改良迷宫手术治疗肥厚型梗阻性心肌病中持续性心房颤动的临床结果分析

Analysis of surgical result of Cox-maze Ⅳ in the treatment of hypertrophic obstructive cardiomyopathy with persistent atrial fibrillation

目的分析肥厚型梗阻性心肌病(HOCM)患者外科手术时同期行改良迷宫(Cox-mazeⅣ)手术的有效性和安全性。方法2016年6月至2019年6月,30例HOCM合并持续性心房颤动(pAF)的患者在行改良扩大Morrow手术同期行Cox-mazeⅣ手术,其中男21例、女9例,平均年龄(51.36±10.27)岁,平均体重(72.48±11.29)kg。所有患者均行左心耳切除术。随访心房颤动(AF)复发、症状改善情况、心功能分级(NYHA)等。结果全组患者无围术期及远期死亡,术后左心室流出道压差与术前比较明显降低(P<0.01),术后二尖瓣收缩期前向运动(SAM)征均消失。30例患者均得到有效随访,平均随访3~40(16.24±8.26)个月,随访期间无死亡,所有患者心功能分级(NYHA)均恢复至Ⅰ~Ⅱ级。随访结束时24例(80.00%)患者维持窦性心律,经可达龙转复后27例(90.00%)患者维持窦性心律。单因素分析显示AF复发与术前吸烟史(P=0.04)、术前左心房直径≥55 mm(P=0.03)、术后左心房直径≥50 mm(P=0.02)及术后三尖瓣反流(P=0.02)相关。多因素分析表明,术后左心房直径增大是AF复发的独立危险因素(P=0.02)。结论HOCM合并pAF的患者外科手术同时行Cox-mazeⅣ手术安全有效,术后的窦性心律维持率显著提高,心功能分级(NYHA)明显改善。术后左心房直径增大是AF复发的独立危险因素。

Objective To evaluate the efficacy and safety of modified maze Ⅳ(Cox-mazeⅣ)in hypertrophic obstructive cardiomyopathy(HOCM)patients.Methods From June 2016 to June 2019,30 HOCM and persistent atrial fibrillation(pAF)patients received Cox-maze Ⅳ operation with modified extended Morrow operation,including 21 males and 9 females.The average age was 51.36±10.27 years and the average weight was 72.48±11.29 kg.All patients underwent left atrial appendectomy.Recurrence of AF,improvement of symptoms,cardiac function(NYHA)were assessed during follow-up.Results There was no death during the perioperative period.Postoperative left ventricular outflow tract gradient was significantly decreased compared with that before operation(P<0.01),and all systolic anterior motion(SAM)signs disappeared after operation.Thirty patients were all effectively followed up for 3-40(16.24±8.26)months.During the follow-up period,there was no death,and the cardiac function(NYHA)of all patients recovered to gradeⅠ-Ⅱ.At the end of follow-up,twenty-four patients(80.00%)maintained sinus rhythm,and twenty-seven patients(90.00%)maintained sinus rhythm after amiodarone conversion.Univariate analysis showed that the smoking history(P=0.04),left atrial diameter≥55 mm before operation(P=0.03),left atrial diameter≥50 mm after operation(P=0.02),postoperative tricuspid regurgitation(P=0.02)were closely related to postoperative AF recurrence.The increase of left atrial diameter after operation was an independent risk factor for AF recurrence(P=0.02).Conclusion Morrow/Cox-mazeⅣprocedure is safe and effective in treatment of patients with HOCM complicated with pAF,which helps to maintain postoperative sinus rhythm,and to improve the cardiac function.The increase of left atrial diameter after operation is an independent risk factor for AF recurrence.