直视下射频消融肺静脉口治疗风湿性心脏病心房颤动的临床观察

目的探讨心脏直视下射频消融肺静脉口治疗风湿性心脏病心房颤动(房颤)的临床疗效。方法对20例风湿性心瓣膜病伴房颤患者(治疗组),在瓣膜置换术中应用射频探针在左心房内行直视下围绕4个肺静脉口的环形线性消融及消融环最低点与二尖瓣环连线的直线消融,输出功率30～40 W,每次放电时间45～60 s。以20例单纯行瓣膜置换术的风湿性心瓣膜病伴房颤患者为对照组,两组均同时应用胺碘酮辅助治疗,比较两组治疗房颤的疗效。患者治疗后均获得随访,平均随访(24±3)个月。结果治疗组心脏复跳后19例转为窦性心律,住院期间房颤复发2例,随访中房颤复发1例,总有效率80%(16／20);对照组心脏复跳后16例为窦性心律,住院期间房颤复发7例,随访中房颤复发2例,总有效率35%(7/20)无心房穿孔、出血及房室传导阻滞等并发症。结论直视下射频消融肺静脉口治疗风湿性心脏病房颤有效率较高,方法简单,并发症少。     

心脏瓣膜置换术同期冲洗式射频消融术效果观察

目的观察瓣膜置换手术同期冲洗式射频消融术对慢性房颤的临床治疗效果。方法对31例心脏瓣膜病患者行瓣膜置换手术同期冲洗式射频消融术，观察手术前后左房变化、术后心电图变化、术后引流量、术后血制品用量等。结果本组患者平均转机时间（105．86±20．88）min，平均阻断时间（60．71±16．57）min，与我院同期心脏瓣膜置换手术比较差异无统计学意义（P〉0．05）；术后13例（41．9％）需临时起搏器维持心率，均于术后12h～12d恢复自主心律（房颤或窦性心律）；术后随访6～21个月，平均（15．6±3．7）个月，术后1个月，14例（14／31）恢复窦性心律，术后1年，20例（20／27）恢复窦性心律。术后1个月随访恢复窦性心律的14例（转复组）与未复律的17例（房颤组）比较，两组术前左房内径、术后左房内径／术前左房内径差异有统计学意义（P〈0．05）。结论心脏瓣膜置换术同期冲洗式射频消融术是治疗心脏瓣膜病患者慢性房颤的有效、安全手段。     

心瓣膜轩换术后心房颤动电转复后对维持窦性心律的？…

目的 探讨心瓣膜置换术后心房颤动（Ａｆ）电转复后影响维持窦性心律的因素。方法 心瓣膜置换术后１个月心律仍为Ａｆ的瓣膜病患者１５２例，电转复后随机分为两组，胺碘酮组和对照组（不用任何抗心律失常药物）；随访１年，动态观察Ａｆ复发情况。结果 电转复后前３个月内两组间Ａｆ复发率差异无显著性；３～８个月内对照组Ａｆ复发率明显高于胺碘酮组，而８个月后两组间Ａｆ的复发率无显著差异。除与是否使用抗心律失常药物有关     

胺碘酮对体外循环后心脏复跳及自律性的影响

目的观察胺碘酮对体外循环术后心脏复跳及自律性的影响。方法择期二尖瓣置换的房颤患者64例随机分为三组,分别在体外循环期间静脉注射胺碘酮8mg/kg（A组）,4mg/kg（B组）或等量生理盐水（C组）。观察转流时间、心脏复跳时间、自律性、临时心脏起搏及血管活性药物使用情况。结果与A、B组相比,C组的后并行时间和转流时间显著延长（P〈0.01）,自动复跳、复跳后窦律比例显著降低（P〈0.05和P〈0.01）,停机后多巴胺使用量显著增加（P〈0.01）。A组临时起搏器使用比例较其它两组显著增加（P〈0.05）。各组复跳后窦律患者左房小于房颤患者（P〈0.01）,C组窦律患者左房小于其它两组（P〈0.01）。结论体外循环术中心脏复跳前使用胺碘酮可以增加房颤患者心脏自动复跳的成功率,更好地维持窦性心律,稳定血流动力学,减少多巴胺用量及体外循环时间。     

心内直视手术同期双极射频消融治疗心房颤动137例的临床效果

目的评估双极射频消融术在心内直视手术中治疗心房颤动(房颤)的临床效果。方法回顾性分析2009年5月至2014年6月137例合并房颤(21例合并左心房血栓)的心脏病患者行心脏直视手术同期进行双极射频消融术的临床资料,男61例、女76例,年龄35~73(48.3±11.6)岁。患者术后口服胺碘酮6个月,并定期随访,记录窦性心律转复率、术中术后并发症发生率,心功能改善情况、术后生存率、血栓栓塞发生率以及其他手术并发症等。结果 137例患者术中体外循环时间为(122±38)min,主动脉阻断时间为(78±22)min,射频时间为(20±4)min。手术当日130例房颤消除,其中转为窦性心律114例,交界性心律16例,房颤消除率为94.9%。围手术期死亡2例,住院死亡率为1.5%。术后1个月、6个月、1年、2年的窦性心律转复率分别为81.5%(110/135)、88.1%(111/126)、83.1%(74/89)、83.0%(39/47)。术后1年和2年生存率分别为96.6%(86/89)和93.6%(44/47)。随访期间无远期血栓栓塞发生。结论心内直视手术同期双极射频消融手术有选择地治疗合并有房颤的心脏疾病患者,仅轻微增加了转流及主动脉阻断时间。双极射频消融手术窦性心律转复率高,短中期效果好,远期效果仍需进一步观察。     

心瓣膜置换术后心房颤动电转复后对维持窦性心律的影响因素

目的　探讨心瓣膜置换术后心房颤动 (Af)电转复后影响维持窦性心律的因素。　方法　心瓣膜置换术后 1个月心律仍为 Af的瓣膜病患者 15 2例 ,电转复后随机分为两组 ,胺碘酮组和对照组 (不用任何抗心律失常药物 ) ;随访 1年 ,动态观察 Af复发情况。　结果　电转复后前 3个月内两组间 Af复发率差异无显著性 ;3～ 8个月内对照组Af复发率明显高于胺碘酮组 ,而 8个月后两组间 Af的复发率无显著差异。除与是否使用抗心律失常药物有关外 ,Af的复发还与术前心功能、心瓣膜置换数、术前左心房和左心室大小及术前 Af持续时间有关。　结论　抗心律失常药物治疗可减少心瓣膜置换术后 Af电转复后 Af复发的风险 ,提高患者生存质量 ;有左心房、室扩大及 Af史是维持窦性心律的不利因素。     

双极射频消融迷宫术后同步电复律治疗心房颤动

目的总结双极射频消融迷宫术（CoxⅣ）术后同步电复律治疗心房颤动（AF）的临床经验。方法 2006年7月至2009年7月沈阳军区总医院对223例AF患者行CoxⅣ治疗,其中13例患者（包括男4例,女9例;年龄41~69岁;风湿性心脏病7例,退行性心瓣膜病5例,继发孔型房间隔缺损合并三尖瓣关闭不全1例）于出院后仍为AF而药物转复不佳,行同步电复律治疗。电复律后观察心率和心律情况,监测生命体征,出院后继续口服胺碘酮200 mg,1次/天,定期门诊随访。结果 CoxⅣ手术后6个月内行同步电复律4例,即刻转复窦性心律3例;6个月以上行同步电复律9例,即刻转复窦性心律4例、AF 2例、交界性心律3例。CoxⅣ术后1年以上行电复律3例,转复窦性心律2例。13例均获随访,随访时间6个月~1年。随访期间窦性心律8例（61.54%）、AF4例（30.77%）、交界性心律1例（7.69%）。7例电复律后即刻转复为窦性心律的患者中有1例复发,窦性心律维持率为85.71%（6/7）;6例即刻未转复为窦性心律患者中有2例转为窦性心律。窦性心律患者复律后左心房内径（LAD）较复律前明显减小（39.00±5.15 mm vs.54.50±3.63 mm,t=6.958,P=0.000）,而AF患者LAD在复律前后无明显改变（51.00±5.72 mm vs.48.00±5.89 mm,t=0.731,P=0.493）。结论 CoxⅣ手术后电复律治疗AF安全有效,成功率高,是CoxⅣ术后控制AF的重要治疗手段。复律时机以术后6个月以内为宜,即刻转复窦性心律成功率较高,维持率也高。LAD明显缩小者电复律效果较好。     

胺碘酮治疗不同病因房颤患者的疗效观察及护理体会

目的:探讨静脉注射盐酸胺碘酮对不同病因房颤患者转复的疗效及转复期间护理的技巧和安全对策.方法:对104例房颤患者给予胺碘酮转律治疗,先静脉匀速注射,后静脉微量泵注射.结果:胺碘酮可有效转复房颤,不同病因房颤患者转复率不同.结论:静脉注射盐酸胺碘酮对不同病因房颤患者转复率不同,有基础心脏疾病患者转复率低于无基础心脏疾病患者.加强护理更有利于转复期间降低不良反应和提高转复疗效.     

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。     

房颤或房扑患者行心内直视手术静脉注射胺碘酮及美托洛尔对心律的作用

目的 比较观察术前存在房颤或房扑患者行心内直视手术在主动脉开放后静脉注射胺碘酮或美托洛尔对患者心律的作用.方法 选择术前存在房颤和房扑拟行心内直视手术患者68例.随机分为三组:胺碘酮组(A组,23例),在主动脉开放后,自主心跳已恢复,给予胺碘酮150 mg静脉推注,其后10 mg·kg-1·d-1维持;美托洛尔组(B组,23例),在主动脉开放后,自主心跳已恢复,给予美托洛尔2 mg静脉推注,其后美托洛尔1 mg/h总量10 mg;对照组(C组,22例),在主动脉开放后静注安慰剂.监测ECG、桡动脉压(ASP)、中心静脉压(CVP)、心脏指数(CI),随访术后心律转复情况.结果 A组和B组不增加心律转复成功率,但与C组比较HR较慢(P<0.01),CI较高(P<0.01).并且ICU滞留时间较短(P<0.01),A组和B组相比差异无统计学意义.转复率与房颤病史密切相关.结论 房颤或房扑患者在心内直视手术中,主动脉开放后静脉给予胺碘酮或美托洛尔虽然都不增加心律转复成功率,但能更好地控制心室率,而达到更稳定的血流动力学效果.     

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.     

心脏瓣膜置换同期双极射频消融的围术期护理体会

目的探讨心脏瓣膜病合并房颤的患者,在行瓣膜置换的同时联合进行双极射频消融术时,在围术期各阶段所采取的护理措施。方法我科从2012年6月至2013年4月对80例风湿性心脏瓣膜病合并房颤的患者,实施了心脏瓣膜置换联合双极射频消融术,其中二尖瓣置换＋双极射频消融术17例,二尖瓣置换＋三尖瓣成形术＋双极射频消融术31例,主动脉瓣置换＋二尖瓣置换＋双极射频消融术9例,主动脉瓣置换十二尖瓣置换＋三尖瓣成形术＋双极射频消融术23例。结果本组共11例患者出现心律失常,其中7例为室上速,4例口服可达龙后心率维持在100~／min左右,3例经静脉泵入后心率维持在100～120~／min,上述患者出院时心率基本正常,嘱患者出院后继续口服可达龙;另有4例出现窦性心动过缓,心率50～60次／min,经过停用可达龙,1例心率恢复正常,2例给予异丙肾上腺素0．01—0．05斗∥（kg·min）微量泵泵入,2～7d后心率恢复正常,1例使用心表临时起搏器,2周后顺利停用,恢复正常心率。所有患者均康复出院,出院时维持窦性心律。出院后随访3—12个月,均维持窦性心律,未见心脑血管意外等并发症。结论心脏瓣膜病合并房颤的患者,在行瓣膜置换的同时联合进行双极射频消融术,具有安全、疗效显著、远期复发率低等优点。在围术期各阶段采取正确、有针对性的护理措施,有利于促进患者更快的恢复,并有效防止远期并发症的发生。     

Atrial fibrillation after cardiac operation: risks, mechanisms, and treatment

Atrial fibrillation (AF) is a common complication of cardiac operations that leads to increased risk for thromboembolism and excessive health care resource utilization. Advanced age, previous AF, and valvular heart operations are the most consistently identified risk factors for this arrhythmia. Dispersion of repolarization leading to reentry is believed to be the mechanism of postoperative AF, but many questions regarding the pathophysiology of AF remain unanswered. Treatment is aimed at controlling heart rate, preventing thromboembolic events, and conversion to sinus rhythm. Multiple investigations have examined methods of preventing postoperative AF, but the only firm conclusions that can be drawn is to avoid beta-blocker withdrawal after operation and to consider beta-blocker therapy for other patients who may tolerate these drugs. Preliminary investigations showing sotalol and amiodarone to be effective in preventing postoperative AF are encouraging, but early data have been limited to selective patient populations and have not adequately evaluated safety. Newer class III antiarrhythmic drugs under development may have a role in the treatment of postoperative AF, but the risk of drug-induced polymorphic ventricular tachycardia must be considered. Nonpharmacologic interventions under consideration for the treatment of AF in the nonsurgical setting, such as automatic atrial cardioversion devices and multisite atrial pacing, may eventually have a role for selected cardiac surgical patients.     

Pharmacologic strategies for prevention of atrial fibrillation after open heart surgery

Postoperative atrial fibrillation is a common complication after open heart surgery; it increases morbidity, hospital stay, and costs. In an analysis of 8 large cardiac surgery trials totaling 20,193 patients, the incidence of postoperative atrial fibrillation was estimated to be 26% and ranged from 17% to 35%. We reviewed the results of 52 studies published between 1966 and 2003 that evaluated pharmacologic strategies to prevent postoperative atrial fibrillation in nearly 10,000 patients undergoing open heart operations. Supraventricular tachyarrhythmias, including atrial fibrillation, after open heart operations occurred in 29% of patients who did not receive prophylactic drugs, compared with 12% in patients who received intravenous followed by oral amiodarone, 15% in those given sotalol, 16% in those given oral amiodarone, and 19% in those given β-blockers. Pharmacologic strategies and regimens aimed at preventing postoperative atrial fibrillation are necessary to optimize the postoperative care of patients undergoing open heart operations. Although no strategy has consistently been shown to be superior to another, the most effective approach to preventing postoperative atrial fibrillation likely involves multiple interventions. In the absence of contraindications, all patients should receive β-blocker therapy before and after the operation. For patients with 1 or more risk factors for postoperative atrial fibrillation, regimens consisting of either sotalol (β-blocker with class III antiarrhythmic properties) alone or β-blockers in combination with amiodarone seem to be the safest, most effective pharmacologic strategies for preventing postoperative atrial fibrillation.     

心包内心脏植物神经节丛的术中探查方法及其意义

目的 探讨外科手术中经心外膜探查心包内心脏植物神经节丛的位置和微波消融神经节丛的即时效果.方法 16例接受心脏手术者同期行高频电刺激心包内植物神经节丛.窦性心律者使用同步高频刺激,房颤者使用连续高频刺激,观察出现迷走效应的位置.探查后对房颤病人使用微波消融,消融和电复律后使用同步电刺激原有迷走效应的植物神经节丛,观察有无迷走效应出现.结果 2例病人麻醉后因故不能进行试验被排除.14例在1～5处脂肪颦引出迷走效应.13 例病人在右上肺静脉根部脂肪垫有迷走效应,位于心脏右侧的植物神经节丛发生迷走效应的频率明显高于心脏左侧.消融后,原有迷走效应的植物神经节未再引出迷走效应.结论 自心外膜使用高频电刺激心脏周围脂肪垫可在1处或多处诱发迷走效应,心脏右侧脂肪垫的迷走效应诱发率高于左侧,右上肺静脉周围脂肪垫诱导率最高.心外膜微波消融可以消除迷走效应.     

85例感染性心内膜炎的临床诊断与外科治疗

【摘要】 目的 总结感染性心内膜炎(IE)的临床诊断、外科手术和围手术期处理的经验。方法 回顾性分析2004年9月至2012年12月在我院接受手术治疗的85例IE患者的临床资料。其中男52例,女33例,年龄15~71岁,平均年龄35±16.2岁。85例患者中,12例患者接受了急诊手术治疗;71例患者术前进行了血培养检查,其中阳性18例(阳性率25.4%);超声心动图检查发现赘生物患者73例。所有患者均经外科手术清除感染病灶,纠治瓣膜病变及心脏畸形。结果 全组无手术死亡,均痊愈出院。随防72例,随防时间2~95月,平均53.3±26月,1例因自行停服抗凝药导致机械瓣栓塞死于出院后半年。其余71例术后感染性心内膜炎均未复发。术后心功能恢复至I级61例,心功能恢复至II级24例。结论 早期诊断、适时手术,彻底清除感染病灶,和正确使用抗生素是治疗感染心内膜的重要措施。     

Beating-heart surgical treatment of atrial fibrillation with microwave ablation

BACKGROUND: In this feasibility study, early results are presented of our first series of patients with microwave ablation for atrial fibrillation (AF) on the beating heart. METHODS: From June 2001 until December 2001, a total of 24 patients underwent beating-heart epicardial ablation for AF. With a microwave antenna, the left and right pulmonary veins were isolated and connected to each other followed by amputation of the left atrial appendage. Subsequently, patients underwent either off-pump coronary artery bypass graft or valve surgery on pump. The mean age of the patients was 67.4 +/- 6 years. Three patients experienced paroxysmal atrial fibrillation and all others chronic AF. Mean left atrial diameter was 5.4 +/- 0.6 cm, and mean ablation time was 13 min. RESULTS: All procedures but one were completed successfully on the beating heart. All patients were in sinus rhythm after the procedure. A total of 15 patients experienced periods with postoperative AF during hospital stay; 9 of these patients were discharged with AF. All patients received either sotalol or amiodarone. At latest follow-up (3 to 9 months), 20 of 23 patients were in sinus rhythm. CONCLUSIONS: With microwave ablation, electrical isolation of the pulmonary veins can be achieved epicardially without cardiopulmonary bypass support.     

Intravenous amiodarone bolus versus oral quinidine for atrial flutter and fibrillation after cardiac operations

The safety and efficacy of amiodarone and quinidine in reverting atrial tachyarrhythmias after cardiac operations were compared in a randomized cross-over trial. Patients with sustained atrial fibrillation or flutter for more than 2 hours' duration, stable hemodynamic status, and prior digoxin therapy were randomized to receive either intravenous amiodarone, 5 mg/kg over 20 minutes (41 patients), or oral quinidine, 400 mg immediately and 400 mg in 4 hours (39 patients), with cross-over at 8 hours if reversion was not achieved. Thirty-six patients had a coronary artery operation, 35 a valvular operation, five had both, and there were four miscellaneous cases. There was a male:female ratio of 1.5:1 and a mean age of 58 years (range 23 to 75 years). Preoperative atrial fibrillation or flutter was present in nine patients, and four patients had an ejection fraction less than 40%. Twenty-five of 39 patients (64%) given quinidine first reverted to sinus rhythm, compared with 17 of 41 patients (41%) given amiodarone first (2p = 0.04). Side-effects occurred in 18 patients given quinidine and five patients given amiodarone (2p = 0.01). Two patients, both given quinidine, were withdrawn from the study. There was no correlation, with either drug, between serum levels and clinical efficacy. Multivariate analysis identified longer times from arrhythmia to treatment, preoperative atrial fibrillation, mitral valve operations, and concomitant propranolol therapy as factors predictive of failure to revert to sinus rhythm. Oral quinidine was more effective than intravenous amiodarone in reverting postoperative atrial fibrillation and flutter but caused more side-effects.     

Efficacy of intraoperative mapping to optimize the surgical ablation of atrial fibrillation in cardiac surgery

BACKGROUND: Observation during open heart surgery in patients with chronic atrial fibrillation (AF) showed that the activation sequence of the left atrium was regular and that of the right atrium chaotic in most patients. We speculate that the left atrium plays a role as an important electrical driving chamber for AF and by mapping pre-operatively, optimal sites for the cryoablation can be determined to minimize the extensiveness of the cryolesions. METHODS: Forty patients who underwent cardiac surgery and cryoablation guided by epicardial mapping data to eliminate AF originating from the left atrium were included in this study. RESULTS: Sustained reentrant movement or repetitive firing from foci located in the right atrium was never observed. Foci or reentry circuits located in the left atrium were clearly identified in 11 cases. Nine of the 11 cases resumed sinus rhythm by placing cryolesions at these sites. Two cases needed a pacemaker implantation. The exact site had not been identified in the 29 remaining cases. In these 29 cases a left atrial posterior longitudinal linear cryoablation was placed. Sinus rhythm resumed in 22 cases. Six cases still remained in AF and a pacemaker was implanted in 1 case. Ultimately, in this series of operations sinus rhythm was resumed in 31 of 40 cases; AF remained in 6 of them and pacemaker implantation was required in 3 cases. CONCLUSIONS: Mapping was useful to distinguish the two etiologies of the AF to facilitate optimal placement of the cryolesions. Sustained reentrant movement or repetitive firing from foci located in the right atrium was never observed and the left atrium played an important role as the electrical driving chamber for AF.     

Diminished Circadian Variation in Heart Rate Variability before Surgery in Patients Developing Postoperative Atrial Fibrillation

Objective - To evaluate the role of the autonomic nervous system for the development of atrial fibrillation (AF) after coronary artery bypass surgery. Design - Eighty patients without a previous history of AF were included. The sympathetic and parasympathetic activity were evaluated by the analysis of heart rate variability (HRV) in the frequency domain from 24-h Holter recordings and by measuring neuropeptides (neuropeptide Y, chromogranin A, chromogranin B, and pancreatic polypeptide (PP)) and catecholamines, obtained pre- and postoperatively. Results - Preoperatively, patients (36.3%) developing AF postoperatively showed a statistically significant less circadian variation in the HRV variables, the high-frequency (HF) component ( p = 0.013) and the low-frequency (LF)/HF ratio ( p = 0.007), than patients remaining in sinus rhythm. The HF component and PP, both reflecting parasympathetic activity, and all other variables in the frequency domain, decreased significantly after surgery in both patient groups ( p < 0.0001). Although catecholamines increased significantly postoperatively in both patient groups, neither catecholamines nor neuropeptides expressing sympathetic activity, differed between the two groups. PP was, however, significantly higher in patients with postoperative AF than in those with sinus rhythm post-operatively on day 1. Conclusion - The diminished circadian variation in HRV before surgery and the indirect signs of a higher parasympathetic activity in patients developing postoperative AF compared with patients remaining in sinus rhythm, may indicate a propensity for AF.