心房颤动对不同病因的二尖瓣手术治疗预后的影响

The influence of atrial fibrillation on prognosis after mitral valve surgery in rheumatic mitral valve stenosis and mitral valve prolapse patients

目的 分析风湿性二尖瓣狭窄（MS）和二尖瓣脱垂（MVP）手术后的心房颤动（房颤）变化特点.方法 2009年11月至2012年3月期间因MS或MVP而单纯行二尖瓣置换术或成形术的成年患者中,按术后6 min时心律分为窦性心律组和房颤组,再以年龄配对分为MS和MVP亚组,即风湿性心脏病窦性心律组（RS组）、二尖瓣脱垂窦性心律组（PS组）、风湿性心脏病房颤组（RAF组）和二尖瓣脱垂房颤组（PAF组）,每组30例.各组之间比较采用独立样本t检验和x2检验,各组术前、术后比较采用配对t检验.结果 术后6 min时为窦性心律的MS患者术前有15例（50％）为房颤,术后1 min时有10例（33.3％）仍为房颤,而MVP患者术前、术后心律无明显变化;房颤组患者左心房内径（LAD）明显大于RS组,P＜0.05,MS组与MVP组之间差异无统计学意义;RS组患者术前及术后1 min的LAD明显大于PS组,P为0.008和0.018,而术后6 min时RS组和PS组之间差异无统计学意义,P=0.558;风湿性心脏病（RHD）患者术前、术后1 min、6 min的二尖瓣瓣环侧壁处收缩期峰速（Smm）明显低于正常范围;PAF组患者Smm术前基本正常,而术后1 min和6 min时明显降低,与RHD患者相近.结论 房颤的发生、发展机制在MS与MVP两种患者中存在一定差异,伴有慢性房颤的部分MS患者术后随左心房缩小可转为并维持窦性心律;术后仍为持续性房颤的MVP患者其左心室收缩功能出现降低趋势.

Objective Atrial structure remodeling is the important pathologic basis of generate and development in chronic atrial fibrillation（AF） of valvular heart disease.To analyze the changed feature of AF in rheumatic mitral valve stenosis （MS） and mitral valve prolapse（MVP） after mitral valve surgery,along with fundamental change of hemodynamics in left atrial.Methods Firstly,divided into sinus rhythm （SR） group and AF group according to cardiac rhythm postoperative 6 months,and then divided into MS and MVP two subgroups with age matched,namely rheumatic sinus rhythm group （RS group）,MVP sinus rhythm group（PS group）,rheumatic AF group（RAF group） and MVP AF group（PAF group）,30 patients in each group.Independent sample t test andx2 test were used in comparison among groups,and matched t test in preoperative and postoperative comparison of each group.Results There are 15 （50%） AF patients before surgery and 10 （33.3%） AF patients postoperative 1 month in RS group.But cardiac rhythm of MVP patients has no significant change.Left atrial diameter（LAD） in AF group was larger than in SR group significantly preoperative and postoperative 1 month and 6 months（P 〈 0.05）,and LAD have no significant difference between RAF and PAF group,P 〉 0.05 ; LAD in RS group preoperative and postoperative 1 month was larger than in PS group（P =0.008 and 0.018,respectively）,but there is no significant difference between RS and PS groups postoperative 6 months（P =0.558）.Systolic peak velocity（Smm） at valve ring with PWTDI were（6.0 ± 1.4） cm/s,（6.7 ± 1.8） cm/s and （6.2 ± 1.6） cm/s preoperative and postoperative 1 month and 6 months,lower than normal range obviously; Smm before surgery in PAF group was（9.3 ± 3.7）cm/s,but reduced obviously after surgery 1 month and 6 months and near the level of rheumatic patients.Conclusion Generate and development mechanism of AF in MS and MVP patients exist some extent difference,the rhythm of partial MS patients with chronic AF will turn to and maintain sinus rhythm along with LAD decreased,there is no this characteristic in MVP patients.