外科微创手术治疗心房颤动对左心房功能的影响

doi:10.3969/j.issn.1006-7795.2015.03.007

摘要/Abstract

摘要：

目的通过检测阵发性心房颤动(以下简称房颤)患者行外科微创手术治疗前后左心房功能的变化,探讨该手术对左心房功能的影响.方法选择2012年10月至2014年6月在首都医科大学附属北京安贞医院心外科九病房行外科微创手术(胸腔镜辅助射频消融、左心耳切除及Marshall韧带离断)治疗的阵发性房颤患者52例,分别于术前(窦性心律时)、术后7 d及术后3个月,应用实时经胸三维超声心动图测量左心房功能,进行统计学分析.结果 1) 消融术后 6 例患者房颤复发, 余 46 例完成研究,手术转窦率为88.5%(46/52).无手术相关严重合并症发生,术后3个月所有患者均未发生栓塞事件.左心耳切除成功率为77%(40/52,左心耳残端 <1cm).2)患者术后7 d及术后3个月左心房最大容积(left atrial maximum volume, LAVmax)较术前逐渐减小,差异有统计学意义(P <0.001);左心房最小容积(left atrial minimum volume,LAVmin)术后3个月较术前、术后7 d均减小,差异有统计学意义(P <0.001);左心房总排空分数(left atrial emptying fraction,LAEF)术后7 d较术前、术后3个月低,差异有统计学意义(P <0.001),术前、术后3个月差异无统计学意义(P=0.235);左心房被动排空分数(left atrial passive ejection fraction,LAPEF)术后7 d、术后3个月较术前减低,差异有统计学意义(P <0.05);左心房主动排空分数(left atrial active ejection fraction,LAAEF)术后3个月较术前、术后7 d增强,术后7 d较术前减弱,差异有统计学意义(P <0.05).A峰流速术后3个月较术后7 d增强,差异有统计学意义(P <0.001),术后3个月与术前差异无统计学意义(P=0.497).结论 1)外科微创手术是治疗阵发性房颤安全、有效的方法,能有效的恢复患者的窦性心律、预防栓塞事件的发生.2)外科微创手术治疗阵发性房颤有利于左心房逆重塑及功能增强,其远期影响有待进一步随访研究.

关键词: 心房颤动, 心房功能, 外科手术, 微创性

Abstract:

Objective To compare the left atrial function in paroxysmal atrial fibrillation patients before and after undergoing minimally invasive surgery. Methods Consecutive 52 patients with paroxysmal atrial fibrillation who underwent minimally invasive surgery (pulmonary vein isolation, left atrial appendage excision, ligament of Marshall resection) in Anzhen Hospital from October 2012 to June 2014 were enrolled into this study. Left atrial function was measured by real-time three-dimensional echocardiography before operation, 7 days and 3 months after operation. Results 1) Each of the 52 patients successfully underwent the surgery. Neither serious complications related to the operation happened nor embolism events occurred within the 3-month follow-up period. Apart from 6 recurrence, 88.5% (46/52) patients were free of atrial fibrillation. The left atrial appendage of 77% (40/52) patients were successfully excised(left atrial appendage stump <1 cm). 2) Postoperative left atrial maximum volume (LAVmax) was gradually decreased compared to preoperative value (P <0.001), and left atrial minimum volume (LAVmin) detected at postoperative 3 months was decreased as compared with postoperative 7 days and preoperative values respectively (P <0.001). Left atrial emptying fraction (LAEF), as an indicator for storage function, displayed a lower level at postoperative 7 days (P <0.001), but the difference between preoperative and postoperative 3 months was not statistically significant(P=0.235). Left atrial passive ejection fraction (LAPEF) indicating atrial transmission function detected at postoperative 7 days and 3 months both were decreased as compared with preoperative values (P <0.05), but the difference between postoperative 7 days and 3 months was not statistically significant (P=0.052). Left atrial active ejection fraction (LAAEF) indicating atrial pumping function detected at postoperative 3 months was higher than postoperative 7 days and preoperative values. And the value for postoperative 7 days was lower than preoperative value (P <0.05). The peak velocity of A wave detected at postoperative 3 months was higher than that at postoperative 7 days (P <0.05), but the difference between postoperative 3 months and preoperative was not statistically significant (P=0.497). Conclusion 1Minimally invasive surgery can be used as an effective treatment for paroxysmal atrial fibrillation patients to restore sinus rhythm and prevent embolism events. 2We will benefit in strengthening atrial function and reverse remodeling from this operation. Further follow-up studies are warranted to provide a more definite explanation about the effect of minimally invasive surgery on atrial function on our observation.

Key words: atrial fibrillation, atrial function, surgical procedures, minimally invasive

中图分类号:

R541.7

张振华, 张海波, 韩建成, 孟旭, 韩杰, 李岩, 王刚. 外科微创手术治疗心房颤动对左心房功能的影响[J]. 首都医科大学学报, 2015, 36(3): 371-375.

Zhang Zhenhua, Zhang Haibo, Han Jiancheng, Meng Xu, Han Jie, Li Yan, Wang Gang. Effect of minimally invasive surgery on left atrial function in atrial fibrillation patients[J]. Journal of Capital Medical University, 2015, 36(3): 371-375.

参考文献

[1] Sakellaridis T, Argiriou M, Charitos C, et al. Left atrial appendage exclusion-Where do we stand?[J]. J Thorac Dis,2014,6 Suppl 1:S70-S77.
[2] Romero J, Perez I E, Krumerman A, et al. Left atrial appendage closure devices[J]. Clin Med Insights Cardiol,2014,8:45-52.
[3] Wolf P A, Dawber T R, Thomas H E Jr, et al. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study [J]. Neurology, 1978, 28(10): 973-977.
[4] Calkins H, Kuck K H, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patients selection, procedural techniques, patient management and follow-up definitions, endpoints, and research trial design[J]. Europace,2012,14(4):528-606.
[5] Hassaguerre M, Jas P, Shah D C,et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins[J].N Engl J Med, 1998,339(10):659-666.
[6] Wolf R K, Schneeberger E W, Osterday R, et al. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation[J]. J Thorac Cardiovasc Surg,2005,130(3):797-802.
[7] Beyer E, Lee R, Lam B K. Point: Minimally invasive bipolar radiofrequency ablation of lone atrial fibrillation: early multicenter results[J]. J Thorac Cardiovasc Surg, 2009,137(3):521-526.
[8] La Meir M, Gelsomino S, Luca F, et al. Minimal invasive surgery for atrial fibrillation: an updatedreview[J].Europace,2013, 15(2), 170-182.
[9] Di Biase L, Burkhardt J D, Mohanty P, et al. Left atrial appendage: an underrecognized trigger site of atrial fibrillation[J]. Circulation,2010,122(2):109-118.
[10] Kanderian A S, Gillinov A M, Pettersson G B, et al. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography[J]. J Am Coll Cardiol,2008, 52(11):924-929.
[11] Appleton C P, Kovács S J. The role of left atrial function in diastolic heart failure [J].Circ Cardiovasc Imaging,2009,2(1):6-9.
[12] Cianciulli T F, Saccheri M C, Lax J A, et al. Two-dimensional speckle tracking echocardiography for the assessment of atrial function[J].World J Cardiol,2010,2(7): 163-170.
[13] 刘洪涛,张俊权,李治安,等. 实时三维超声心动图评价微创外科治疗持续性心房颤动左心房功能的研究[J]. 心肺血管病杂志,2011,30(4):287-289.
[14] 朱彩霞. 超声评价不同消融术式对阵发性心房颤动患者左心房功能的影响[D] 上海:同济大学,2007.
[15] 罗学胜,张红,刘建民,等. 心房颤动患者射频消融术后肺静脉狭窄误诊分析[J]. 临床误诊误治,2012,25(11):62-64.
[16] Aikawa M, Watanabe H, Shimokawa T, et al. Preoperative left atrial emptying fraction is a powerful predictor of successful maze procedure[J]. Circ J,2009,73(2):269-273.
[17] La Meir M, Gelsomino S, Luca F, et al. Improvement of left atrial function and left atrial reverse remodeling after minimally invasive radiofrequency ablation evaluated by 2-dimensional speckle tracking echocardiography[J]. J Thorac Cardiovasc Surg,2013,146(1):72-77.
[18] 高岚. 瓣膜置换同期双极射频消融治疗房颤的手术配合[J]. 中国煤炭工业医学杂志. 2012,15(10):1562-1563.
[19] Rodrigues A C, Scannavacca M I, Caldas M A, et al.Left atrial function after ablation for paroxysmal atrial fibrillation [J].Am J Cardiol,2009,103(3):395-398.
[20] 李俊峡. 心血管疾病介入治疗发展概述及展望[J]. 解放军医药杂志,2012,24(9):1-6.