病合并持续AF的患者在行心瓣膜置换术时,同期行盐水冲洗的射频改良迷宫手术是合理及有效的。     

射频消融迷宫手术治疗大左房心房颤动合并瓣膜病变临床效果观察（附9例报告）

心瓣膜病患者出现心房颤动（AF）较为常见,二尖瓣病变患者其AF发生率可达60％左右.一般认为瓣膜病变合并大左房AF患者射频消融迷宫手术效果较差,且大左房合并血栓者复发率更高.2011年1月至2013年7月我们对9例瓣膜病变合并大左房AF患者行心脏瓣膜手术同期施行射频消融迷宫手术.术后随访近中期临床效果良好,总结治疗经验,现报告如下.     

盐水冲洗射频改良迷宫Ⅲ手治疗心房颤动的临床效果

目的 评价心瓣膜手术时用盐水冲洗射频改良迷宫Ⅲ手术(IRFMM)治疗心房颤动(AF)的临床效果.方法 自2003年12月至2005年10月,我科采用外科手术射频消融系统,在20例心瓣膜病患者手术中用IRFMM治疗AF.射频功率设定为25W,盐水冲洗速度为5ml/min.结果 术后20例中16例转为窦性心律.随访1～22个月,17例维持窦性心律,1例为结性心律,2例仍为AF.结论 在行伴有AF的风湿性心脏病瓣膜置换术时,采用盐水冲洗射频改良迷宫Ⅲ手术治疗AF,具有安全简便、疗效确切的效果,值得推广应用.     

盐水冲洗射频改良迷宫Ⅲ手术治疗心房颤动的临床效果

目的评价心瓣膜手术时用盐水冲洗射频改良迷宫Ⅲ手术（IRFMM）治疗心房颤动（AF）的临床效果。方法白2003年12月至2005年10月，我科采用外科手术射频消融系统，在20例心瓣膜病患者手术中用IRFMM治疗AF。射频功率设定为25W，盐水冲洗速度为5ml／min。结果术后20例中16例转为窦性心律。随访1～22个月，17例维持窦性心律，1例为结性心律，2例仍为AF。结论在行伴有AF的风湿性心脏病瓣膜置换术时，采用盐水冲洗射频改良迷宫Ⅲ手术治疗AF，具有安全简便、疗效确切的效果，值得推广应用。     

心外膜环左心房消融联合肺静脉消融对心房颤动的影响

目的评价心外膜环左心房消融(CLAA)联合肺静脉隔离(PVI)治疗心房颤动(AF)的有效性。方法实验用猪30例,体重60~78 kg,应用抽签法随机分为3组:心房颤动对照组(AF组,n=10)、肺静脉消融组(PVI组,n=10)、环左心房消融联合肺静脉消融组(CLAA+PVI组,n=10)。通过心房快速起搏构建持续的AF模型。AF构建成功后,AF组不做消融处理;PVI组应用双极射频消融钳做肺静脉隔离消融;CLAA+PVI组应用双极射频消融钳先做肺静脉隔离消融,再做环左心房消融。消融后,应用电复律将所有AF猪恢复窦性心律,再次检测并比较各组AF易感性及AF维持时间的差异。结果所有猪均经左心房快速起搏成功构建成稳定、持续的AF模型。PVI组和CLAA+PVI组顺利在心脏不停跳下实施心外膜消融术。单纯PVI使3例(15%)终止AF,CLAA+PVI使5例(62.5%)终止AF(P=0.022)。全部猪恢复窦性心律后,burst起搏可使AF组10例全都诱发成持续的AF;PVI组仅有3例(P=0.003)诱发成持续的AF,CLAA+PVI组(P0.001)无持续的AF诱发成功,均显著低于AF组;而PVI组与CLAA+PVI组差异无统计学意义(P=0.211)。PVI组的房颤平均维持时间较AF组明显缩短(P=0.003);CLAA+PVI组也较AF组明显缩短(P0.001);与PVI组相比,CLAA+PVI组的房颤平均维持时间也明显缩短(P=0.008)。结论与单纯PVI相比,CLAA+PVI可以更有效终止AF,抑制AF的复发,提高AF的治疗效果。     

心内直视手术中射频消融改良迷宫术治疗心房纤颤

目的评价心内直视手术中射频消融（radiofrequency ablation,RFA）改良迷宫术（MazeⅢ）治疗心房纤颤（atrial fibrillation,AF）的手术疗效。方法2002年5月～2008年4月,102例风湿性心脏病（风心病）合并AF的患者接受心内直视手术,同时采用RFA改良迷宫手术,回顾性分析并随访比较手术前后心电图、超声心动图检查等指标。结果RFA改良迷宫术所需时间（15.2±4.3）min。全组无死亡。与RFA相关并发症包括：二次开胸止血1例（1.0%）,心包积液2例（2.0%）,Ⅲ度房室传导阻滞安置永久起搏器2例（2.0%）。术后12个月时,窦性心律恢复率79.4%（81/102）。其中左心房最大径≤55mm者12个月时窦性心律维持率明显高于左心房最大径〉55mm的患者[98.3%（57/58）vs54.5%（24/44）,χ2=29.265,P=0.000];房颤病程短于2年者12个月时窦性心律维持率明显高于病程长于2年者[100.0%（35/35）vs68.7%（46/67）,χ2=13.814,P=0.000]。结论心内直视手术中射频消融改良迷宫术治疗AF安全可行,临床效果好。     

用ND：YAG激光行心房迷宫术治疗心房颤动的研究

应用ＮＤ：ＹＡＧ激光代替ＣＯＸ用手术刀切开进行心房迷宫术治疗心房颤动的离体犬心和体外循环下犬的动物实验，结果表明，ＮＤ：ＹＡＧ激光烧灼心房肌是安全可靠的。按ＣＯＸ心房迷宫术的切口进行激光烧灼，能阻断心房折返环的通道，并保留特定通道传导窦房结冲动至房室结，激动心室。作者对动物模型的建立，激光烧灼心房肌时的注意事项、优越性及其临床应用前景进行了讨论。     

A Swedish consensus on the surgical treatment of concomitant atrial fibrillation

Atrial fibrillation (AF) is a common arrhythmia among patients scheduled for open heart surgery and is associated with increased morbidity and mortality. According to international guidelines, symptomatic and selected asymptomatic patients should be offered concomitant surgical AF ablation in conjunction with valvular or coronary surgery. The gold standard in AF surgery is the Cox Maze III ("cut-and-sew") procedure, with surgical incisions in both atria according to a specified pattern, in order to prevent AF reentry circuits from developing. Over 90% of patients treated with the Cox Maze III procedure are free of AF after 1 year. Recent developments in ablation technology have introduced several energy sources capable of creating nonconducting atrial wall lesions. In addition, simplified lesion patterns have been suggested, but results with these techniques have been unsatisfactory. There is a clear need for standardization in AF surgery. The Swedish Arrhythmia Surgery Group, represented by surgeons from all Swedish units for cardiothoracic surgery, has therefore reached a consensus on surgical treatment of concomitant AF. This consensus emphasizes adherence to the lesion pattern in the Cox Maze III procedure and the use of biatrial lesions in nonparoxysmal AF.     

A Swedish consensus on the surgical treatment of concomitant atrial fibrillation

Abstract

Atrial fibrillation (AF) is a common arrhythmia among patients scheduled for open heart surgery and is associated with increased morbidity and mortality. According to international guidelines, symptomatic and selected asymptomatic patients should be offered concomitant surgical AF ablation in conjunction with valvular or coronary surgery. The gold standard in AF surgery is the Cox Maze III (“cut-and-sew”) procedure, with surgical incisions in both atria according to a specified pattern, in order to prevent AF reentry circuits from developing. Over 90% of patients treated with the Cox Maze III procedure are free of AF after 1 year. Recent developments in ablation technology have introduced several energy sources capable of creating nonconducting atrial wall lesions. In addition, simplified lesion patterns have been suggested, but results with these techniques have been unsatisfactory. There is a clear need for standardization in AF surgery. The Swedish Arrhythmia Surgery Group, represented by surgeons from all Swedish units for cardiothoracic surgery, has therefore reached a consensus on surgical treatment of concomitant AF. This consensus emphasizes adherence to the lesion pattern in the Cox Maze III procedure and the use of biatrial lesions in nonparoxysmal AF.     

Surgery for atrial fibrillation: a worldwide review

Maze procedure is highly effective in converting atrial fibrillation (AF) back to sinus rhythm and significantly prevents thromboembolism postoperatively. However, the procedure has not been widely performed by many surgeons, because of the technical demand and potential risk of complications of the procedure. During the past several years, the surgical strategy for AF has evolved dramatically and significantly. The evolution can be classified into two strategies: simplification of the lesion set and development of ablation devices. Isolation of the pulmonary veins with or without left atrial incisions has been shown to cure AF in selected patients. During the past decade, a number of ablation devices have been developed to replace the cut-and-sew lesions of the maze procedure and lessen the invasiveness of the procedure. The challenge in AF surgery is in the development and establishment of an off-pump thoracoscopic procedure in the patients with isolated AF. In addition to the development of ablation devices, intraoperative electrophysiological assessment of the triggers and substrates of AF for a step-by-step tailored approach and verification of conduction block over the ablation line should be established to accomplish a high success rate for AF.     

An overview of energy sources in clinical use for the ablation of atrial fibrillation

Recent years have seen many developments in the field of alternative energy sources for arrhythmia surgery. The impetus behind these advances is to replace the traditional, "cut-and-sew" Cox maze III procedure with lesion sets that are simpler, shorter, and safer but just as effective. There is demand for technology to make continuous, linear, transmural ablations reliably with a versatile energy source via an epicardial approach. This would make minimally invasive endoscopic surgical ablation of atrial fibrillation (AF) without cardiopulmonary bypass and with a closed chest feasible. These advances would shorten cardio-pulmonary bypass and improve outcomes in patients having surgical ablation and concomitant cardiac surgery. This review summarizes the technology behind alternative energy sources used to treat AF. Alternative energy sources include hypothermic sources (cryoablation) and hyperthermic sources (radiofrequency, microwave, laser, ultrasound). For each source, the biophysical background, mode of tissue injury, factors affecting lesion size, and advantages and complications are discussed.     

Medium-term outcome of different surgical methods to cure atrial fibrillation: is less worse?

Different lesion sets and ablation techniques have been performed. We compared these outcomes in search of the best method. We performed a retrospective analysis of patients who have undergone AF surgery different from the maze III. The surgical lesion sets were pulmonary vein isolation (PVI) alone, left atrial maze (LAM) and bi-atrial maze (BAM) and were made with different ablation techniques. During surgery one patient died due to bleeding of a pulmonary vein. The number of patients in the PVI-, LAM-, BAM-groups was 12, 28 and 26, respectively, with freedom from AF at latest follow-up [22.0+/-15.6 (3.1-81.2) months] of 33%, 59% and 60%, respectively. Atrial flutter occurred less in the BAM-group (4%) than in the left-sided procedures (15.4%) (P=0.231). Multivariate analysis demonstrated a higher recurrence of AF for PVI alone (OR 4.42, CL 0.95-20.6, P=0.0583) and a lower recurrence for the 'cut-and-sew' technique (OR 0.13, CL 0.030-0.60, P=0.0084). Left- and bi-atrial maze procedures are equally effective in the suppression of AF, whereas omission of right-sided lesions results in a higher prevalence of atrial flutter. The 'cut-and-sew' technique is superior in terms of freedom from AF compared to bipolar and unipolar radiofrequency.     

Current Status of the Surgical Treatment of Atrial Fibrillation

Atrial fibrillation (AF) affects several million patients worldwide and is associated with a number of heart conditions, particularly coronary artery disease, rheumatic heart disease, hypertension, and congestive heart failure. The treatment of AF and its complications is quite costly. Atrial fibrillation usually results from multiple macro-re-entrant circuits in the left atrium. Very frequently, particularly in association with mitral valve disease, these circuits arise from the area of the junction of the pulmonary venous endothelium and the left atrial endocardium. Pharmacological therapy is at best 50% effective. Therapeutic options for AF include antiarrhythmic drugs, cardioversion, atrioventricular (A-V) node block, pacemaker insertion, and ablative surgery. In 1987, Cox developed an effective surgical procedure to achieve ablation. Current ablative procedures include the classic cut-and-sew Maze operation or a modification of it, namely through catheter ablation, namely, cryoablation, radiofrequency ablation (dry or irrigated), and other forms of ablation (e.g., laser, microwave). These procedures will be described, along with the indications, advantages and disadvantages of each. Special emphasis on the alternative means to cutting and sewing to achieve appropriate effective atrial scars will be stressed, and our experience with these approaches in 50 patients with AF and associated cardiac lesions and their outcomes is presented.     

Surgical topics in the management of cardiac arrhythmia, focusing on atrial fibrillation

Among cardiac arrhythmias, surgical treatment for atrial fibrillation (AF) has developed the most in recent years. Instead of the cut-and-saw method in the Cox-Maze procedure, which had been the gold standard for AF surgery, surgical ablation systems using various energy source and devices have been utilized to facilitate rapid, safe creation of lines of conduction block under direct view. The challenge of establishing a minimally invasive off-pump surgical ablation procedure via the thracoscopic approach continues.     

What is essential for the elimination of persistent or chronic atrial fibrillation?

Dr. James Cox devised the maze procedure as a radical intervention for lone atrial fibrillation (AF) based on the multiple reentry theory. Dr. Micheal Haissaguerre discovered ectopic foci from the pulmonary veins were the trigger for paroxysmal AF. We demonstrated the efficacy of the pulmonary vein box isolation procedure for chronic AF. Dr. Koonlfawee Nademanee reported the complex fractionated atrial electrogram (CFAE) procedure to eliminate the substrate of chronic AF, which is distributed around the pulmonary veins. The complete isolation of all pulmonary veins is essential for the elimination of AF.     

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.     

Learning what works in surgical cryoablation of atrial fibrillation: results of different application techniques and benefits of prospective follow-up

Atrial fibrillation (AF) in cardiac surgical patients is detrimental in the long perspective. Concomitant surgical ablation of AF is recommended in guidelines and performed in most centers. The article describes the experiences in a single institution with concomitant surgical argon-based cryoablation in 115 patients using three different application techniques (epicardial left atrium, endocardial left atrium, biatrial cryo-maze) and a structured local follow-up to one year postoperatively. Results showed cryoablation to be safe with few complications related to the ablation procedure and few thromboembolic events. In this study, a complete biatrial lesion set according to the classic Cox-maze III (CM III) lesion pattern yielded a higher success rate than left atrial procedures. At 12 months, patients in sinus or pacing rhythm, free of AF without antiarrhythmic drugs, were 27/39 (69%), 24/32 (74%) and 36/44 (82%) in the EpiLA, EndoLA and cryo-maze groups, respectively. A consistent prospective follow-up is essential not only for research purposes but also for assessing the local results of AF surgery in everyday practice. It may direct and develop the surgical ablation program, guide individual postoperative arrhythmia management and is needed to increase overall quality of surgical AF ablation.