二尖瓣置换同期全迷宫射频消融术后患者心房功能与心房纤维化的关系

目的观察二尖瓣置换同期全迷宫射频消融术后患者心房功能的恢复情况,并探讨其与心房纤维化的关系。方法采用队列研究方法分析2010年1～8月期间沈阳军区总医院收治以二尖瓣病变为主的心瓣膜病合并慢性心房颤动（房颤）32例患者的临床资料,其中男11例、女21例,年龄（49.8±8.7）岁;其中单纯风湿性二尖瓣狭窄14例,风湿性二尖瓣狭窄伴关闭不全8例,二尖瓣脱垂10例;术前房颤持续时间（3.6±4.6）年。所有患者均行二尖瓣置换加全迷宫射频消融术。以左心耳纤维化程度的中位数10.9%为割点,将32例患者按心房纤维化的程度不同分为纤维化较重患者（纤维化程度〉10.9%）19例,纤维化较轻患者（纤维化程度〈10.9%）13例。采用免疫组织化学法检测心肌纤维化程度,用超声心动图检测左心房结构和功能的改变。结果无围术期死亡。体外循环时间（84.6±22.6）min,主动脉阻断时间（47.6±15.6）min;监护室停留时间（3.2±1.5）d。32例患者均随访半年以上,随访时间（1.3±0.6）年。32例患者的心房壁纤维化程度为4.8%～18.3%（10.7%±4.2%）,19例纤维化较重患者术前和术后3个月左心房内径（LAD）、左心房面积变化分数（LAFAC）及瓣环运动与13例纤维化较轻患者差异无统计学意义（P〉0.05）;心房纤维化较轻患者术后6个月LAD明显缩小（P〈0.05）;二尖瓣侧壁瓣环处的舒张晚期运动峰速（Am）显著提高（P〈0.05）;LAFAC有一定改善（P=0.067）。32例患者中二尖瓣置换术加射频消融术后3个月时有28例患者（87.5%）恢复为窦性心律,21例可维持窦性心律6个月以上（65.6%）,左心房后壁纤维化程度较轻的患者容易维持窦性心律（P=0.010）。结论二尖瓣手术同期行全迷宫射频消融术后6个月心房功能得到改善,与心房纤维化程度有一定的关系。

Relationship between postoperative Atrial Function and Fibrosis of Patients after Mitral Valve Replacement and Concomitant Radiofrequency Ablation for Atrial Fibrillation

Objective To investigate the restoration of left atrial function and its relationship with atrial fibrosis of patients after mitral valve replacement （MVR） and concomitant radiofrequency ablation （RFA） for atrial fibrillation （AF）. Methods Clinical data of 32 patients with mitral valve disease and chronic AF who underwent surgical treatment in General Hospital of Shenyang Military Area Command from January to August 2010 were retrospectively analyzed in this cohort study. There were 11 male and 21 female patients with their age of 49.8 ___ 8.7 years. There were 14 patients with rheumatic mitral stenosis （MS）, 8 patients with rheumatic MS and mitral regurgitation, and 10 patients with mitral valve prolapse. Preoperative AF duration was 3.6___4.6 years. All the patients received MVR and concomitant RFA for AF. According to the cutting off extent of left atrial fibrosis （10.9%）, all the 32 patients were divided into 2 groups. There were 19 patients with more severe left atrial fibrosis （ 〉 10.9%） in group A and 13 patients with milder left atrial fibrosis （ 〈 10.9%） in group B. Immunohistochemistry was performed to examined left atrial fibrosis, and echocardiography was performed to examined the structure and function of left atrium. Results There was no perioperative death. Cardiopulmonary bypass time was 84.6 ± 22.6 minutes, aortic cross-clamping time was 47.6 ± 15.6 minutes, and ICU stay was 3.2 ± 1.5 days. All the 32 patients were followed up for longer than 6 months （ 1.3 ± 0.6 years）. The extent of left atrial fibrosis of the 32 patients was 4.8%-18.3% （ 10.7% ± 4.2% ）. There was no statistical difference in left atrial diameter （LAD）, left atrial fractional area change （LAFAC） or mitral annular motion between group A and group B preoperatively and 3 months after surgery respec- tively （P 〉 0.05 ）. At 6 month after surgery, LAD of group B was significantly smaller than that of group A （P 〈 0.05 ）, late diastolic mitral annular velocity （Am） o