单独心房颤动综合治疗的单中心经验与入路演变
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摘要
目的探讨单独心房颤动综合治疗的临床经验、手术入路的演变及各种术式的优劣。方法回顾性分析2015年1月至2017年5月于本中心行单独心房颤动外科消融手术69例患者的临床资料,其中男50例、女19例,平均年龄57.2岁。根据手术入路将患者分为3组:正中开胸组9例,左后外侧腔镜组7例,双前外侧腔镜组53例。3组分别有1例(11.1%)、3例(42.9%)和26例(49.1%)于外科消融术后行导管标测和补充射频消融。结果开胸组平均随访10.2个月,随访中9例(100.0%)维持窦性心律;左后外侧腔镜组平均随访7.4个月,5例(71.4%)维持窦性心律;双前外侧腔镜组平均随访5.0个月,47例(88.7%)维持窦性心律。全组无围术期死亡,随访期间无死亡、卒中、大出血和肺静脉狭窄等。结论经典迷宫Ⅳ手术成功率高,是治疗心房颤动的基础术式,而新式迷你迷宫手术有微创、可重复性强等优点,联合导管射频消融可取得与经典迷宫Ⅳ手术相近的治疗效果。单独心房颤动综合治疗是非阵发性心房颤动治疗的最佳方案。
Objective To investigate the preliminary experience, the evolution of surgical approach of multidisciplinary therapy for atrial fibrillation and the advantages and disadvantages of each procedure. Methods We retrospectively analyzed the clinical data of 69 patients with stand-alone surgical ablation with or without transcatheter radiofrequency ablation for atrial fibrillation in our center from January 2015 to May 2017. There were 50 males and 19 females at average age of 57.2 years. The patients were divided into three groups according to the surgical approach including a median sternotomy group(n=9), a left unilateral thoracoscopy group(n=7) and a bilateral thoracoscopy group(n=53). One(11.1%) patient, 3(42.9%) patients and 26(49.1%) patients received transcatheter mapping and radiofrequency ablation after surgical ablation in each group, respectively. Results The mean follow-up time in the median sternotomy group was 10.2 months. All 9 patients maintained sinus rhythm. The mean follow-up time of the left unilateral thoracoscopy group was 7.4 months. Five(71.4%) patients maintained sinus rhythm. While the mean follow-up time of the bilateral thoracoscopy group was 5.0 months. Forty-seven(88.7%) patients maintained sinus rhythm.There was no perioperative death, or death, stroke, major bleeding nor pulmonary vein stenosis during follow-up.Conclusion The classic Cox-Maze Ⅳ procedure with high success rate is still the basic operation for the surgical treatment of atrial fibrillation, while the thoracoscopic mini maze procedure has the advantages of minimally invasiveness,repeatibility, and can achieve similar results as Cox-Maze Ⅳ procedure when combined with transcatheter radiofrequency ablation. Multidisciplinary therapy could be the best solution for non-paroxysmal atrial fibrillation.
Objective To investigate the preliminary experience, the evolution of surgical approach of multidisciplinary therapy for atrial fibrillation and the advantages and disadvantages of each procedure. Methods We retrospectively analyzed the clinical data of 69 patients with stand-alone surgical ablation with or without transcatheter radiofrequency ablation for atrial fibrillation in our center from January 2015 to May 2017. There were 50 males and 19 females at average age of 57.2 years. The patients were divided into three groups according to the surgical approach including a median sternotomy group(n=9), a left unilateral thoracoscopy group(n=7) and a bilateral thoracoscopy group(n=53). One(11.1%) patient, 3(42.9%) patients and 26(49.1%) patients received transcatheter mapping and radiofrequency ablation after surgical ablation in each group, respectively. Results The mean follow-up time in the median sternotomy group was 10.2 months. All 9 patients maintained sinus rhythm. The mean follow-up time of the left unilateral thoracoscopy group was 7.4 months. Five(71.4%) patients maintained sinus rhythm. While the mean follow-up time of the bilateral thoracoscopy group was 5.0 months. Forty-seven(88.7%) patients maintained sinus rhythm.There was no perioperative death, or death, stroke, major bleeding nor pulmonary vein stenosis during follow-up.Conclusion The classic Cox-Maze Ⅳ procedure with high success rate is still the basic operation for the surgical treatment of atrial fibrillation, while the thoracoscopic mini maze procedure has the advantages of minimally invasiveness,repeatibility, and can achieve similar results as Cox-Maze Ⅳ procedure when combined with transcatheter radiofrequency ablation. Multidisciplinary therapy could be the best solution for non-paroxysmal atrial fibrillation.
引文
1Cox JL, Schuessler RB, D'Agostino HJ, et al. The surgical treatment of atrial fibrillation.Ⅲ. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg, 1991, 101(4):569-83.
2Garcia-Villarreal OA, Fernández-Cese?a E, Vega-Hernández R.Cox mazeⅢprocedure:The best alternative in surgery for atrial fibrillation. J Thorac Cardiovasc Surg, 2014, 148(1):368-369.
3Johansson Bi, V??rt O, Edvardsson N, et al. Low mortality and low rate of perceived and documented arrhythmias after Cox MazeⅢsurgery for atrial fibrillation. Pacing Clin Electrophysiol, 2014,37(2):147-156.
4Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation:recommendations for patient selection,procedural techniques, patient management and follow-up,definitions, endpoints, and research trial design:a report of the Heart Rhythm Society(HRS)Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association(EHRA), a registered branch of the European Society of Cardiology(ESC)and the European Cardiac Arrhythmia Society(ECAS); and in collaboration with the American College of Cardiology(ACC), American Heart Association(AHA), the Asia Pacific Heart Rhythm Society(APHRS), and the Society of Thoracic Surgeons(STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm, 2012, 9(4):632-696.e21.
5Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006guidelines for the management of patients with atrial fibrillation:full text:A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines(Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation)Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace, 2006, 8(9):651-745.
6January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation:A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation, 2014, 130(23):e199-e267.
7Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J, 2016, 37(38):2893-2962.
8Shi J, Bai Z, Zhang B, et al. A modified Cox mazeⅣprocedure:a simpler technique for the surgical treatment of atrial fibrillation.Interact Cardiovasc Thorac Surg, 2016, 23(6):856-860.
9曹向戎,孙广龙,张富恩,等.双侧腋下小切口肺静脉隔离术治疗孤立性心房颤动.临床外科杂志, 2014, 22(4):293-295.
10 Wolf RK, Schneeberger EW, Osterday R, et al. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg, 2005,130(3):797-802.
11马南,姜兆磊,尹航,等.单中心连续353例梅氏微创消融术经验和2年随访结果.中华胸心血管外科杂志, 2015, 31(11):670-673.
12Damiano RJ, Schwartz FH, Bailey MS, et al. The Cox mazeⅣprocedure:Predictors of late recurrence. J Thorac Cardiovasc Surg,2011, 141(1):113-121.
13Henn MC, Lancaster TS, Miller JR, et al. Late outcomes after the Cox maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg, 2015, 150(5):1168-1178.e2.
14Lawrance CP, Henn MC, Damiano RJ. Concomitant Cox-Maze IV techniques during mitral valve surgery. Ann Cardiothorac Surg,2015, 4(5):483-486.
15Lawrance CP, Henn MC, Miller JR, et al. Comparison of the standalone Cox-Maze IV procedure to the concomitant Cox-Maze IV and mitral valve procedure for atrial fibrillation. Ann Cardiothorac Surg, 2014, 3(1):55-61.
16Philpott JM, Zemlin CW, Cox JL, et al. The ABLATE Trial:safety and efficacy of Cox Maze-Ⅳusing a bipolar radiofrequency ablation system. Ann Thorac Surg, 2015, 100(5):1541-1548.
17Saint LL, Bailey MS, Prasad S, et al. Cox-MazeⅣresults for patients with lone atrial fibrillation versus concomitant mitral disease. Ann Thorac Surg, 2012, 93(3):789-795.
18Weimar T, Schena S, Bailey MS, et al. The Cox-Maze procedure for lone atrial fibrillation:A single-center experience over 2 decades.Circ Arrhythm Electrophysiol, 2012, 5(1):8-14.
19Boersma LVA, Castella M, van Boven W, et al. Atrial fibrillation catheter ablation versus surgical ablation treatment(FAST):A 2-center randomized clinical trial. Circulation, 2012, 125(1):23-30.
20Edgerton JR, Brinkman WT, Weaver T,et al. Pulmonary vein isolation and autonomic denervation for the management of paroxysmal atrial fibrillation by a minimally invasive surgical approach. J Thorac Cardiovasc Surg, 2010, 140(4):823-828.
21Edgerton JR, Jackman WM, Mack MJ. A new epicardial lesion set for minimal access left atrial maze:the Dallas lesion set. Ann Thorac Surg, 2009, 88(5):1655-1657.
22Krul SP, Driessen AH, van Boven WJ, et al. Thoracoscopic videoassisted pulmonary vein antrum isolation, ganglionated plexus ablation, and periprocedural confirmation of ablation lesions:first results of a hybrid surgical-electrophysiological approach for atrial fibrillation. Circ Arrhythm Electrophysiol, 2011, 4(3):262-270.
23Yilmaz A, Geuzebroek GSC, Van Putte BP, et al. Completely thoracoscopic pulmonary vein isolation with ganglionic plexus ablation and left atrial appendage amputation for treatment of atrial fibrillation. Eur J Cardiothorac Surg, 2010, 38(3):356-360.
24 Yilmaz A, Van Putte BP, Van Boven WJ. Completely thoracoscopic bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg, 2008,136(2):521-522.
2Garcia-Villarreal OA, Fernández-Cese?a E, Vega-Hernández R.Cox mazeⅢprocedure:The best alternative in surgery for atrial fibrillation. J Thorac Cardiovasc Surg, 2014, 148(1):368-369.
3Johansson Bi, V??rt O, Edvardsson N, et al. Low mortality and low rate of perceived and documented arrhythmias after Cox MazeⅢsurgery for atrial fibrillation. Pacing Clin Electrophysiol, 2014,37(2):147-156.
4Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation:recommendations for patient selection,procedural techniques, patient management and follow-up,definitions, endpoints, and research trial design:a report of the Heart Rhythm Society(HRS)Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association(EHRA), a registered branch of the European Society of Cardiology(ESC)and the European Cardiac Arrhythmia Society(ECAS); and in collaboration with the American College of Cardiology(ACC), American Heart Association(AHA), the Asia Pacific Heart Rhythm Society(APHRS), and the Society of Thoracic Surgeons(STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm, 2012, 9(4):632-696.e21.
5Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006guidelines for the management of patients with atrial fibrillation:full text:A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines(Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation)Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace, 2006, 8(9):651-745.
6January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation:A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation, 2014, 130(23):e199-e267.
7Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J, 2016, 37(38):2893-2962.
8Shi J, Bai Z, Zhang B, et al. A modified Cox mazeⅣprocedure:a simpler technique for the surgical treatment of atrial fibrillation.Interact Cardiovasc Thorac Surg, 2016, 23(6):856-860.
9曹向戎,孙广龙,张富恩,等.双侧腋下小切口肺静脉隔离术治疗孤立性心房颤动.临床外科杂志, 2014, 22(4):293-295.
10 Wolf RK, Schneeberger EW, Osterday R, et al. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg, 2005,130(3):797-802.
11马南,姜兆磊,尹航,等.单中心连续353例梅氏微创消融术经验和2年随访结果.中华胸心血管外科杂志, 2015, 31(11):670-673.
12Damiano RJ, Schwartz FH, Bailey MS, et al. The Cox mazeⅣprocedure:Predictors of late recurrence. J Thorac Cardiovasc Surg,2011, 141(1):113-121.
13Henn MC, Lancaster TS, Miller JR, et al. Late outcomes after the Cox maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg, 2015, 150(5):1168-1178.e2.
14Lawrance CP, Henn MC, Damiano RJ. Concomitant Cox-Maze IV techniques during mitral valve surgery. Ann Cardiothorac Surg,2015, 4(5):483-486.
15Lawrance CP, Henn MC, Miller JR, et al. Comparison of the standalone Cox-Maze IV procedure to the concomitant Cox-Maze IV and mitral valve procedure for atrial fibrillation. Ann Cardiothorac Surg, 2014, 3(1):55-61.
16Philpott JM, Zemlin CW, Cox JL, et al. The ABLATE Trial:safety and efficacy of Cox Maze-Ⅳusing a bipolar radiofrequency ablation system. Ann Thorac Surg, 2015, 100(5):1541-1548.
17Saint LL, Bailey MS, Prasad S, et al. Cox-MazeⅣresults for patients with lone atrial fibrillation versus concomitant mitral disease. Ann Thorac Surg, 2012, 93(3):789-795.
18Weimar T, Schena S, Bailey MS, et al. The Cox-Maze procedure for lone atrial fibrillation:A single-center experience over 2 decades.Circ Arrhythm Electrophysiol, 2012, 5(1):8-14.
19Boersma LVA, Castella M, van Boven W, et al. Atrial fibrillation catheter ablation versus surgical ablation treatment(FAST):A 2-center randomized clinical trial. Circulation, 2012, 125(1):23-30.
20Edgerton JR, Brinkman WT, Weaver T,et al. Pulmonary vein isolation and autonomic denervation for the management of paroxysmal atrial fibrillation by a minimally invasive surgical approach. J Thorac Cardiovasc Surg, 2010, 140(4):823-828.
21Edgerton JR, Jackman WM, Mack MJ. A new epicardial lesion set for minimal access left atrial maze:the Dallas lesion set. Ann Thorac Surg, 2009, 88(5):1655-1657.
22Krul SP, Driessen AH, van Boven WJ, et al. Thoracoscopic videoassisted pulmonary vein antrum isolation, ganglionated plexus ablation, and periprocedural confirmation of ablation lesions:first results of a hybrid surgical-electrophysiological approach for atrial fibrillation. Circ Arrhythm Electrophysiol, 2011, 4(3):262-270.
23Yilmaz A, Geuzebroek GSC, Van Putte BP, et al. Completely thoracoscopic pulmonary vein isolation with ganglionic plexus ablation and left atrial appendage amputation for treatment of atrial fibrillation. Eur J Cardiothorac Surg, 2010, 38(3):356-360.
24 Yilmaz A, Van Putte BP, Van Boven WJ. Completely thoracoscopic bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg, 2008,136(2):521-522.