左心房折叠与射频消融治疗重症二尖瓣病变合并巨大左心房的临床研究

目的：对比左心房折叠（LAP）与射频消融（RFA）对重症二尖瓣病变合并巨大左心房的临床效果。方法2010年7月至2013年6月，38例重症二尖瓣病变合并巨大左心房左心房内径＞100 mm，心胸比（C/T）＞0.8]患者，随机分为三组：LAP组16例（二尖瓣置换＋LAP）、RFA组10例（二尖瓣置换＋RFA）和对照组12例（二尖瓣置换）。观察术中、后临床指标，并随访3～40个月，比较三组术后左心房大小、心功能改善及窦性心律恢复率等指标。结果术后早期死亡3例，对照组2例死于低心排综合征和肺部感染，RFA组1例死于术后肺部感染。LAP组体外循环时间、ICU时间、呼吸机辅助时间、低心排综合征及肺部感染发生率均低于对照组（P＜0.05）；RFA组主动脉阻断时间和体外循环时间明显高于对照组（P＜0.05），肺部感染发生率低于对照组（P＜0.05），而 ICU 时间、呼吸机辅助时间及低心排综合征发生率与对照组无明显差异（P＞0.05）。术后3个月，与术前资料相比较，三组患者左心房内径LAP组（P＜0.01）、RFA组（P＜0.05）、对照组（P＜0.05）]均较术前明显缩小；术后三组患者C/T均明显缩小（P＜0.01）；NYHA 心功能分级示术后三组患者心功能均有明显改善（P＜0.05）；术后三组 LVEF 均明显升高LAP组（P＜0.01）、RFA组（P＜0.05）、对照组（P＜0.05）]。术后3个月，与对照组比较， LAP组在左心房内径（P＜0.01）、C/T（P＜0.05）、NYHA分级（P＜0.05）以及LVEF（P＜0.05）方面均有显著差异；而 RFA 组的上述各指标与对照组均无明显差异（P＞0.05）。三组患者窦性心律恢复率在术后3个月无明显差异（P＞0.05）。术后随访的3～40个月中，1例失访，1例于2年后死于脑卒中，其余患者心脏大小、C/T以及心功能均有明显改善。结论对于重症二尖瓣病变合并巨大左心房的患者，LAP术可以明显改善心肺功能，安全、高效，优于RFA术，而RFA术并没有明显提高术后窦性心律的恢复率，需慎重选择。LAP联合RFA能否进一步提高疗效，有待进一步研究。

Clinical study on left atrial plicaflon and radiofrequency ablation for severe mitral valve disease with giant left atrium

Objective To compare the clinical effects of left atrial plication （LAP） and radiofrequency ablation （RFA） for severe mitral valve disease with giant left atrium. Methods From July 2010 to June 2013, 38 patients with severe mitral valve disease and giant atrium left atrium diameter over 100 mm and cardiothoracic ratio（C/T） over 0.8] were randomly divided into three groups. Patients in Group LAP （n= 16） were treated by mitral valve replacement （MVR） and LAP. Patients in Group RFA （n= 10） were treated by MVR and RFA. And patients in Group Control were only treated by MVR. The clinical data of three groups in perioperative period was observed and all patients were followed up from 3 to 40 months. Lefi atrium size, cardiac function and rate of restoration to sinus rhythm in three groups were compared. Results 3 cases were died in early postoperative period. 2 cases in Group Control died of low cardiac syndrome and lung infection and 1 case in Group RFA died of lung infection. Cardiopulmonary bypass time, ICU time, mechanical ventilation time, and the incidence of low output cardiac syndrome and lung infection in Group LAP were significantly lower than those in Group Control （P〈0.05）. Aortic clamping time and cardiopulmonary bypass time in Group RFA were obviously higher than those in Group Control （P〈0.05）, and the incidence of lung infection was significantly lower than that in GroupControl （P〈0.05）. While ICU time, mechanical ventilation time and the incidence of low output cardiac syndrome between Group RFA and Group Control had no significant difference （P〉0.05）. The left atrium diameters in 3 months after operation in three groups were all significant decreased than before operation （P〈0.01 in Group LAP, P〈0.05 in Group RFA and P〈0.05 in Group Control, respectively）. And the ratio of C/T in 3 groups in 3 months after operation was also reduced obviously than before operation. The data of NYHA heart function classification shows that cardiac function in three groups was improved significantly （P〈0.05）. The LVEF was also increased significantly （P〈0.01 in Group LAP, P〈0.05 in Group RFA and P〈0.05 in Group Control respectively）. The rate of restoration to sinus rhythm in three groups had no significant difference （P〉0.05）. By followed up from 3 to 40 months, one case was lost to follow-up and another case died of stroke after 2 years. The cardiac size, C/T and cardiac function of other cases were improved significantly. Conclusions For the patients with severe mitral valve disease and giant left atrium, LAP during MVR, better than RFA, can improve cardiac and pulmonary function safely and effectively. For these patients, RFA during MVR could not significantly increase the rate of restoration to sinus rhythm and should be chosen carefully. Whether LAP combined with RFA during MVR could improve the clinical effects need to be studied further.