左心房后壁盒式消融的改良心脏迷宫手术疗效

The effect of different ablation lines in left atrium on modified cardiac Cox maze procedure

目的探讨盒式消融术式能否提高心房颤动（房颤）治疗的成功率。方法2009年1至12月，心脏直视手术同期行改良迷宫下术患者中，行左心房后壁盒式消融术者60例，同期配对选择60例非盒式消融术者作为对照组。两组均经过相对一致的术前检查和围手术期处理。结果除盒式消融组体外循环时间较长外，两组在年龄、房颤时间、左心房直径、左心室射血分数、同期手术等差异无统计学意义，两组围手术期均无死亡病例。所有病例均顺利随访，平均（9．0±8．4）个月。盒式消融组1例在术后2个月死于脑出血，非盒式消融组1例在术后12个月出现脑梗塞。术后1与3个月，两组免于房颤率分别为70．0％对51．2％（P=0．039）与78．3％对60．0％（P=0．030）；术后6个月分别为80．0％对71．7％（P=0．286）。8例因房颤心律复发再次人院，两组分别有4例和2例行导管消融，两组各有1例行电复律，均恢复窦性心律，并继续口服胺碘酮治疗3个月。结论盒式消融组通过增加左、右肺静脉之间连线，比非盒式消融组左、右肺静脉之间单一连线，明显提高射频消融迷宫手术后早期（1～3个月）窦性心律的维持率；但在术后半年，两组窦性心律的维持率差异无统计学意义。

Objective Background and objective The Cox maze Ⅲ procedure has been considered the gold standard for the surgical treatment of atrial fibrillation （AF） and the modified Cox maze use bipolar radiofrequency ablation instead of the cut-and-sew technique, while also reducing the connecting lines in left atrium. This study was to understand whether complete- ly isolation the posterior left atrium by increasing left atrium ablation lines can enhance the survival after modified Cox maze pro- cedure. Methods From Jan 2009 to Dec 2009, all the patients underwent the Cox maze procedure, following the same exami- nation, were divided into two groups （case-control） ： box lesion group （n = 60） , which is means the right and left pulmonary vein lesions were connected inferiorly by adding ablation lines, thereby completely isolating the posterior left atrium and the non-box lesion group （ n = 60）. Similar interventions were given during the perioperative periods. Comparing the risk factors before surgeries, then follow-up was 100% complete,and the mean follow-up was 9 ± 8.4 months. Results Except the box le- sion had long time of extraeorporeal circulation, the characteristics of the 2 groups were similar because there were no differences in age, AF duration, left atrial diameter, left ventricular ejection fraction or homochronous operation between the groups and there was no operative death. No patient was lost to follow-up. In the mean follow-up duration, a patient was died of intracere- bral hemorrhage at 2 months postoperationly in the box lesion group and a patient suffered from stroke at 12 months postopera- tionly in the non-box lesion. The overall freedom from AF recurrence was higher in the box lesion group at 1 （70% vs 51.2% , P =0. 039） and 3 （78.3% vs 60% , P = 0. 030） months. While it was 80% vs 71.7% （P =0. 286） at 6 months. Eight patients wrere readmitted because of the recurrence of AF, 4 and 2 patients underwent catheter ablation in box and non-box group respectively, one patient in each group underwent electrical conversion. After treatment, all of the patients were recovered to si- nus rhythm and continued to take cordarone. Conclusion Compared to the single connecting between right and left pulmonary vein, isolating the entire posterior left atrium by creating a box lesion showed higher freedom from AF in the earlier months （1 -3months）. However, half a year after the surgery, there were no significant differences between the two groups.