风湿性心脏瓣膜病、心房颤动经外科手术消融后复发的8例快速房性心律失常导管消融治疗分析  

Recurrence of atrial tachyarrhythmias after Maze procedure concomitant with valve surgery in patients with rheumatic heart disease： electrophysiologieal characteristics and catheter ablation

作　　者：王新华[1] 刘旭[1] 施海峰[1] 谭红伟[1] 韩冰[1] 姜伟峰[1] 刘玉岗[1] 杨国澍[1] 

机构地区：[1]上海交通大学附属胸科医院心内科,200030

出　　处：《中华心律失常学杂志》2009年第6期416-420,共5页Chinese Journal of Cardiac Arrhythmias

摘　　要：目的评价导管消融治疗风湿性心脏病合并心房颤动（房颤）外科消融术后复发的电生理特征和疗效。方法8例风湿性心脏病合并房颤外科消融后复发患者，平均年龄（49．1±4．5）岁（男性3例），二尖瓣置换术后5例，二尖瓣、主动脉瓣联合瓣膜置换术后3例。房性心律失常复发时间距外科手术（1．2±0．9）个月。根据复发的快速房性心律失常类型，消融方法主要包括消融线径补点消融、肺静脉补点隔离、消融局部折返和碎裂电位消融。消融术后随访心电图和24h动态心电图，评价疗效。结果8例患者中5例复发心房扑动（房扑）／房性心动过速（房速），三尖瓣峡部依赖2例，二尖瓣峡部依赖1例，左肺静脉缝隙依赖1例，左心房前壁局部折返1例，导管消融均终止，并实现消融线阻滞（必要时）。3例复发房颤（2例阵发性，1例持续性）均存在至少1根肺静脉传导恢复，消融关闭缝隙达到肺静脉隔离，持续性房颤加碎裂电位消融，同时关闭原消融线缝隙。无明显并发症发生。平均随访（6．7±2．9）个月，共6例（75％）无房性快速性心律失常复发.5例房扑／房速中4例无复发，1例复发阵发性房颤。2例阵发性房颤无复发，1例持续性房颤术后复发阵发性房颤。结论风湿性心脏病合并房颤外科消融术后主要复发房扑／房速，后者主要与原消融线或肺静脉消融环的缝隙有关，或为与初次消融无关的局部折返。少数复发为房颤，可能与肺静脉传导恢复、消融线缝隙有关。导管消融疗效较好。Objective To evaluate the electrophysiological characteristics and catheter ablation of recurrent atrial taehyarrhythmias after Maze procedure and valve surgery in patients with rheumatic heart disease. Methods Eight eases with valve prosthesis replacement （3 males and 5 females, mean age of 49. 1 ± 4. 5 years） and Maze procedure were enrolled after a mean follow-up of （1.2 ±0. 9）months after surgery. Ablation strategies included closing gaps along initial linear lesion lines or circunfferential pulmonary, vein ablation lines, loealized reentries interruption, and additional fractionated eleetrograms ablation, depend on different types of recurrence. Surface ECG and 24h Holter were applied to evaluate the effectiveness of catheter ablation. Resuits Regular atrial flutter/tachycardia recurred in five cases,including tricuspid isthmus dependent atrial flutter in 2 cases,mitral isthmus dependent atrial flutter in I case,left superior pulmonary vein gap related reentry in 1 case,and localized left atrial reentry in 1 case. Closing gaps along initial lesion lines terminated tachycardia and achieved lesion lines block （ when necessary. ） in five cases. Pulmonary vein re-connection was observed in ≥ one pulmonary vein in 3 cases with AF recurrence,and was re-isolated by closing gaps. Gaps in other lesion lines were also closed by further ablation. Additional fractionated electrograms ablation was performed in onecase with persistent AF. The procedures were free of any complications. At the end of （6. 7 ± 2. 9） months of follow-up, four cases with atrial flutter/tachyeardia and 2 cases with paroxysmal AF were free of recurrence of atrial taehyarrhythmia. Conclusions Atrial flutter/taehycardias were the predominant arrhythmias following maze procedure and valve surgery. They were mainly attributed to conduction gaps in index ablation lines, or to localized reentry unrelated to surgical ablation. Less common recurrence was AF, which might be due to pulmonary vein re-connection or gaps in lesion lines.

关 键 词：风湿性心脏病 心房颤动 迷宫术 复发 导管消融 

分 类 号：R541.75[医药卫生—心血管疾病]