Fontan手术后心房扑动的管理。

Management of atrial flutter after the Fontan procedure.

作者信息

Balaji S, Johnson T B, Sade R M, Case C L, Gillette P C

机构信息

South Carolina Children's Heart Center, Medical University of South Carolina, Charleston 29425-0682.

出版信息

J Am Coll Cardiol. 1994 Apr;23(5):1209-15. doi: 10.1016/0735-1097(94)90613-0.

DOI:10.1016/0735-1097(94)90613-0

PMID:8144791

Abstract

OBJECTIVES

The purpose of this study was to review the management of atrial flutter occurring after the Fontan procedure.

BACKGROUND

Atrial flutter occurs frequently after the Fontan procedure and is often hemodynamically poorly tolerated.

METHODS

The patients' charts were reviewed for relevant information.

RESULTS

Between 1984 and 1992, 18 patients had atrial flutter after the Fontan procedure. The underlying heart defect was tricuspid atresia in nine, mitral atresia in six and double inlet left ventricle in three. All but three patients had undergone previous palliative surgery. The time interval from Fontan operation to atrial flutter was < 1 day to 16 years (mean 3.7 years). Seven had early atrial flutter before leaving the hospital. Electrophysiologic study in 15 showed sinus node dysfunction in 12. Atrial flutter was inducible in all patients, and 13 had > 1 flutter configuration. Digoxin and a variety of other antiarrhythmic agents (mean 2.7 drugs/patient) were tried with poor results. Only digoxin, amiodarone, flecainide and propafenone showed some benefit when used alone or in combination. Antitachycardia pacemakers were implanted in 16 patients (endocardial 14, epicardial 2) and, with drugs, were useful in 8 (50%). Because atrial flutter was resistant to treatment, right atriectomy was performed in three patients (with benefit in two, one death), successful radiofrequency catheter His bundle ablation in one patient and catheter ablation of atrial flutter in three patients (two failed, one partial success). One patient underwent heart transplantation, and two died suddenly. Another died of complications after an elective epicardial pacemaker replacement procedure.

CONCLUSIONS

Atrial flutter after the Fontan procedure is difficult to control. Aggressive drug and antitachycardia pacemaker therapy help about half of the patients. When these measures fail, other options, such as atriectomy, His bundle ablation or catheter ablation of atrial flutter, need consideration. The risk of sudden death justifies the use of such aggressive treatment methods.

摘要

目的

本研究旨在回顾Fontan手术术后心房扑动的治疗情况。

背景

心房扑动在Fontan手术后频繁发生，且血流动力学耐受性往往较差。

方法

查阅患者病历以获取相关信息。

结果

1984年至1992年间，18例患者在Fontan手术后发生心房扑动。潜在的心脏缺陷为三尖瓣闭锁9例，二尖瓣闭锁6例，双入口左心室3例。除3例患者外，其余均曾接受过姑息性手术。从Fontan手术至心房扑动的时间间隔为<1天至16年（平均3.7年）。7例在出院前发生早期心房扑动。15例患者的电生理研究显示12例存在窦房结功能障碍。所有患者均可诱发出心房扑动，13例患者有>1种扑动形态。尝试使用地高辛和多种其他抗心律失常药物（平均每位患者2.7种药物），效果不佳。仅地高辛、胺碘酮、氟卡尼和普罗帕酮单独使用或联合使用时显示出一定益处。16例患者植入了抗心动过速起搏器（心内膜14例，心外膜2例），联合药物治疗时8例（50%）有效。由于心房扑动难以治疗，3例患者接受了右心房切除术（2例获益，1例死亡），1例患者成功进行了射频导管希氏束消融，3例患者进行了心房扑动导管消融（2例失败，1例部分成功）。1例患者接受了心脏移植，2例患者猝死。另1例在择期心外膜起搏器更换术后死于并发症。