重度房性功能性二尖瓣反流合并心房颤动的外科治疗策略

Surgical strategies for atrial functional mitral regurgitation with atrial fibrillation

目的分析房性功能性二尖瓣反流合并心房颤动的外科治疗策略。方法回顾性分析2017年6月至2023年1月间112例房颤合并二尖瓣反流的患者资料, 其中重度房性功能性二尖瓣反流合并房颤56例, 退行性二尖瓣反流合并心房颤动56例。所有患者均行迷宫Ⅳ型手术加二尖瓣手术治疗。随访采用门诊复诊和电话等方式。术后二尖瓣病变的情况通过超声心动图检查获取。术后心律情况依据患者自觉症状及心电图、24 h动态心电图等检查。结果术前基本资料对比显示房性二尖瓣反流组患者的年龄、房颤病程、术前合并症等明显高于退行性病变组。两组患者顺利完成手术。术后30天内死亡2例, 均在房性二尖瓣反流组, 死因分别为术后急性呼吸窘迫综合征(ARDS)和肺部感染。术后并发症主要为出血、低心排血量综合征、肺部感染和急性肾损伤等。随访时房性二尖瓣反流组43例(79.6%)患者维持窦性心律, 退行性病变组49例(87.5%)患者维持窦性心律, 但两组窦律维持率的Kaplan-Meier曲线比较差异无统计学意义。房性二尖瓣反流组二尖瓣无反流47例, 二尖瓣反流轻度4例, 中度1例。退行性病变组二尖瓣无反流42例, 二尖瓣反流轻度6例, 中度反流1例, 重度1例。房颤复发的危险因素在房性二尖瓣反流组与术后左心房直径大于50 mm有关, 在退行性病变组房颤复发与术后左心房直径大于50 mm和残余二尖瓣反流有关。结论二尖瓣成形加迷宫Ⅳ型手术是重度房性二尖瓣反流合并房颤患者的有效治疗方式。今后进一步提高房颤治疗的成功率和降低手术创伤会使患者获益更多。

Objective:Analysis of surgical strategies for atrial functional mitral regurgitation with atrial fibrillation.Methods:Retrospective analysis of 112 patients with mitral regurgitation and atrial fibrillation between June 2017 and January 2023.Among them,56 cases were severe atrial functional mitral regurgitation with atrial fibrillation,and the other 56 cases were degenerative mitral regurgitation with atrial fibrillation.All patients underwent mazeⅣprocedure and mitral valve surgery.Follow up will be conducted through outpatient follow-up and telephone calls.The condition of postoperative mitral valve is obtained through echo.The postoperative cardiac rhythm is based on the patient's conscious symptoms,electrocardiogram,24 hour dynamic electrocardiogram.Results:The comparison of preoperative basic data shows that the age,duration of atrial fibrillation,and comorbidity of patients with atrial functional mitral regurgitation are significantly higher than those in the degenerative mitral regurgitation group.All patients successfully completed the surgery.Postoperative death occurred in 2 cases in the atrial mitral regurgitation group.The causes of death were ARDS and pulmonary infection,respectively.The main postoperative complications include bleeding,low cardiac output,pulmonary infection,and acute kidney injury.During follow-up,43 patients(79.6%)in the atrial mitral regurgitation group maintained sinus rhythm,while 49 patients(87.5%)in the degenerative group.However,there was no statistically significant difference in the Kaplan-Meier curves.In the atrial mitral regurgitation group,there were 47 cases with no mitral regurgitation,4 cases with mild regurgitation,and 1 case with moderate regurgitation.In the degenerative group,there were 42 cases with no mitral regurgitation,6 cases with mild regurgitation,1 case with moderate regurgitation,and 1 case with severe regurgitation.The risk for atrial fibrillation recurrence in the atrial mitral regurgitation is related to postoperative left atrial diameter greater than 50 mm,while in the degenerative group,atrial fibrillation recurrence is related to postoperative left atrial diameter greater than 50 mm and residual mitral regurgitation.Conclusion:Mitral valve repair combined with mazeⅣprocedure is an effective treatment for patients with severe atrial functional mitral regurgitation and atrial fibrillation.Further improving the success rate of atrial fibrillation and reducing surgical trauma will benefit patients in the future.