直视下球囊超声消融肺静脉治疗瓣膜病永久性心房颤动的临床观察

Ablation of the orifices of the pulmonary veins under direct vision by using the transballoon ultrasound ablation catheter for permanent atrial fibrillation with rheumatic valve disease

目的探讨在瓣膜置换同时行直视下球囊超声消融肺静脉治疗瓣膜病永久性心房颤动(房颤)的效果和可行性。方法 2002年12月至2003年9月,21例长海医院胸心外科风湿性心脏病伴永久性房颤患者入选本研究。按是否采用超声球囊消融肺静脉口分为超声组和对照组。超声组11例中男6例、女5例,平均年龄(51.55±7.83)岁,房颤持续时间(5.50±5.40)年,左房直径(7.27±1.39)cm,左室射血分数(53.95±4.54)%,术前心功能 NYHA 分级Ⅱ～Ⅳ级,在瓣膜置换同时直视下经球囊超声导管行肺静脉口电隔离。对照组10例中男3例、女7例,平均年龄(53.30±7.86)岁,房颤持续时间(4.50±3.47)年,左房直径(6.74±0.62)cm,左室射血分数(56.91±3.78)%,术前心功能 NYHA 分级Ⅱ～Ⅳ级,单纯行瓣膜置换术。结果两组患者均无心房穿孔、出血、栓塞、房室传导阻滞等并发症。21例患者随访(45.92±4.61)个月。在术后3个月行电复律后,超声组73%的患者维持窦性心律12个月以上,对照组仅为10%,两组相比差异有统计学意义(P=0.003)。术后1年时,超声组左房容积较术后3个月时明显缩小,分别为(97.83±32.39)cm^3与(150.78±52.32)cm^3,P<0.05;左房收缩内径明显缩小,分别为(4.12±0.39)cm 与(5.09±0.98)cm,P<0.05;左房舒张内径明显缩小,分别为(3.47±0.35)cm 与(4.46±1.15)cm,P<0.05;而对照组无明显变化。术后平均46个月随访超声组维持窦性心律63.6%,而对照组100%为房颤心律。结论瓣膜置换时直视下球囊超声肺静脉电隔离安全、有效,对瓣膜病合并永久性房颤复律后具有稳定窦性心律的作用,长期随访左房功能和心排量有明显改善。

Objective To evaluate the effect and possibility of surgical ablation of the pulmonary vein orifices under direct vision with transballoon ultrasound ablation catheter for patients with permanent atrial fibrillation and rheumatic valve disease. Methods 21 consecutive patients with rheumatic valve disease and permanent atrial fibrillation undergoing mitral valve replacement surgery were enrolled for this study from December 2002 to September 2003. All the cases were divided into 2 groups by whether or not receiving an additive pulmonary vein ablation procedure. The test group [6 male, 5 female, aged （51.55 ±7. 83）years, atrial fibrillation duration （5. 50±5.40） years, left atrial diameter （7.27 ±1.39）cm , LVEF （ 53. 95± 4. 54） % and NYHA class Ⅱ- Ⅳ ] undertook a surgical isolation of the pulmonary vein orifices by using a transballoon ultrasound ablation catheter addition to routine mitral valve replacement. The control group [ 3 male, 7 female, aged （ 53. 30 ± 7. 86） years, atrial fibrillation duration （4. 50 ± 3.47） years, left atrial diameter （6.74 ±0.62）cm, LVEF （56.91 ±3.78）% and NYHA class Ⅱ - Ⅳ] received the valve replacement surgery alone. Results There were not any complications in both groups. With an electrical cardioversion 3 months after the surgery, 73% patients in the ultrasound ablation group were free from AF over 1 year while only 10% patients in control group （P =0. 003）. During an average follow-up duration of （45.92 ±4. 61 ） months, 63.6% were in sinus rhythm in ultrasound ablation group while none in the control group. Left atrial volume decreased significantly at 1 year after surgery compared to that at 3 months after surgery in the test group[ （97. 83 ±32. 39）cm^3 vs. （ 150. 78 ±52. 32）cm^3, P 〈0. 05], and the end systolic diameter （LAESD） and end diastolic diameter（LAEDD） also decreased [ （4. 12 ±0. 39）cm vs. （5. 09± 0. 98 ） cm, P 〈 0. 05, respectively ], while there were no apparently changes in the control group. Conclusions Ablation of the orifices of the pulmonary veins under direct vision with transballoon ultrasound ablation catheter during mitral valve surgery seems effective to maintain sinus rhythm after electrical cardioversion and could be performed safely. The function of left atrial and cardiac output improved during long term follow-up of 46 months.