双心房或单纯右心房射频消融术治疗成人先天性心脏病房间隔缺损合并心房颤动的对比研究

Biatrial Ablation versus Right Atrial Ablation in the Surgical Treatment of Atrial Fibrillation for Adult Patients with Atrial Septal Defect

目的分析双心房射频消融术与单纯右心房射频消融术治疗成人先天性心脏病房间隔缺损合并心房颤动（房颤）的效果。方法回顾性分析2007年1月至2012年12月47例房间隔缺损合并心房颤动接受房间隔缺损修补联合射频消融术治疗患者的临床资料，其中男20例，女27例；年龄35～76岁；房颤病程3个月至15年；持续性房颤18例，长程持续性房颤29例。合并二尖瓣轻度至中度以上关闭不全10例，三尖瓣轻度至中度以上关闭不全28例。根据手术方式不同将47例患者分为两组，单纯右心房消融组（n=19）：行房间隔缺损修补术＋单纯右心房射频消融术；双心房消融组（n=28）：行房间隔缺损修补术＋双心房射频消融术。对于二尖瓣、三尖瓣存在轻一中度以上反流者，术中同期行二尖瓣、三尖瓣成形术。所有患者术后3个月、6个月、12个月均接受24h动态心电图检查，1年后间断门诊随访。结果双心房消融组的体外循环时间、主动脉阻断时间及术后住院时间较单纯右心房消融组略长，但两组术后早期并发症及恢复情况无明显差异。心脏复跳时，双心房消融组25例（89．3％）直接恢复窦性心律，3例为交界心律，无房颤心律。单纯右心房消融组14例（73．7％）直接恢复窦性心律，2例为交界心律，3例为房颤心律。出院时，双心房消融组28例（100％）均维持窦性心律；单纯右心房消融组15例（78．9％）维持窦性心律，4例房颤复发（P=0．045）。所有患者均得到随访，随访时间3～75个月，全组无死亡病例；房间隔无残余分流；2例出现二尖瓣轻一中度以上关闭不全，4例出现三尖瓣轻．中度以上关闭不全；双心房消融组术后2年累积窦性心律维持率为87．7％±6．7％，明显高于单纯右心房消融组的47．4％±11．5％（P=0．003）。结论对于成人房间隔缺损合并房颤，双心房射频消融术较单纯右心房射频消融术有更好的治疗效果，而且不会增加手术的风险。

Objective To compare clinical outcomes between biatrial ablation and right atrial ablation in the surgical treatment of atrial fibrillation （AF） for adult patients with atrial septal defect （ASD）. Methods Clinical data of 47 patients with ASD and AF who underwent surgical ASD repair and radiofrequency ablation from January 2007 to December 2012 were retrospectively analyzed. There were 20 male and 27 female patients with their age of 35-76 years. AF duration ranged from 3 months to 15 years. There were 18 patients with persistent AF and 29 patients with long-standing persistent AF. There were 10 patients with mild-to-moderate or more severe mitral regurgitation （MR）, and 28 patients with mild-to-moderate or more severe tricuspid regurgitation （TR）. According to different surgical strategies, all the 47 patients were divided into 2 groups. In right atrial ablation group, there were 19 patients who received ASD repair and right atrial ablation. In biatrial ablation group, there were 28 patients who received ASD repair and biatrial ablation. For patients with mild-to-moderate or more severe MR or TR, concomitant mitral or tricuspid valvuloplasty was performed. All the patients received 24-hour Holter monitoring at 3,6 and 12 months after discharge, and were intermittently followed up thereafter. Results Cardiopulmonary bypass time, aortic cross-clamping time and postoperative hospital stay ofbiatrial ablation group were significantly longer than those of right atrial ablation group. But there was no statistical difference in postoperative morbidity or recovery between the 2 groups. After heart rebeating, there were 25 patients （89.3%） with sinus rhythm （SR） and 3 patients with junctional rhythm （JR）, and none of the patients had AF in biatrial ablation group. There were 14 patients （73.7%） with SR, 2 patients with JR and 3 patients with AF in right atrial ablation group. At discharge, 28 patients （100%） in biatrial ablation group had SR, and in right atrial ablation group there were 15 patients （78.9%）with SR and 4 patients with AF relapse （P= 0.045 ）. All the patients were followed up for 3-75 months, and there was no death or residual ASD shunt during follow-up. Two patients had mild-to-moderate or more severe MR, and 4 patients had mild-to-moderate or more severe TR. Cumulative SR maintenance rate of biatrial ablation group （87.7% ± 6.7%） was significantly higher than that of right atrial ablation group （47.4%_ 11.5%,P=-0.003） at 2 years after discharge. Conclusion For adult patients with ASD and AF, biatrial ablation can produce better clinical outcomes than right atrial ablation without increasing surgical risks.