Inova Heart and Vascular Institute, Falls Church, VA 22042, USA.
Eur J Cardiothorac Surg. 2013 Aug;44(2):295-300; discussion 300-1. doi: 10.1093/ejcts/ezs708. Epub 2013 Jan 17.
Observational studies identified increased age, left atrial (LA) size, type and duration of atrial fibrillation (AF) as independent predictors for failure of AF surgical ablation. Rhythm at discharge following the Cox maze (CM) procedure for AF was never considered a significant predictor of success. The purposes of this study were to: (i) Determine the association of sinus rhythm (SR) at discharge and maintenance of SR. (ii) Identify the variables associated with discharge rhythm. (iii) Identify the effects of discharge rhythm on health-related quality of life (HRQL) post-CM procedure.
A prospective study (n = 534) of CM III/IV patients. Rhythm captured during hospitalization, discharge, 3, 6, 12 and 24 months and verified by electrocardiogram and 24-h holter. Subsequent SR interventions were captured. Logistic regression identified predictors of discharge rhythm. HRQL (Short-Form 12; AF symptom frequency and Severity Checklist V3) obtained during follow-up.
Eighty-eight percent were discharged in SR (n = 469). LA size (OR = 1.36, CI: 1.02-1.82, P = 0.035) and long-standing AF type (OR = 2.68, CI: 1.31-5.50, P = 0.007) were the only independent predictors of non-SR at discharge. Lower rates of SR at 2 years were found in patients discharged in non-SR (75 vs 91%, P = 0.01). Patients discharged in SR had fewer perioperative morbidities [prolonged ventilation >24 h (6 vs 14%, P = 0.03), renal failure requiring dialysis (0.9 vs 5%, 0.04) and pneumonia (2 vs 9%, P = 0.005)]. During follow-up (mean = 43 ± 27 months), patients discharged in SR had fewer cardioversions (15 vs 29%, P = 0.006), similar percutaneous catheter ablations (6 vs 5%, P = 1.00) and no difference in late embolic strokes (1.5 vs 1.1%, P = 0.54).
In this large prospective cohort study, rhythm at discharge was found to be clinically significant with predicting SR at 24 months. Surgeons should be aware that the prognosis of non-SR patients at discharge remains excellent with high rates of SR at 24 months if managed appropriately using rhythm rather than rate control strategies.
观察性研究确定年龄较大、左心房（LA）增大、房颤（AF）类型和持续时间是 AF 手术消融失败的独立预测因素。Cox 迷宫（CM）手术后出院时的节律从未被认为是成功的重要预测因素。本研究的目的是：（i）确定出院时窦性节律（SR）与维持 SR 的相关性。（ii）确定与出院节律相关的变量。（iii）确定出院节律对 CM 术后健康相关生活质量（HRQL）的影响。
前瞻性研究（n = 534），纳入 CM III/IV 患者。在住院期间、出院时、3、6、12 和 24 个月以及通过心电图和 24 小时动态心电图捕获节律，并通过心电图和 24 小时动态心电图进行验证。随后记录 SR 干预情况。Logistic 回归确定出院节律的预测因素。在随访期间获得 HRQL（SF-12；AF 症状频率和严重程度检查表 V3）。
88%的患者（n = 469）出院时处于 SR 状态。LA 大小（OR = 1.36，95%CI：1.02-1.82，P = 0.035）和长程 AF 类型（OR = 2.68，95%CI：1.31-5.50，P = 0.007）是出院时非 SR 的唯一独立预测因素。与出院时处于 SR 状态的患者相比，2 年后 SR 比例较低（75%比 91%，P = 0.01）。出院时处于 SR 状态的患者围手术期并发症较少[长时间通气>24 小时（6%比 14%，P = 0.03）、需要透析的肾功能衰竭（0.9%比 5%，0.04）和肺炎（2%比 9%，P = 0.005）]。在随访期间（平均 = 43 ± 27 个月），出院时处于 SR 状态的患者需要电复律的次数较少（15 次比 29 次，P = 0.006），经皮导管消融术的次数相似（6 次比 5 次，P = 1.00），晚期栓塞性中风的发生率无差异（1.5%比 1.1%，P = 0.54）。
在这项大型前瞻性队列研究中，发现出院时的节律具有临床意义，可预测 24 个月时的 SR。外科医生应该意识到，如果通过节律而不是心率控制策略对非 SR 患者进行适当管理，出院时非 SR 患者的预后仍然很好，24 个月时 SR 比例仍然很高。
