二尖瓣置换术中闭合左心耳预防心房颤动中风的作用

The impact of left atrial appendage exclusion on stroke prevention in atrial fibrillation patients with mitral valve replacement

目的 评价二尖瓣置换术同期闭合左心耳对心房颤动中风的预防作用.方法 选择2008年1月至2013年6月行二尖瓣置换且术前合并心房颤动共543例,年龄（54.1 ±10.1）岁,女性292例（53.8％）.根据患者是否同期行左心耳闭合分为左心耳闭合组（364例）和左心耳未闭组（179例）,比较两组术后住院期间缺血性卒中发生率及其危险因素.采用logistic多因素回归分析方法对术后中风进行危险因素分析.结果 左心耳闭合组女性比例较高,合并高血压、心功能不全和左心房血栓比例较高,同期处理三尖瓣和置入机械瓣者比例较高,术前左心室径较小.两组术后机械通气时间、ICU时间无差异,术后二次开胸止血发生率和住院期间病死率差异无统计学意义.术后住院期间中风9例（1.7％）;左心耳闭合组中风发生率显著低于左心耳未闭组（0.3％对4.5％,P ＜0.001）.logistic回归分析显示,CHADS2评分≥2（OR=10.135,95％CI：1.976～ 51.993,P=0.005）、术后左心房径（OR=1.069,95％CI：1.007～1.136,P=0.030）和术后应用重组人凝血因子Ⅶa（OR=22.693,95％ CI：2.066 ～255.269,P=0.011）是术后中风的危险因子,而左心耳闭合（OR=0.070,95％ CI：0.008 ～0.617,P=0.017）是预防中风的保护因子.结论 心房颤动患者二尖瓣置换术后早期有较高中风危险,术前CHADS2评分≥2、术后左心房径和应用重组人凝血因子Ⅶa是住院期间中风的危险预测因子,而术中左心耳闭合是预防中风的保护因子.

Objective To investigate the role of surgical left atrial appendage （LAA） exclusion in stroke prevention in atrial fibrillation（AF） patients with mitral valve replacement.Methods The data on 543 consecutive AF patients[53.8% female;age（54.1 ± 10.1） years] undergoing mitral valve replacement from January 2008 to June 2013 were extracted from the database and analyzed.The patients were divided into LAA exclusion group（n =364） and Non-LAA exclusion group（n =179）according to whether LAA was closed during surgery.Postoperative stroke in hospital and the risk factors were assessed.Multivariate analysis by logistic regression was performed to determine the variables used to predict postoperative stroke.Results LAA exclusion patients had higher proportion of female,hypertension,cardiac insufficiency,left atrial thrombus,emergency surgery,concurrent tricuspid valve surgery and implanted mechanical valves,and had smaller preoperative left ventricular diameter.There were no statistically significant differences betweenthe two groups in postoperative mechanical ventilation time,ICU time,the incidence of postoperative re-exploration for bleeding and hospital mortality.Postoperative stroke during hospitalization occurred in 9 patents（1.7%）.The stroke incidence in LAA exclusion patients was significantly lower than in the NonLAA exclusion patients（0.3% vs.4.5 %;P 〈 0.001）.In the multivariate analysis,the CHADS2 score ≥ 2 （OR =10.135,95 % CI：1.976-51.993,P =0.005）,postoperative left atrial diameter （OR =1.069,95% CI：1.007-1.136,P =0.030）and use of recombinant activated factor Ⅶ（OR =22.693;95% CI：2.066-255.269,P =0.011） were identified as significant risk factors for postoperative stroke,while LAA exclusion（OR =0.070,95% CI：0.008-0.617,P =0.017） was significant protective factor.Conclusion There is a higher risk of stroke in AF patients with mitral valve replacement,and the CHADS2 score≥2,postoperative left atrial diameter,and use of recombinant activated factor Ⅶ are independent risk predictors of postoperative stroke,LAA exclusion is a significant protective predictor.