心内膜合并心外膜改良迷宫射频消融治疗心房纤颤

Combined endocardial and epicardial radiofrequency modified Maze procedure in the treatment of atrial fibrillation

目的评价心内膜合并心外膜改良迷宫射频消融治疗心房纤颤的疗效。方法对295例房颤患者进行射频消融,185例进行心内膜加心外膜消融,另110例行心内膜消融。其中男124例,女171例;年龄19～77岁,平均(52±11)岁。90.8%(268/295)患者为风湿性病变。瓣膜手术289例,19例合并冠状动脉旁路移植术。结果手术死亡10例(3.4%),其中4例死于低心排综合征,5例死于多器官功能衰竭,1例死于脑疝。随访3～47个月,平均(28±5)个月。随访每组各有1例死亡,均死于神经系统并发症。全组术后窦性心律占77.3%(228/295),其中心内膜组70.9%(78/110);心内膜加心外膜组81.1%(150/185)(P<0.05)。最近随访的259例,窦性心律191例,占73.7%,其中心内膜组66.0%(64/97),心内膜加心外膜组78.4%(127/162)(P<0.05)。组织学可见心内膜组心肌细胞凝固性坏死灶集中在心内膜侧,近心外膜的坏死灶减少。而心内膜加心外膜组可见病灶分布组织全层,局部有炎症细胞浸润,心肌细胞网状结构破坏消失。结论心内膜合并心外膜射频消融是一种简易、安全、有效的治疗房颤的外科方法,而且效果优于心内膜消融。

Objective To evaluate the effectiveness of the combined endocardial and epicardial saline-irrigated radiofrequency modified maze procedure for the treatment of atrial fibrillation （AF）. Methods During a period of 3 years, 295 patients with AF having concomitant cardiac surgery underwent the procedure. Patients underwent either the endocardial and epicardial group （n = 185） or the endocardial group （n = 110） radiofrequency ablation. There were 124 males, 171 females with a mean age of （52±11 ） year old. Mean duration of preoperative AF was 36 ± 43 months. And about 90.8 percent valve pathology was rheumatic. Valve operation was performed in 289 patients, coronary artery bypass graft surgery in 19 patients and congenital heart disease operation in 6 patients respectively. Follow-up for the whole patients ranged from 3 to 47months （ mean 28 ± 5 months ）. Resulls Ten patients died postoperatively （ 3. 4% ）. Four patients died of low cardiac output, five patients died of multisystem and organ failure, one patient died of cerebral hernia. There were 2 patients died of nerves system complication during follow-up. At the end of the procedure 228 patients （77.3%） were sinus rhythm, including 78 patients （70. 9% ） in endocardial group while 150 patients （81.1%） in endocardial and epicardial group （P 〈0. 05）. At late follow-up, 191 of 259 patients （73. 7% ） were in stable sinus rhythm. Sinus rhythm was present in 64 patients （66. 0% ） in endocardial group while 127 patients （ 78.4% ） in endocardial and epicardial group （ P 〈 0. 05 ）. Histopathology of the endocardial group revealed foci coagulative necrosis was limited to the endocardial side. While endocardial and epicardial ablation had full-thickness alteration of atrial tissue besides illdefined borders and inflammatory cell infiltration. Conclusions Combined endocardial and epicardial salineirrigated radiofrequency modified maze procedure was performed safely and efficiently. And it restored sinus rhythm better than endocardial ablation only.