综合手术方法治疗变异肺静脉解剖的心房颤动患者。

Comprehensive surgical approach to treat atrial fibrillation in patients with variant pulmonary venous anatomy.

机构信息

Scripps Memorial Hospital, San Diego, CA, USA.

出版信息

J Thorac Cardiovasc Surg. 2013 Mar;145(3):790-5. doi: 10.1016/j.jtcvs.2012.03.019. Epub 2012 Apr 11.

DOI:10.1016/j.jtcvs.2012.03.019

PMID:22498088

Abstract

OBJECTIVES

Catheter radiofrequency ablation procedures yield fairly successful results for the treatment of atrial fibrillation; however, patients with anatomic variant pulmonary veins (PV) are generally thought not to benefit from catheter ablation technique, with recurrence rates observed as high as 78%. We report a comprehensive surgical approach to treat this subset of patients with a modified full maze procedure.

METHODS

From January 2002 to December 2009, 72 patients undergoing cardiac surgery who had drug-refractory and/or recurrent AF after catheter ablation were identified. PV variance was observed on preoperative multislice chest computed tomography. All patients underwent multiple PV epicardial circumferential isolation and epicardial-endocardial longitudinal PV ablations along with standard maze as an adjunct to the cardiac surgical procedure. Patients were followed up at 6 months, 1 year, and 2 years postoperatively.

RESULTS

Typical patterns of PV variation were observed in 72 patients. Left common PV trunk was found in 49 patients (68%), with a mean length of 21 ± 4.6 mm, diameter of 28.6 ± 4.9 mm, and wall thickness of 2.1 ± 1.7 mm. Right PV variants, including right middle and right top PVs, were found in 23 patients (32%), with a length of 20 ± 2.1 mm, diameter of 9.9 ± 3.4 mm, and wall thickness of 1.9 ± 1.7 mm. Overall restoration of sinus rhythm was confirmed in 64 patients (94%) at 1-year follow-up. Twelve patients were defibrillated into sinus rhythm within 90 days after the operation.

CONCLUSIONS

A modified full maze procedure should be considered as a first choice treatment for atrial fibrillation with variant drainage of PVs because of the nature of PV size, wall thickness, and specific foci in the arrhythmogenic veins. Multiple PV isolation and epicardial-endocardial longitudinal PV ablations along with the standard maze are essential to success. Early referral for surgical ablation allows higher success rates.

摘要

目的

导管射频消融术治疗心房颤动效果相当成功；然而，解剖变异肺静脉（PV）的患者通常认为不能从导管消融技术中获益，复发率高达 78%。我们报告了一种综合的手术方法，通过改良的全迷宫手术来治疗这部分患者。

方法

从 2002 年 1 月至 2009 年 12 月，我们共发现 72 例在导管消融后药物难治性和/或复发性房颤患者需要心脏手术。术前多层胸部 CT 观察到 PV 变异。所有患者均行多根 PV 心外膜环形隔离和心外膜-心内膜 PV 消融术，同时作为心脏手术的辅助治疗行标准迷宫手术。患者在术后 6 个月、1 年和 2 年进行随访。

结果

在 72 例患者中观察到典型的 PV 变异模式。左共干 PV 在 49 例患者（68%）中发现，长度为 21 ± 4.6mm，直径为 28.6 ± 4.9mm，壁厚度为 2.1 ± 1.7mm。右 PV 变异，包括右中间和右顶部 PV，在 23 例患者（32%）中发现，长度为 20 ± 2.1mm，直径为 9.9 ± 3.4mm，壁厚度为 1.9 ± 1.7mm。在 1 年的随访中，64 例（94%）患者证实窦性心律恢复。12 例患者在术后 90 天内被除颤转为窦性心律。