瓣膜性心房颤动冷冻消融迷宫Ⅳ术后心房收缩功能恢复规律分析

Recovery rule of atrial contractility after Maze Ⅳ in patients with valvular atrial fibrillation

目的分析瓣膜性心房颤动(atrial fibrillation,AF)迷宫Ⅳ术后心房收缩力(atrial contractility,AC)变化规律及对手术疗效的影响。方法纳入2016年3月至2018年4月我院103例二尖瓣病变伴随持续性或长期持续性AF接受冷冻消融迷宫Ⅳ手术治疗的患者,其中男42例、女61例,平均年龄(58.5±9.1)岁。分别于出院时,术后1个月、3个月、6个月、12个月进行心电图和超声心动图随访。应用多因素Cox回归模型分析AC恢复的预测因素。结果 103例患者均获得1年随访。术后AC恢复率逐步升高,术后3个月后多数右心房收缩力(right atrial contractility,RAC)可伴有相应左心房收缩力(left atrial contractility,LAC)的同步恢复(Kappa系数≥0.40,P<0.05)。而直到术后1年窦性心律(sinus rhythm,SR)与双侧AC共存的一致性才尚可(Kappa系数≥0.40,P<0.05),术后1年时SR和双侧AC恢复率分别为86.4%(89/103)和66.0%(68/103)。Cox多元回归分析显示,较长术前AF时间(P=0.040)、较大术前左心房内径(left atrial diameter,LAD,P=0.003)、术后3个月AC缺失(P=0.037)是术后中晚期(>3个月)AF复发的预测因素。同时,较长术前AF持续时间、较大术前LAD也是LAC以及双侧AC中晚期恢复的负性预测因素(P均<0.05)。受试者工作特征曲线分析显示,术前AF时间与术前LAD对双侧AC恢复的最佳预测临界值分别为37个月(敏感度99.6%,特异性76.3%)和60.5 mm(敏感度98.5%,特异性78.9%)。结论冷冻消融迷宫Ⅳ术后AC恢复是一个动态提高的过程。早期AC恢复有利于将来稳定维持SR。术前AF持续时间延长、LAD增大对手术结局存在不利影响。

Objective To analyze the recovery rule of atrial contractility(AC) function after Maze IV procedure of valvular atrial fibrillation(AF).Methods In our hospital from March 2016 to April 2018,103 patients who underwent cryoablation Maze IV procedure due to mitral valve lesions associated with persistent or long-term persistent AF were enrolled.There were 42 males and 61 females,with an average age of 58.5±9.1 years.Electrocardiogram and echocardiography were followed up at discharge and 1,3,6,12 months after procedure.A multivariate Cox analysis of predictive factors for AC recovery was applied.Results All the 103 patients were followed up for 1 year.The recovery rate of AC increased gradually after operation.It was not until 3 months after procedure that most of the right atrial contractility(RAC) was accompanied by synchronous recovery of the corresponding left atrial contractility(LAC,Kappa coefficient≥0.40,P<0.05).However,the coexistence of sinus rhythm(SR) and bilateral AC was not consistent well until 1 year after operation(Kappa coefficient≥0.40,P<0.05).One year after procedure,the recovery rates of SR and bilateral AC were 86.4%(89/103) and 66.0%(68/103) respectively.By Cox multivariate regression analysis,longer preoperative AF duration(P=0.040),larger preoperative left atrial diameter(LAD,P=0.003),and AC deletion 3 months after surgery(P=0.037) were predictive factors for AF recurrence in the middle and advanced stages(>3 months) after Maze surgery.At the same time,longer preoperative AF duration and larger preoperative LAD were also negative predictors of middle and late recovery of LAC and bilateral AC(All P<0.05).Receiver operating characteristic curve analysis showed that the best critical value of preoperative AF time and preoperative LAD for prediction of AC recovery was 37 months(sensitivity99.6%,specificity 76.3%) and 60.5 mm(sensitivity 98.5%,specificity 78.9%),respectively.Conclusion The recovery of AC after Maze procedure is a dynamic improvement process.Early recovery of AC is beneficial to the stable maintenance of SR in the future.Prolonged duration of AF and enlarged LAD have adverse effects on the outcome of Maze Ⅳprocedure.