La Meir Mark
University Hospital Brussels, Belgium; and University Hospital Maastricht, The Netherlands.
Rambam Maimonides Med J. 2013 Jul 25;4(3):e0016. doi: 10.5041/RMMJ.10116. Print 2013 Jul.
The Cox maze III and Cox maze IV procedures are surgical solutions for the treatment of symptomatic stand-alone atrial fibrillation. Despite their proven efficacy, these procedures have not gained widespread acceptance because of the invasiveness, complexity, and technical difficulty. Endocardial pulmonary vein isolation is the cornerstone of percutaneous catheter ablation for atrial fibrillation. It is currently accepted as an invasive therapy, if rhythm control has failed using antiarrhythmic drugs or electrical cardioversions. Pulmonary vein isolation is reported to be effective in 60%-85% of patients with paroxysmal atrial fibrillation and in 30%-50% of patients with persistent atrial fibrillation. A second or third ablation is often necessary to achieve these results, and complications may occur in up to 6% of patients. Surgical treatment of atrial fibrillation has seen important improvements in the last decade. New technologies have simplified creation of transmural lesions on the beating heart through a less-invasive, thoracoscopic procedure. This allows for pulmonary vein isolation, isolation of the posterior wall, and left atrial appendage exclusion-usually combined with ganglionic plexi evaluation and destruction. Nonetheless, it is still uncertain whether these procedures are effective in restoring permanent sinus rhythm since transmurality of a lesion set cannot be guaranteed with current ablation catheters on the beating heart. In an attempt to limit the shortcomings of an endo- or an epicardial technique, a hybrid approach has recently been introduced. This approach is based on a close collaboration between the surgeon and the electrophysiologist, employing a patient-tailored procedure which is adapted to the origin of the patient's atrial fibrillation and takes into consideration triggers and substrate. Using a mono- or bilateral energy source, a thoracoscopic epicardial approach is combined with a percutaneous endocardial ablation in a single-step or in a sequential-step procedure. This article provides our experience and an overview of the current knowledge in the hybrid treatment of stand-alone atrial fibrillation.
Cox迷宫III和Cox迷宫IV手术是治疗症状性孤立性心房颤动的外科解决方案。尽管已证实其疗效，但由于其侵入性、复杂性和技术难度，这些手术尚未得到广泛接受。心内膜肺静脉隔离是经皮导管消融治疗心房颤动的基石。如果使用抗心律失常药物或电复律未能实现节律控制，目前它被认为是一种侵入性治疗方法。据报道，肺静脉隔离对60%-85%的阵发性心房颤动患者和30%-50%的持续性心房颤动患者有效。通常需要进行第二次或第三次消融才能达到这些效果，并且高达6%的患者可能会出现并发症。在过去十年中，心房颤动的外科治疗有了重要进展。新技术通过侵入性较小的胸腔镜手术简化了在跳动心脏上创建透壁病变的过程。这允许进行肺静脉隔离、后壁隔离和左心耳切除，通常还结合神经节丛评估和破坏。然而，由于目前的消融导管在跳动心脏上无法保证病变组的透壁性，这些手术是否能有效恢复永久性窦性心律仍不确定。为了限制心内膜或心外膜技术的缺点，最近引入了一种杂交方法。这种方法基于外科医生和电生理学家之间的密切合作，采用根据患者心房颤动的起源量身定制的手术，并考虑触发因素和基质。使用单源或双源能量，胸腔镜心外膜方法与经皮心内膜消融在一步或序贯步骤中相结合。本文介绍了我们在孤立性心房颤动杂交治疗方面的经验以及当前知识的概述。
