Gaita Fiorenzo, Riccardi Riccardo, Gallotti Roberto
Division of Cardiology, Ospedale Mauriziano di Torino, Torino, Italy.
Card Electrophysiol Rev. 2002 Dec;6(4):401-5. doi: 10.1023/a:1021184324825.
Atrial fibrillation (AF) remains an unsurmounted hurdle toward the cure of supraventricular arrhythmias. Despite its high prevalence, a definitive treatment approach has not been established. AF is triggered in most cases by early premature atrial beats and is maintained by anomalies of the substrate. Elimination or modification of either one or both may be effective in the cure of AF. Surgical ablation, which originated with the favorable results of the Maze procedure developed by Cox, has an important role in the cure of AF associated with heart diseases that require cardiac surgery. This is due to the high success rate and to the simplification of the procedure now used which has resulted in reduction of the procedural time and complications. Various techniques have been proposed, however, it is noteworthy that the posterior part of the left atrium and the ostia of pulmonary veins are involved in all approaches despite the different energy sources used (radiofrequency or cryo energy) and the different design of the intended lesion. These results imply that the posterior part of the left atrium is crucial in the genesis and maintenance of atrial fibrillation. On the other hand, it is not clear if the results of the ablation are due to the linear lesions that modify the substrate or to the electrical isolation that eliminate the triggers. A thorough electrophysiological evaluation post ablation has been performed only in few cases. Greater understanding of the mechanism of success of surgical ablation may advance the development and success of other approaches. Considering that surgical ablation is usually performed in patients with permanent AF, linear lesions modifying the substrate together with pulmonary vein isolation have shown better results than the elimination of the triggers with a pure electrical isolation of the pulmonary veins. Prevention of AF recurrences has been relatively good, however some severe complications (atrioesophagus fistula, coronary artery damage, etc.) have been reported. Considering the relatively benignity of AF in absence of associated cardiopathy, the risk of complications should discourage widespread application of surgical ablation in patients with lone AF. On the contrary it should be routinely proposed in most patients with permanent or paroxysmal AF undergoing cardiac surgery.
心房颤动（AF）仍然是治愈室上性心律失常难以逾越的障碍。尽管其患病率很高，但尚未确立明确的治疗方法。在大多数情况下，AF由早期房性早搏触发，并由基质异常维持。消除或改变其中之一或两者可能对治愈AF有效。起源于Cox开发的迷宫手术良好结果的外科消融术，在治疗与需要心脏手术的心脏病相关的AF中具有重要作用。这是由于成功率高以及目前使用的手术简化，导致手术时间和并发症减少。然而，已经提出了各种技术，值得注意的是，尽管使用了不同的能量源（射频或冷冻能量）以及预期病变的不同设计，但所有方法都涉及左心房后部和肺静脉开口。这些结果表明，左心房后部在房颤的发生和维持中至关重要。另一方面，尚不清楚消融结果是由于改变基质的线性病变还是由于消除触发因素的电隔离。仅在少数情况下进行了消融术后的全面电生理评估。对手术消融成功机制的更深入了解可能会推动其他方法的发展和成功。考虑到手术消融通常在永久性AF患者中进行，改变基质的线性病变与肺静脉隔离一起显示出比单纯肺静脉电隔离消除触发因素更好的结果。AF复发的预防相对较好，然而，已经报道了一些严重并发症（心房食管瘘、冠状动脉损伤等）。考虑到在无相关心脏病的情况下AF相对良性，并发症风险应阻碍在孤立性AF患者中广泛应用手术消融。相反，对于大多数接受心脏手术的永久性或阵发性AF患者，应常规建议进行手术消融。
