附加扩大左房减容与直流电转复模式对瓣膜病合并心房颤动患者心房颤动的影响

Combination of left atrial plication and external direct current cardioversion in the operation for valve disease associated with atrial fibrillation

目的研究在进行基础瓣膜置换或成形手术时附加左房减容和直流电复律术对瓣膜病合并心房颤动(简称房颤)患者房颤的影响。方法选取有心脏瓣膜病变且合并左房扩大病例298例,均伴有诊断明确的房颤病史,根据左房内径大小分成Ⅰ、Ⅱ、Ⅲ3组:左房内径40～59mm为Ⅰ组,共83例,60～79mm为Ⅱ组,共161例,80mm以上为Ⅲ组,共54例。按照住院号单双数随机将三组又分为2个亚组行瓣膜手术附加左房减容术和直流电转复为a组,未附加手术为b组;左房减容包括左房折叠和左房壁切除,直流电电转复包括电复律,起始量为10J,依次10J累加,最大达30J。如果a组自动复跳为窦性心律,依然加10J电击一次。所有病例均于术前口服可达龙并术后维持治疗。结果Ⅰa组和Ⅰb组术后早期和出院时的窦性转复率无明显差异,但随访9～12个月,Ⅰa组的窦性转复率明显高于Ⅰb组(35.3%vs28.6%P(0.05);Ⅱ组和Ⅲ组中a亚组的窦性转复率在术后早期、出院时以及随访期间均明显高于b亚组。Ⅰa组与在出院和随访期间窦性转复率高于Ⅱa、Ⅲa(44.1%vs34.4%、27.3%;35.3%vs30.0%、12.1%,P均(0.05),Ⅱa组在出院和随访期间窦性转复率亦高于Ⅲa组(34.4%vs27.3%;30.0%vs12.1%,P(0.05)。结论对于左房扩大的瓣膜病变伴房颤患者,在进行基础瓣膜置换或成形手术时附加左房减容和直流电复律手术,可以达到一个非常理想的房颤转复率和维持率,但左房内径达80mm以上的病例其远期效果不佳。

Objective To evaluate the effectiveness of additional left atrial plieation and external direct current cardioversion after value operation on maintaining sinus rhythem in patients with atrial fibrillation（AF） associated with giant left atrium. Methods According to the size of left atrial diameter, 298 patients were divided into three groups： Group I ： Left atrial diameter was between the 40 to 59mm, Group Ⅱ ：Left atrial diameter was between the 60 to 79 mm, Group Ⅲ ： Left atrial diameter was larger than 80 mm. Three groups were randomly divided into two sub-groups, in which sub-group a underwent additional left atrial plication and external direct current cardioversion after valve operation and sub-group b underwent valve operation only. All patients were treated with amiodarone before and after the operation. Result There was no significant difference in rate of maintaining sinus rhythm between group Ia and group Ib on the time of postoperative and discharged from the hospital. But at follow-up of 9 - 12 months, the rate of maintaining sinus rhythm of group Ⅰa was significantly higher than that of group Ⅰb（35.3% vs 28.6% ,P 〈 0.05） ;Similarly, There was significant difference in rate of maintaining sinus rhythm between group Ⅰa, Ⅱa,ma on the time discharge and follow-up（44. 1% vs 34.4% ,27.3% ;35.3% vs 30.0% ,12. 1% ; P 〈 0.05）. Conclusion Additional left atrial plication and external direct current cardioversion after valve operation has considerably benefiticial effects on rate of maintaining sinus rhythm in patients with AF associated with giant left atrium. But for patients that left atrial diameter is larger than 80 mm, the result is not optimistic and it also revealed that the occurrence of AF is closely related to left atrial size.