Bulava Alan, Mokracek Ales, Kurfirst Vojtech
Department of Cardiology, Budweis Hospital, Ceske Budejovice, Czech Republic; Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic; Faculty of Health and Social Sciences, University of South Bohemia, Ceske Budejovice, Czech Republic.
Department of Cardiac Surgery, Budweis Hospital, Ceske Budejovice, Czech Republic; Faculty of Health and Social Sciences, University of South Bohemia, Ceske Budejovice, Czech Republic.
Ann Thorac Surg. 2017 Dec;104(6):2024-2029. doi: 10.1016/j.athoracsur.2017.05.018. Epub 2017 Jul 29.
Long-term efficacy of catheter-based treatment of persistent atrial fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently but their true efficacy has never been systematically tested.
Seventy patients (median age 63.5 years) with persistent atrial fibrillation underwent epicardial thoracoscopic radiofrequency pulmonary vein (PV) isolation, linear ablation, Marshal ligament disruption, and exclusion of the left atrial appendage. The procedure was followed by electroanatomic mapping 2 to 3 months later.
Only 76% of patients were in sinus rhythm at the beginning of electroanatomic mapping. Right PVs were found isolated in a higher proportion of patients compared with left PVs (75.7% versus 91.4%, p < 0.001). All four PVs and the left atrial posterior wall were isolated in 68.6% and 22.9% of patients, respectively. Most of the gaps around left PVs were localized in the superior and anterior quadrants, whereas in right PVs, the gaps were found predominantly on the roof and posterior wall. A typical site of reconduction on the inferior connecting line was the segment adjacent to the right inferior PV. No typical reconduction sites were found on the roof line, as 58.5% of patients required completion of the roof line along its full length.
Epicardial PV isolation was successful in the majority of patients, but was underwhelming with regard to isolation of the left PVs. Effective epicardially placed linear lines were rare. Our results highlight the significant limitations associated with a single-stage surgical approach and underline the necessity for a two-staged hybrid approach in the treatment of persistent atrial fibrillation.
基于导管的持续性心房颤动治疗的长期疗效并不理想。近年来已开发出微创外科消融技术，但尚未对其真正疗效进行系统测试。
70例持续性心房颤动患者（中位年龄63.5岁）接受了心外膜胸腔镜下射频肺静脉（PV）隔离、线性消融、Marshall韧带离断以及左心耳切除。术后2至3个月进行电解剖标测。
电解剖标测开始时，仅有76%的患者处于窦性心律。与左肺静脉相比，右肺静脉隔离的患者比例更高（75.7%对91.4%，p<0.001）。分别有68.6%和22.9%的患者实现了所有四条肺静脉及左心房后壁的隔离。左肺静脉周围的大多数间隙位于上象限和前象限，而右肺静脉的间隙主要位于顶部和后壁。下连接线的典型再传导部位是与右下肺静脉相邻的节段。在顶部线上未发现典型的再传导部位，因为58.5%的患者需要沿顶部线全长完成消融。
心外膜肺静脉隔离在大多数患者中取得成功，但在左肺静脉隔离方面效果不佳。有效的心外膜线性消融线较少。我们的结果凸显了单阶段手术方法存在的显著局限性，并强调了在持续性心房颤动治疗中采用两阶段杂交方法的必要性。
