二尖瓣置换术联合左心房减容术、改良迷宫Ⅲ型术治疗风湿性心脏瓣膜病并慢性心房颤动

Mitral Valve Replacement Combined with Left Atrial Volume Reduction Surgery and Modified Maze Ⅲ Procedure for Rheumatic Heart Disease Associated with Chronic Atrial Fibrillation

目的探讨二尖瓣置换术联合左心房减容术、改良迷宫Ⅲ型术治疗风湿性心脏瓣膜病并慢性心房颤动(at-rial fibrillation,AF)的临床疗效。方法将60例左心房容积指数(LAVI)≥55mL.m-2的风湿性心脏瓣膜病并慢性AF患者按不同的治疗方法分为2组:二尖瓣置换术联合左心房减容术、改良迷宫Ⅲ型术组(LAVR组),30例;二尖瓣置换术联合改良迷宫Ⅲ型术组(对照组),30例。观察2组患者围术期的体外循环(CPB)时间、主动脉阻闭时间、呼吸机辅助时间、ICU时间、住院时间、胸瓶引流量和术后并发症发生率、病死率及术前、术毕,术后1、3、6、12个月窦性心律维持率、术前和术后12个月心功能NYHA分级、左心房内径(LAD)、左心房容积指数(LAVI)、左心室射血分数(LVEF)、心胸比(C/T)、术前和术后第1、7天,6个月血浆脑利钠肽(BNP)水平等情况。结果 2组患者CPB时间、主动脉阻闭时间、呼吸机辅助时间、ICU时间、住院时间、胸瓶引流量及术后并发症发生率、病死率比较差异均无统计学意义(均P>0.05)。LAVR组患者术后1、3、6、12个月窦性心律维持率均明显高于对照组,差异均有统计学意义(均P<0.05)。LAVR组患者术后12个月心功能NA分级明显好于对照组(P<0.05)。LAVR组患者术后12个月LAD、LAVI、LVEF、C/T值与对照组比较差异均有统计学意义(均P<0.05)。LAVR组患者术后第1、7天,6个月血浆BNP水平与对照组比较差异均有统计学意义(P<0.05或P<0.01)。结论对LAVI≥55mL.m-2的风湿性心脏瓣膜病并慢性AF患者行二尖瓣置换术联合左心房减容术、改良迷宫Ⅲ型术治疗有较好的疗效,并可预防术后AF复发,长期维持窦性心率,进一步改善左心房、室主动收缩功能。

Objective To explore the curative effects of mitral valve replacement（MVR） combined with left atrial volume reduction surgery（LAVR） and modified maze Ⅲ procedure on rheumatic heart disease（RHD） associated with chronic atrial fibrillation（AF）.Methods According to different treatment methods,60 RHD patients with chronic AF and left atrial volume index（LAVI） ≥55 mL·m-2 were divided into two groups：MVR combined with LAVR and modified maze Ⅲ procedure group（LAVR group,30 patients） and MVR combined with modified maze Ⅲ procedure group（control group,30 patients）.Perioperative parameters,including cardiopulmonary bypass（CPB） time,aortic occlusion time,auxiliary ventilation time,ICU time,hospital stay,chest bottle drainage and incidence of postoperative complications,and mortality rate were observed in the two groups.Sinus rhythm maintenance rate was measured surgery before,surgery completed and 1,3,6 and 12 months after operation.The New York Heart Association（NYHA） functional classification,left atrial diameter（LAD）,left atrial volume index（LAVI）,left ventricular ejection fraction（LVEF） and cardiothoracic ratio（C/T） were determined before and 12 months after operation.Plasma brain natriuretic peptide（BNP） levels were detected before and 1 day,7 days and 6 months after operation.Results There were no significant differences in CPB time,aortic occlusion time,auxiliary ventilation time,ICU time,hospital stay,chest bottle drainage and incidence of postoperative complications,and mortality rate between LAVR group and control group（P0.05）.The sinus rhythm maintenance rate,NYHA functional classification,LAD,LAVI,LVEF,C/T and BNP levels were significantly improved in LAVR group compared with control group（P0.05 or P0.01）.Conclusion MVR combined with LAVR and modified maze Ⅲ procedure is curative effect in RHD patients with chronic AF and LAVI≥55 mL·m-2,and can prevent postoperative AF recurrence,maintain sinus rhythm and further improve the left atrial and ventricular contraction function.