风湿性二尖瓣病变并发心房颤动患者483例临床分析

目的分析风湿性心脏病合并房颤的发病特点及各临床因素与房颤发生、发展的关系,探讨外科治疗经验。方法回顾性分析2008年3月至2009年6月我科接受二尖瓣置换手术的483例患者临床资料。男性143例,女性340例,年龄22～74(45.23±11.51)岁,其中单纯二尖瓣病变355例,二尖瓣及主动脉瓣双瓣病变128例。合并左心房血栓51例,有脑栓塞病史4例,术中同期行氩气刀心内膜消融术10例,左心房折叠术26例,行三尖瓣成形127例(其中使用人工成形环21例)。全组病例根据有无房颤及房颤持续时间分为慢性房颤组(268例)、阵发性房颤组(133例)及窦性心律组(82例),于我科标本库中随机抽取每组患者右心房组织蜡块5例,行Masson染色,观察心房纤维化情况,计算胶原容积分数。结果阵发性房颤组右心房组织胶原容积分数(14.17±1.96)显著高于窦性心律组(8.65±2.30,P<0.05),慢性房颤组(19.06±1.85)显著高于阵发性房颤组及窦性心律组(P<0.05)。手术后死亡8例,病死率1.66%,体外循环时间(90.27±46.86)min。术后二次开胸止血9例,发生瓣周漏2例,术后呼吸机辅助时间(11.20±5.87)h。10例同期接受心内膜消融术患者有8例由房颤转为窦性心律。结论风湿性心脏病二尖瓣狭窄及关闭不全促进了房颤的发生、发展,右心房纤维化程度随房颤持续时间的延长而加重。瓣膜置换术同期行迷宫手术,术后早期应用抗心律失常药物是治疗风湿性心脏病合并房颤的有效方法。

Clinical analysis of 483 cases of rheumatic mitral valve disease with atrial fibrillation

Objective To analyze the clinical characteristics of rheumatic heart valve disease(RHVD) with atrial fibrillation(AF) and the relationship between clinical factors and the progress of AF,and to discuss the surgical treatment of RHVD with atrial fibrillation.Methods Retrospective analysis was conducted on 483 patients [143 men and 340 women,aged 22-74(45.23±11.51)] who received mitral valve replacement from March 2008 to June 2009 in Xinqiao Hospital,China.The patients included 355 cases with simple mitral valve disease and 128 cases with mitral valve and aortic valve diseases.Fifty-one of the patients suffered from left atrial thrombus,and 4 had suffered from cerebral embolism.During mitral valve replacement,10 cases underwent endocardial ablation using argon beam diathermy,26 cases left atrial plication,and 127 cases tricuspid valvuloplasty and tricuspid valve replacement(21 cases using the Carpentier ring).All the patients were divided into a chronic AF(cAF) group,a paroxysmal AF(pAF) group,and a sinus rhythm(SR) group according to AF incidence and duration.The right atrial specimens(formalin-fixed paraffin-embedded tissue blocks) of 5 random cases in each group were sectioned and treated through Masson’s trichrome staining to detect atrial fibrosis and measure collagen volume fraction(CVF).Results The CVF of right atrium in the pAF group was significantly higher than that in the SR group(P<0.05).Compared with the SR and pAF groups,the cAF group had a significantly higher CVF of right atrium(P<0.05).The extracorporeal circulation time was(90.27±46.86) min in operation.Eight deaths occurred after operation,with a mortality rate of 1.66%.After operation,9 cases received thoracotomy for hemostasis,and perivalvular leakage was found in 2 cases.The mechanical ventilation duration after operation was(11.20±5.87) h.Eight of ten patients who underwent endocardial ablation had AF to sinus rhythm conversion.Conclusion RHVD accelerates the progress of AF.The degree of right atrial fibrosis increases with the duration of AF.The valve replacement along with maze procedure as well as applying antiarrhythmic drug early after operation is an effective means of treating RHVD with AF.