Department of Cardiology, The Melbourne Royal Melbourne Hospital, University of Melbourne, 3004 Melbourne, Australia.
Eur Heart J. 2010 Nov;31(22):2774-82. doi: 10.1093/eurheartj/ehq224. Epub 2010 Jul 11.
The cornerstone of catheter ablation for atrial fibrillation (AF) is pulmonary vein electrical isolation (PVI). Recurrent AF post-PVI is a major limitation of the procedure with PV reconnection present in most patients. Single (SLT) and double (DLT) lung transplant surgery involves a 'cut and sew' PV antral isolation analogous to a catheter-based approach providing an opportunity to assess the efficacy of durable PVI.
A total of three hundred and twenty-seven consecutive lung transplant patients were compared with 201 control non-transplant thoracic surgery (THR) patients between 1998 and 2008. The primary analysis was the incidence of 'early' post-operative AF and 'late' AF (AF occurring following discharge from hospital after the index operation). Risk factors for the development of late AF were analysed using regression analysis. Acute post-operative AF was more common post-lung transplant (DLT 58/200 (29%) and SLT 36/127 (28%) vs. THR 28/201 (13.9%), P < 0.001) occurring at 4.7 ± 5.0 days in DLT, 3.4 ± 2.5 days after SLT, and 7.4 ± 11.2 days in the thoracic group (P < 0.001). At a mean follow-up of 5.4 ± 2.9 years late AF occurred in 1/200 (0.5%) in DLT vs. 16/127 (12.6%) in SLT and 23/201 (11.4%, P < 0.001) in THR groups. Kaplan-Meier survival analysis demonstrated the association of DLT with long-term freedom from AF. Significant variables [hazard ratio (HR) on univariate regression analysis fo late AF were: DLT 0.06, age 1.09, LA diameter 1.2, hypertension 3.0, preoperative AF 12.2, early AF 8.8, rejection 3.2].
Double but not SLT provides long-term freedom from AF despite a similar early post-operative incidence. This supports the critical role of the pulmonary veins in the pathogenesis of atrial fibrillation and the importance of durable electrical isolation of the pulmonary veins as the cornerstone in strategies for the long-term prevention of AF.
房颤（AF）导管消融的基石是肺静脉电隔离（PVI）。PVI 后复发性 AF 是该手术的主要局限性，大多数患者存在 PV 再连接。单肺（SLT）和双肺（DLT）移植手术涉及到“切割和缝合”肺静脉窦隔离，类似于基于导管的方法，为评估持久的 PVI 疗效提供了机会。
1998 年至 2008 年，共比较了 327 例连续肺移植患者和 201 例非移植胸外科（THR）患者。主要分析是“早期”术后 AF 和“晚期”AF（指数手术后从医院出院后发生的 AF）的发生率。使用回归分析分析晚期 AF 发生的危险因素。肺移植后急性术后 AF 更为常见（DLT 58/200（29%）和 SLT 36/127（28%）与 THR 28/201（13.9%），P < 0.001），DLT 发生在术后 4.7 ± 5.0 天，SLT 术后 3.4 ± 2.5 天，胸外科组为 7.4 ± 11.2 天（P < 0.001）。在平均 5.4 ± 2.9 年的随访中，DLT 中有 1/200（0.5%）发生晚期 AF，而 SLT 中有 16/127（12.6%）和 THR 中有 23/201（11.4%）发生晚期 AF，P < 0.001）。Kaplan-Meier 生存分析表明 DLT 与长期无 AF 相关。单变量回归分析中晚期 AF 的显著变量[风险比（HR）为：DLT 0.06，年龄 1.09，LA 直径 1.2，高血压 3.0，术前 AF 12.2，早期 AF 8.8，排斥 3.2]。
尽管术后早期发病率相似，但 DLT 而非 SLT 可提供长期无 AF 。这支持了肺静脉在心房颤动发病机制中的关键作用，以及持久的肺静脉电隔离作为长期预防 AF 策略的基石的重要性。
