Sakamoto Shun-ichiro, Yamauchi Shigeo, Yamashita Hiromasa, Imura Hajime, Maruyama Yuji, Ogasawara Hidetsugu, Hatori Nobuo, Shimizu Kazuo
Thoracic and Cardiovascular surgery, Chiba Hokusoh Hospital, Nippon Medical School, 1715 Kmagari, Inba, Chiba 270-1694, Japan.
Eur J Cardiothorac Surg. 2006 Jul;30(1):132-9. doi: 10.1016/j.ejcts.2006.03.060. Epub 2006 May 30.
The atrial conduction properties associated with cardiac disease are speculated as the background of postoperative atrial fibrillation (POAF). We examined the atrial conduction patterns and conduction properties during sinus rhythm (SR) in patients that had undergone cardiac operations and evaluated the incidence of POAF in all patients.
Fifty-two patients with stable SR who underwent cardiac surgery, with a diagnosis of valvular disease in 25, ischemic heart disease in 24, and others in 3, were enrolled in this study. The epicardial recordings were made using a mapping system with 60 unipolar electrodes placed on the right atrium (RA) intraoperatively. The activation patterns of the RA were assessed, and the longitudinal, transverse and oblique conduction velocity and max anisotropic ratio were also examined.
Sinus activation was initiated from various sites (single origin at the high-lateral RA in 40, mid-lateral RA in 4, low-lateral RA in 2, and multiple origins in 6 patients) and it demonstrated anisotropic conduction (1.8+/-0.6) with the longitudinal conduction being more rapid than transverse and oblique conduction. Fifteen patients demonstrated non-uniform activation patterns such as, a localized conduction delay in seven, functional conduction block in two and mosaic-activation pattern associated with multiple origins in six. A total of 21 patients (44%) developed POAF. A conduction delay and mosaic activation pattern was found significantly more often in patients with POAF than in patients who remained in sinus rhythm. Multivariate analysis revealed that non-uniform activation pattern (odds ratio=8.71; 95% confidence interval [CI]=1.74-43.67; p=0.008) and TR (odds ratio=4.95; 95% CI=1.14-21.37; p=0.032) were independently associated with the development of POAF. Although all patients had converted to SR at the time of discharge, the administration of antiarrhythmic drugs caused sinus bradycardia in two patients who demonstrated a mosaic activation pattern in RA.
Cardiac surgery patients exhibited a variety of sinus activation patterns, which also provided an arrhythmogenic substrate for POAF. A better understanding of the sinus activation using an intraoperative mapping system may provide benefit in the clinical management of POAF.
推测与心脏疾病相关的心房传导特性是术后房颤（POAF）的发病背景。我们研究了心脏手术后患者窦性心律（SR）期间的心房传导模式和传导特性，并评估了所有患者中POAF的发生率。
本研究纳入了52例SR稳定且接受心脏手术的患者，其中25例诊断为瓣膜病，24例为缺血性心脏病，3例为其他疾病。术中使用带有60个单极电极的标测系统在右心房（RA）进行心外膜记录。评估RA的激动模式，并检测纵向、横向和斜向传导速度以及最大各向异性比率。
窦性激动起始于多个部位（40例起源于高位外侧RA，4例起源于中位外侧RA，2例起源于低位外侧RA，6例为多源性），呈现各向异性传导（1.8±0.6），纵向传导速度快于横向和斜向传导。15例患者表现出不均匀的激动模式，如7例存在局部传导延迟，2例存在功能性传导阻滞，6例存在与多源性相关的镶嵌式激动模式。共有21例患者（44%）发生POAF。与维持窦性心律的患者相比，POAF患者中传导延迟和镶嵌式激动模式更为常见。多因素分析显示，不均匀激动模式（比值比=8.71；95%置信区间[CI]=1.74 - 43.67；p = 0.008）和TR（比值比=4.95；95% CI = 1.14 - 21.37；p = 0.032）与POAF的发生独立相关。尽管所有患者出院时均已转为SR，但抗心律失常药物治疗导致2例RA呈现镶嵌式激动模式的患者出现窦性心动过缓。
心脏手术患者表现出多种窦性激动模式，这也为POAF提供了致心律失常基质。使用术中标测系统更好地了解窦性激动可能有助于POAF的临床管理。
