冷冻消融迷宫术治疗瓣膜病合并心房颤动的围术期管理

The perioperative care for Cox Maze prodecure using cryoablation in treatment of atrial fibrillation associated with valvular heart disease

目的总结冷冻消融迷宫手术治疗瓣膜病合并心房颤动(房颤)的围术期管理经验。方法选取2015年10月至2017年6月在沈阳军区总医院住院行冷冻消融迷宫术治疗瓣膜病合并房颤的患者65例,其中男性24例,女性41例,年龄37~71(58.33±9.01)岁,房颤病程0.5~240(48.86±74.46)月,左房内径34~59(49.09±5.93)mm。结果全部患者无围术期死亡,术中主动脉阻断时间44~159(92.40±30.58)min,体外循环时间101~229(156.60±35.57)min,术中出血200~600(340.00±76.38)ml,呼吸机辅助时间15~48(23.29±11.22)h,监护室停留时间16~96(41.57±31.41)h。电复律治疗7例(10.77%),临时起搏治疗27例(41.54%),无永久起搏器植入患者。出院时,窦性心律42例(64.62%),心房扑动11例(16.92%),心房颤动12例(18.46%)。结论充分的术前准备,准确熟练的操作,良好的心肌保护,密切的心律监测及心律失常的积极防治,依据漂浮导管的指导治疗,详细的出院指导,对于患者围术期管理至关重要。

Objective To summarize the experience of perioperative care for Cox Maze prodecure using cryoablationin treatment of atrial fibrillation（ AF） associated with valvular heart disease. Methods Clinical data of 65 patients who underwent Cox Maze prodecure using cryoablation in our center between October 2015 and June 2017 were retrospectively analyzed. There were 24 male and41 female patients with the age of 37-71（ 58.33±9.01） years. The AF duration was 0.5-240（ 48.86±74.46） months,and the left atrial diameter was 34-59（ 49.09±5.93） mm. Results There was no perioperative death. The aortic-clamp time was 44-159（ 92.40±30.58）min,and the cardiopulmonary bypass time was 101-229（ 156.60±35.57） min. The bleeding volume was 200-600（ 340.00±76.38） ml.The assisted mechanical ventilator time was 15-48（ 23.29±11.22） h,and the ICU stay time was 16-96（ 41.57± 31.41） h. Seven patients（ 10.77%） received cardioversion,and 27 patients（ 41.54%） received temporary pacemaker implantation but none required permanent pacemaker. At discharge,there were 42 patients（ 64. 62%） in sinus rhythm,eleven patients（ 16. 92%） in atrial flutter rhythm,and 12 patients（ 18.46%） in atrial fibrillation rhythm. Conclusions Sufficient preoperative preparation,accurate and skilled operation,appropriate myocardial protection,closely monitoring of the heart rhythm,active precaution and therapy of postoperative arrhythmia,treatment directed by Swan-Ganz catheter and detailed discharge instruction are critical for the successful Cox Maze prodecure using cryoablation in treatment of atrial fibrillation associated with valvular heart disease.