术前心房颤动对单纯二尖瓣置换术患者术后中远期疗效的影响

Influence of Preoperative Atrial Fibrillation on Midterm and Longterm Outcomes of Patients after Mitral Valve Replacement

目的探索术前心房颤动(AF)对二尖瓣置换术患者术后中远期疗效的影响。方法回顾性分析2000年1月至2005年12月在第二军医大学附属长海医院行二尖瓣置换术,伴或不伴有三尖瓣成形术的二尖瓣病变患者1 029例的临床资料,按照纳入与排除标准共筛选出621例,按照术前是否发生AF分为两组,术前出现AF为AF组,395例,男134例、女261例,年龄(51.1±11.5)岁;术前窦性心律(SR)为SR组,226例,男82例、女144例,年龄(48.2±14.1)岁。比较两组早期临床结果和中远期死亡率、并发症发生率。结果 10年随访结果显示,两组患者早期并发症发生率和死亡率差异无统计学意义,但AF组血栓栓塞发生率明显高于SR组,且差异有统计学意义[0.9‰(31例/33 984患者月)vs.0.4‰(9例/21 151患者月),χ2=4.26,P=0.039]。AF组术后10年生存率明显低于SR组,且差异有统计学意义(83.2%vs.92.7%,χ2=10.26,P=0.002)。经Cox多因素分析,影响二尖瓣置换术患者术后中远期死亡率的独立危险因素包括术前AF[HR=2.878,95%CI(1.166,4.129)]、左心室射血分数低[HR=0.948,95%CI(0.917,0.981)]和年龄偏高[HR=1.073,95%CI(1.038,1.109)]。AF除了对患者生存率及血栓栓塞并发症发生率有显著影响外,对左心、右心功能及三尖瓣反流量同样存在负面效应。结论 AF是影响二尖瓣置换术患者预后的危险因素,如果出现AF先兆如多发房性早搏或左心房扩张时尽早进行手术,或许可改善患者预后。

Objective To determine the influence of preoperative atrial fibrillation（AF） on midterm and longterm clinical outcomes of patients after mitral valve replacement（MVR）.Methods We retrospectively analyzed clinical data of 1 029 patients who underwent MVR with or without tricuspid valve repair in Changhai Hospital,Second Military Medical University,from January 2000 to December 2005.According to the exclusion criteria,621 patients were selected and divided into two groups depending on presence of preoperative AF.Those 395 patients with preoperative AF belonged to the AF group,including 134 males and 261 females with their average age of 51.1±11.5 years.Those 226 patients with preoperative sinus rhythm（SR） were in the SR group,including 82 males and 144 females with their average age of 48.2±14.1 years.Early postoperative outcomes,midterm and longterm mortality and morbidity of the two groups were compared.Results During 10 years of follow-up,there was no statistical difference in early postoperative mortality and morbidity between the two groups,but the incidence of late thromboembolism was significantly higher in AF group than that in SR group [0.9‰（31 patients/33 984 patient-months） vs.0.4‰（9 patients/21 151 patient-months）,χ2=4.26,P=0.039].Ten-year survival rate in patients in AF group was significantly lower than that in SR group（83.2% vs.92.7%,χ2=10.26,P=0.002）.Multivariate analysis identified preoperative AF [HR=2.878,95% CI（1.166,4.129）],low left ventricular ejection fraction [HR=0.948,95% CI（0.917,0.981）],and old age [HR=1.073,95% CI（1.038,1.109）] as independent risk factors for late mortality after MVR.Apart from its influence on patient survival rate and incidence of thromboembolism,preoperative AF also had an adverse effect on left ventricular function,right ventricular function and tricuspid regurgitation.Conclusion AF is an independent risk factor for poor prognosis after MVR.Prognosis after MVR might be improved if surgery could be performed early when patients have predictive signs of AF such as multiple premature atrial contractions or left atrium enlargement.