一站式杂交手术治疗难治性心房颤动的长期随访效果  

Long-term follow-up of one-stage hybrid approach in the treatment of refractory atrial fibrillation

作　　者：吕家顺 付亮[2] 沈成兴 魏盟[1] 赵金龙[2] 毕亚光 赵雨 励峰[2] 张庆勇 Lyu Jiashun;Fu Liang;Shen Chengxing;Wei Meng;Zhao Jinlong;Bi Yaguang;Zhao Yu;Li Feng;Zhang Qingyong(Department of Cardiology,Shanghai Sixth People’s Hospital,Shanghai Jiao Tong University,Shanghai 200233,China;Department of Cardiovascular Surgery,Shanghai Sixth People’s Hospital,Shanghai Jiao Tong University,Shanghai 200233,China;Department of Cardiology,Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai 200003,China)

机构地区：[1]上海交通大学附属第六人民医院心血管内科,200233 [2]上海交通大学附属第六人民医院心血管外科,200233 [3]上海交通大学医学院附属第九人民医院心血管内科,200003

出　　处：《中华心律失常学杂志》2020年第4期397-401,共5页Chinese Journal of Cardiac Arrhythmias

基　　金：上海市科学技术委员会科研计划项目(17411966600)。

摘　　要：目的评估一站式杂交手术(胸腔镜外科射频消融联合内科导管消融)治疗难治性心房颤动(房颤)的安全性和有效性,初步总结治疗经验。方法2015年8月至2018年1月连续在上海市第六人民医院接受一站式杂交手术治疗的难治性房颤(包括持续性房颤、长程持续性房颤以及多次导管消融失败的阵发性房颤)患者21例。其中男14例,女7例,年龄(63±11)岁,中位房颤持续时间为3年。首先外科经双侧胸壁胸腔镜途径消融两侧肺静脉,离断Marshall韧带,并结扎左心耳。之后内科行左心房三维建模,结合电压标测,应用导管消融对外科消融径线的完整性进行验证,并补点消融,确保双向阻滞。消融终点为肺静脉电位隔离。术后6、12、18、24个月进行定期随访。结果21例患者均实现两侧肺静脉电位隔离,平均随访(32±10)个月后,并发症2例,死亡3例。进入6个月随访期71.4%(15/21)的患者维持窦性心律(窦律),进入12个月随访期57.1%(12/21)的患者维持窦律,进入18个月随访期50.0%(10/20)的患者维持窦律。复发11例,其中心房扑动4例,房颤7例。3例患者接受了再次导管消融,2例恢复窦律。长期随访发现,杂交手术对于肺静脉电位隔离的干预依旧彻底。经再次导管消融或电复律后,总体治疗成功率为71.4%(15/21)。杂交术后1年,平均左心房内径为(48.4±7.0)mm,平均左心室射血分数为64%±4%,与术前相比有改善,但差异无统计学意义(P>0.05)。结论内外科一站式杂交手术作为一种新兴术式,解决了很多单纯内科和外科本身无法解决的难题,也弥补了各自的局限性。就单中心目前治疗经验,对于难治性房颤患者杂交手术并发症较少且总体成功率较高,初步证实了其安全性及有效性。Objective We aimed to evaluate the efficacy and safety of one-stage hybrid approach(thoracoscopic surgical ablation combined with catheter ablation)in the treatment of refractory atrial fibrillation(AF),and preliminarily summarized the experience.Methods Twenty-one patients with refractory AF(including persistent AF,long-standing persistent AF and paroxysmal AF with repeated failures of catheter ablation)who underwent one-stage hybrid approach in Shanghai Sixth People’s Hospital from August 2015 to January 2018 were selected,including 14 males and 7 females,with an average age of(63±11)years,and the median duration of AF was 3 years.Firstly,bilateral pulmonary veins were ablated by thoracoscopic approach through bilateral chest wall,Marshall ligament was cut off,and left atrial appendage was ligated.After that,three-dimensional modeling of the left atrium was performed,and the integrity of surgical ablation pathway was verified and residual conduction was blocked by catheter endocardium pathway combined with voltage mapping.The endpoint of ablation was pulmonary vein isolation.The patients were followed up regularly at 6,12,18 and 24 months after operation.Results Twenty-one patients achieved electrical isolation of bilateral pulmonary veins.After an average of(32±10)months,surgery related complications occurred in 2 cases,and three died.At the 6th month of follow-up,71.4%(15/21)of the patients maintained sinus rhythm,at the 12th month of follow-up,57.1%(12/21)of the patients maintained sinus rhythm,at the 18th month of follow-up,50.0%(10/20)of the patients maintained sinus rhythm.There were 11 cases of recurrence,including 4 cases of atrial flutter and 7 cases of AF.Three patients underwent re-catheter ablation,of which 2 patients recovered sinus rhythm.It was found that in the long-term follow-up,the intervention of hybrid surgery for pulmonary vein potential isolation was still thorough.The overall success rate after re-catheter ablation or cardioversion was 71.4%(15/21).One year after the hybrid approach,

关 键 词：心房颤动 持续性心房颤动 杂交手术 导管消融 胸腔镜外科消融 

分 类 号：R654.2[医药卫生—外科学]