Viganò M, Graffigna A, Ressia L, Minzioni G, Pagani F, Aiello M, Gazzoli F
Institute of Cardiac Surgery, University of Pavia, I.R.C.C.S. Policlinico S. Matteo, Italy.
Eur J Cardiothorac Surg. 1996;10(7):490-7. doi: 10.1016/s1010-7940(96)80413-1.
The mechanisms of atrial fibrillation arc multiple reentry circuits spinning around the atrial surface, and these baffle any attempt to direct surgical interruption. The purpose of this article is to report the surgical experience in the treatment of isolated and concomitant atrial fibrillation at the Cardiac Surgical Institute of the University of Pavia.
In cases of atrial fibrillation secondary to mitral/valve disease, surgical isolation of the left atrium at the time of mitral valve surgery can prevent atrial fibrillation from involving the right atrium, which can exert its diastolic pump function on the right ventricle. Left atrial isolation was performed on 205 patients at the time of mitral valve surgery. Atrial partitioning ("maze operation") creates straight and blind atrial alleys so that non-recentry circuits can take place. Five patients underwent this procedure. In eight-cases of atrial fibrillation secondary to atrial septal defect, the adult patients with atrial septal defect and chronic or paroxysmal atrial fibrillation underwent surgical isolation of the right atrium associated which surgical correction of the defect, in order to let sinus rhythm govern the left atrium and the ventricles. "Lone" atrial fibrillation occurs in hearts with no detectable organic disease. Bi-atrial isolation with creation of an atrial septal internodal "corridor" was performed on 14 patients.
In cases of atrial fibrillation secondary to mitral valve disease, left atrial isolation was performed on 205 patients at the time of mitral valve surgery with an overall sinus rhythm recovery of 44%. In the same period, sinus rhythm was recovered and persisted in only 19% of 252 patients who underwent mitral valve replacement along (P < 0.001). Sinus rhythm was less likely to recover in patients with right atriomegaly requiring tricuspid valve annuloplasty: 59% vs 84% (P < 0.001). Restoration of the right atrial function raised the cardiac index from 2.25 +/- 0.55 1/min per m2 during atrial fibrillation to 2.54 +/- 0.58 1/min per m2, with a mean percentage increase in cardiac index of 13.5% (P < 0.00018). Atrial partitioning ("maze operation") was performed on five patients with an immediate sinus rhythm recovery of 100%, but with two patients requiring pacemaker implant. Seven out of eight patients (87.5%), with atrial fibrillation secondary to atrial septal defect, who underwent surgical isolation of the right atrium at the time of surgery were free from atrial fibrillation and without medications. 2-52 months after operation. Thirteen of 14 patients with "lone" atrial fibrillation who underwent corridor procedure remained in sinus rhythm with a sinus rhythm recovery rate of 92%.
Different surgical options can be chosen for different cases of atrial fibrillation, according to the underlying cardiac disease.
房颤的机制是多个折返环在心房表面环绕，这使得任何直接手术阻断的尝试都受到阻碍。本文旨在报告帕维亚大学心脏外科研究所治疗孤立性和合并性房颤的手术经验。
在二尖瓣疾病继发房颤的病例中，二尖瓣手术时行左心房隔离可防止房颤累及右心房，右心房可对右心室发挥舒张期泵血功能。205例患者在二尖瓣手术时进行了左心房隔离。心房分隔术（“迷宫手术”）可形成笔直且盲端的心房通道，从而实现非折返性传导。5例患者接受了该手术。在8例继发于房间隔缺损的房颤病例中，患有房间隔缺损且伴有慢性或阵发性房颤的成年患者在手术矫正缺损的同时接受了右心房隔离，以使窦性心律控制左心房和心室。“孤立性”房颤发生于无明显器质性疾病的心脏。14例患者进行了双心房隔离并创建了房间隔结间“走廊”。
在二尖瓣疾病继发房颤的病例中，205例患者在二尖瓣手术时进行了左心房隔离，窦性心律总体恢复率为44%。同期，仅接受二尖瓣置换术的252例患者中，窦性心律恢复并持续的比例仅为19%（P<0.001）。需要进行三尖瓣环成形术的右心房扩大患者窦性心律恢复可能性较小：分别为59%和84%（P<0.001）。右心房功能恢复使心脏指数从房颤时的2.25±0.55升/分钟每平方米提高到2.54±0.58升/分钟每平方米，心脏指数平均增加13.5%（P<0.00018）。5例患者接受了心房分隔术（“迷宫手术”），窦性心律立即恢复率为100%，但有2例患者需要植入起搏器。8例继发于房间隔缺损的房颤患者中，7例（87.5%）在手术时接受了右心房隔离，术后2至52个月未再发生房颤且无需药物治疗。14例接受“走廊”手术的“孤立性”房颤患者中有13例维持窦性心律，窦性心律恢复率为92%。
根据潜在的心脏疾病，可针对不同类型的房颤选择不同的手术方案。
