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心房颤动的心房分隔手术:是否隔离左心房?

Atrial compartment operation for atrial fibrillation: to isolate the left atrium or not?

作者信息

Lo Huey-Ming, Lin Fang-Yue, Tseng Yung Zu

机构信息

Department of Internal Medicine, Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan.

出版信息

Ann Thorac Surg. 2003 Oct;76(4):1259-63. doi: 10.1016/s0003-4975(03)00722-7.

Abstract

BACKGROUND

The atrial compartment operation was designed to convert atrial fibrillation (AF) to sinus rhythm with intentional preservation of the electrical connection between adjacent atrial compartments. However, incidental left atrial isolation was observed in some patients. This study compared the long-term clinical outcomes of left atrial isolation for AF with those with right and left atrial connection.

METHODS

Twenty patients with mitral valve disease and chronic AF who underwent atrial compartment operation with successful sinus conversion were studied. Left atrial isolation was documented by local electrogram recording. When there were no signs of electrical connection between the left atrium and the rest of the heart, either during sinus rhythm or during stimulation from various atrial compartments, left atrial isolation was confirmed. All patients were followed by electrocardiogram and echocardiogram serial recordings. Clinical signs and symptoms of cardiac performance and thromboembolism were also examined.

RESULTS

Seven patients showed an isolated left atrium and 13 patients had electrical connection between the right and left atria. The age, gender, AF duration, and underlying disease were not different between the two groups of patients. During a mean follow-up period of 66 +/- 15 months, none of the patients with left atrial isolation showed recurrence of AF, although one experienced paroxysmal atrial flutter. However, 8 of the 13 patients with right and left atrial connection experienced recurrent atrial flutter/fibrillation (6 atrial flutter and 5 AF) (p = 0.058). The propensity for recurrent atrial flutter/fibrillation in these patients may be related to the conduction delay between the two atrial compartments, measured at 142 +/- 48 ms. At the end of the follow-up period, all patients with left atrial isolation remained in normal sinus rhythm without antiarrhythmic drugs. Of the patients who had right and left atrial connection, 2 developed sustained AF and 1 developed atrial flutter. Patients with left atrial isolation showed a decreased transmitral "A" flow compared with those with right and left atrial connection. Postoperative left atrial diameter and clinical functional class did not differ between patients with and without left atrial isolation. The incidence of embolization observed in both treatment groups did not differ significantly: 14% (1/7) in patients with left atrial isolation and 8% (1/13) in patients with right and left atrial connection (p > 0.05 between the groups).

CONCLUSIONS

Left atrial isolation confers a better arrhythmia outcome but at the expense of poorer mechanical performance as compared with preserved electrical connection between the two atria. Nonetheless, all patients remain at risk for systemic embolization. Therefore, modifications of current surgical incisions for AF are needed.

摘要

背景

心房分隔手术旨在将心房颤动(AF)转为窦性心律,同时有意保留相邻心房腔之间的电连接。然而,在一些患者中观察到了意外的左心房隔离。本研究比较了AF患者左心房隔离与左右心房连接患者的长期临床结局。

方法

对20例二尖瓣疾病合并慢性AF且接受心房分隔手术并成功转为窦性心律的患者进行研究。通过局部电图记录记录左心房隔离情况。当在窦性心律期间或来自各个心房腔的刺激期间左心房与心脏其余部分之间没有电连接迹象时,确认左心房隔离。所有患者均接受心电图和超声心动图系列记录。还检查了心脏功能和血栓栓塞的临床体征和症状。

结果

7例患者显示左心房隔离,13例患者左右心房之间存在电连接。两组患者的年龄、性别、AF持续时间和基础疾病无差异。在平均66±15个月的随访期内,左心房隔离的患者均未出现AF复发,尽管有1例经历了阵发性心房扑动。然而,13例左右心房连接的患者中有8例经历了复发性心房扑动/颤动(6例心房扑动和5例AF)(p = 0.058)。这些患者复发性心房扑动/颤动的倾向可能与两个心房腔之间的传导延迟有关,传导延迟为142±48毫秒。在随访期末,所有左心房隔离的患者在未使用抗心律失常药物的情况下仍保持正常窦性心律。在左右心房连接的患者中,2例发生持续性AF,1例发生心房扑动。与左右心房连接的患者相比,左心房隔离的患者二尖瓣“ A”血流减少。有无左心房隔离的患者术后左心房直径和临床功能分级无差异。两个治疗组中观察到的栓塞发生率无显著差异:左心房隔离患者为14%(1/7),左右心房连接患者为8%(1/13)(两组之间p> 0.05)。

结论

与保留两个心房之间的电连接相比,左心房隔离可带来更好的心律失常结局,但代价是机械性能较差。尽管如此,所有患者仍有全身栓塞的风险。因此,需要对当前的AF手术切口进行改良。

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