瓣膜置换术同时行射频消融迷宫手术治疗风心瓣膜病合并房颤的临床经验

Clinical experience of valve replacement combined with radiofrequency Maze Ⅲ procedure for atrial fibrillation

目的总结瓣膜置换术同时行射频消融迷宫手术的临床治疗经验。方法对我科70例风心瓣膜病患者行直视下瓣膜置换术和射频消融迷宫手术，术中切除左右心耳，经改良的CoxMazeⅢ线路行射频消融治疗，术后随访其疗效。运用单因素和多因素回归分析确定影响房颤射频消融迷宫手术后复发的危险因素。结果术后2例死亡，死因为低心排。心脏复跳后转复窦性心律者45例（64．3％），64例患者随访至12个月，窦性心律49例（76．6％），房颤12例（18．8％），结性心律3例（4，7％）。多因素回归分析显示术前左房直径是术后房颤复发的危险因素。结论瓣膜置换术同时行射频消融迷宫手术安全可行，疗效确切，已成为风心瓣膜病合并房颤患者的首选治疗方法。

Objective To evaluate the effectiveness and advantages of the radiofrequency ablation maze procedure in the treatment of atrial fibrillation associated with rheumatic valve disease. Methods A total of 70 patients （25 males and 45 females, mean age：57.3 ± 11.0 years） underwent valve replacement and radiofrequency Maze Ⅲ procedure. The mean course of the disease was 5.4 ± 5.9 years （5 months - 14 years ）. The mean diameter of left atrium and diastolic ventricle was 5.6 ± 0.8 cm （ 3.6 - 6.9 era） and 5.5 ± 1.0 cm （ 3.5 - 8.0 cm ）. The mean LVEF was 58.6% ± 7.9% （ 31% - 74% ）. The left and right appendage were excised and radiofrequency ablation were performed through modified Maze Ⅲ route during the operation. Follow - up data were obtained from medical record. Univariate and multivariate logistic analyses were applied to identify the independent factors that would influence the efficiency of radiofrequency Maze Ⅲ procedure. Results Two cases died of low cardiac input. Sinus rhythm was found in 45 cases （64.3 % ）after the heart beat again. 64 cases were followed up for twelve months. Sinus rhythm was found in 49 cases（76.6% ）. Atrial fibrillation developed in 12 cases（ 18.8% ）. Nodal rhythm appeared in 3 cases（4.7% ）. Sinus bradycardia occurred in 10 cases, but none of the patients were implanted the permanent pacemaker. There was significant difference in the diameter of left atrium between before and after the operation （5.6 ± 0.8 vs 4.8 ± 1.0 cm）. Unvariate analyses showed that factors predictive of postoperative AF recurrence were duration of permanent AF more than 60 months,preoperative left atrial（LA） and ventricular size. Preoperative left atrial diameter was identified to be the independent factor of postoperative atrial fibrillation recurrence by multivariate logistic analyses. Conclusions Valve replacement combined with radiofrequency Maze Ⅲ procedure is safe and efficient in the treatment of atrial fibrillation associated with rheumatic valve disease.