Kiser Andy C, Landers Mark D, Boyce Ker, Sinkovec Matjaz, Pernat Andrej, Geršak Borut
Division of Cardiothoracic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7065, USA.
Innovations (Phila). 2011 Jul;6(4):243-7. doi: 10.1097/IMI.0b013e31822ca15c.
Transmural and contiguous ablations and a comprehensive lesion pattern are difficult to create from the surface of a beating heart but are critical to the successful treatment of persistent, isolated atrial fibrillation. A codisciplinary simultaneous epicardial (surgical) and endocardial (catheter) procedure (Convergent procedure) addresses these issues.
Patients with symptomatic atrial fibrillation who failed medical treatment were evaluated. Using only pericardioscopy, the surgeon performed near-complete epicardial isolation of the pulmonary veins and a "box" lesion on the posterior left atrium using unipolar radiofrequency ablation. Simultaneous endocardial catheter radiofrequency ablation completed pulmonary vein isolation, performed a mitral annular and cavotricuspid isthmus line of block, and debulked the coronary sinus. Twelve-month results for the Convergent procedure were compared with 12-month results for concomitant and pericardioscopic (stand-alone transdiaphragmatic/thoracoscopic) atrial fibrillation procedures using unipolar radiofrequency ablation.
Sixty-five patients underwent the Convergent procedure (mean age, 62 y; mean body surface area, 2.17 m²; mean atrial fibrillation duration, 4.8 y; mean left atrial size, 5.2 cm). Ninety-two percent were in persistent or long-standing persistent atrial fibrillation. At 12 months, evaluation with 24-hour Holter monitors found 82% of patients in sinus rhythm, while only 47% of pericardioscopic and 77% of concomitant patients treated with unipolar radiofrequency ablation were in sinus rhythm.
Simultaneous epicardial and endocardial ablation improves outcomes for patients with persistent or longstanding persistent atrial fibrillation. This successful collaboration between cardiac surgeon and electrophysiologist is an important treatment option for patients with large left atriums and chronic atrial fibrillation.
在跳动的心脏表面难以实现透壁连续消融及形成全面的损伤模式，但这对于持续性孤立性心房颤动的成功治疗至关重要。一种跨学科的同步心外膜（外科）和心内膜（导管）手术（联合手术）可解决这些问题。
对药物治疗无效的有症状心房颤动患者进行评估。外科医生仅通过心包镜检查，使用单极射频消融术对肺静脉进行近乎完全的心外膜隔离，并在左心房后壁进行“盒状”损伤。同步的心内膜导管射频消融完成肺静脉隔离，进行二尖瓣环和腔静脉峡部阻滞，并缩减冠状窦。将联合手术的12个月结果与使用单极射频消融的同期及心包镜检查（单独经膈/胸腔镜）心房颤动手术的12个月结果进行比较。
65例患者接受了联合手术（平均年龄62岁；平均体表面积2.17 m²；平均心房颤动持续时间4.8年；平均左心房大小5.2 cm）。92%为持续性或长期持续性心房颤动。在12个月时，通过24小时动态心电图监测评估发现，82%的患者处于窦性心律，而接受单极射频消融治疗的心包镜检查患者中只有47%、同期患者中有77%处于窦性心律。
同步心外膜和心内膜消融可改善持续性或长期持续性心房颤动患者的治疗效果。心脏外科医生和电生理学家之间的这种成功合作是左心房增大和慢性心房颤动患者的重要治疗选择。
