心房颤动患者一站式杂交手术疗效及安全性分析

Efficacy and safety of hybrid ablation for treatment of atrial fibrillation:clinical experience from 29 cases

目的分析心房颤动(房颤)一站式杂交手术的有效性和安全性。研究对象纳入2015年5月至2017年10月在河北燕达医院连续29例接受一站式杂交手术的房颤患者,男性21例,女性8例,平均年龄(59±8)岁,其中5例为阵发性房颤,24例为持续性房颤。干预措施经左侧胸腔镜途径消融两侧肺静脉、左心房后壁及Marshall韧带,并切除左心耳。之后经导管心内膜途径对外科消融径线的完整性进行验证,并进行心房的基质改良。后者的靶点包括:房颤状态下心房电位振幅<0.3 mV,且形态复杂碎裂并呈片状分布的区域;局部心房激动频率快于周围的区域、三尖瓣峡部消融线。消融终点为经导管消融终止房颤。观测指标及测量方法观察指标为即刻成功和临床成功。即刻成功即术中成功终止房颤,转为房性心动过速(房速)、心房扑动(房扑)或窦性心律;临床成功即手术空白期(3个月)后无房性心律失常复发,以及术后1个月内无严重并发症。严重并发症包括:死亡、因出血转为开胸手术、心包填塞、心房食管瘘、急性心肌梗死、卒中。结果所有患者均实现包括两侧肺静脉在内的左心房后壁隔离及左心耳切除。术中的房颤终止率为83%(24/29),单次消融成功率为76%(22/29)。复发的7例患者中,4例患者接受了再次导管消融,其中2例成功;1例患者接受电复律并维持窦性心律;另2例未接受再治疗。平均随访时间(18±9)个月,最终手术成功率为86%(25/29)。无严重并发症。其他并发症包括2例皮下气肿,1例左侧胸腔积液。结论一站式杂交手术治疗房颤安全、有效。

Objective To investigate the efficacy and safety of hybrid ablation for the treatment of atrial fibrillation(AF).Subjects Between May 2015 and October 2017,29 consecutive patients(21 males and 8 females,59±8 years old)underwent one‑step hybrid ablation for symptomatic paroxysmal AF(n=5)or persistent AF(n=24)in Hebei Yanda Hospital.Interventions Bilateral pulmonary vein isolation(PVI),left atrial posterior wall(LAPW)isolation,ablation of ligament of Marshall and resection of left atrial appendage were performed through the left thoracoscopic approach.Conduction block of epicardial lesions was verified by endocardial mapping.Additional endocardial ablation was performed to modify the atrial substrate.In addition,the cavotricuspid isthmus and areas with the following electrogram characteristics were ablated:(1)complex fractionated atrial potentials with low voltage(<0.3 mV during AF)or(2)atrial deflections more rapid than those from the adjacent sites.The end point of hybrid ablation was termination of AF via ablation.Main Outcomes and Measurements We described the main outcomes including acute success and clinical success.Acute success was defined as AF termination during ablation(converted to atrial tachycardia/flutter or sinus rhythm).Clinical success was defined as absence of major complication within 1 month after the procedure and maintenance of sinus rhythm without recurrence after the blanking period(3 months).Major complications were defined as death,transfer to surgery due to bleeding,cardiac tamponade,atrial‑esophageal fistula,acute myocardial infarction and ischemic stroke.Results Bilateral PVI,LAPW isolation and left atrial appendage exclusion were achieved in all patients.During ablation,AF was terminated in 24(83%)patients.The single‑procedure success rate was 76%(22/29).Among the 7 patients with recurrent AF,4 patients underwent redo catheter ablation(2 patients maintained sinus rhythm after redo).One patient underwent cardioversion and achieved sinus rhythm.Two patients did not receive any further intervention.After a follow‑up period of(18±9)months,the success rate was 86%(25/29).There were no major complications.Minor complications occurred in 3 patients including subcutaneous emphysemas in 2 patients and left pleural effusion in 1 patient.Conclusion Hybrid ablation is a safe and effective procedure for the treatment of AF.