心脏瓣膜术同期行房颤射频消融术及左心耳夹闭术预防心源性脑卒中的临床研究

doi:10.3877/cma.j.issn.1674-0785.2023.02.006

目的

探讨心脏瓣膜手术单独或同期行房颤射频消融术或进一步联合左心耳夹闭术分别在预防心源性脑卒中的临床效果以及手术安全性。

方法

回顾性分析临汾市人民医院胸外科与西安西京医院心脏外科于2015年3月至2021年8月期间收治的45例瓣膜性心脏病合并房颤患者的临床资料。其中男性21例，女性24例，平均年龄（62.3±7.7）岁。永久性房颤患者19例，持续性房颤患者22例，阵发性房颤患者4例。

结果

围手术期无死亡，18例行单独瓣膜置换手术，12例行瓣膜置换手术+射频消融术，15例行瓣膜置换+射频消融+左心耳夹联合手术。单独瓣膜置换平均手术时间（241.00±26.55）min，瓣膜置换手术+射频消融术平均手术时间（275.50±12.69）min，瓣膜置换+射频消融+左心耳夹联合手术平均手术时间（298.33±19.92）min。术后即刻转窦性心律36例（4/5），9例未转窦（1/5）。左心耳夹位置良好无移位（15例，100%）。单纯瓣膜手术组和瓣膜手术+射频消融组术后脑卒中发生各1例，瓣膜置换+射频消融+左心耳夹联合手术组术后无脑卒中发生。单纯瓣膜手术组术后出现1例胸腔积液患者和1例出血患者；瓣膜手术+射频消融组术后出现1例出血患者；瓣膜置换+射频消融+左心耳夹联合手术组术后未出现并发症。

结论

心脏瓣膜手术同期行房颤射频消融术及左心耳夹闭术显著降低了脑卒中的发生率，术后的并发症发生率未受手术的复杂度增加而影响，具有安全高效的特点。

关键词: 结构性心脏病, 心房颤动, 心源性脑卒中, 左心耳夹闭术

Objective

To investigate the clinical efficacy and safety of heart valve surgery alone or simultaneously with atrial fibrillation radiofrequency ablation or further combined with left atrial appendage clipping in the prevention of cardiogenic stroke.

Methods

The clinical data of 45 patients with valvular heart disease complicated with atrial fibrillation treated at the Department of Thoracic Surgery of Linfen people's Hospital and the Department of Cardiac Surgery of Xi'an Xijing Hospital from March 2015 to August 2021 were analyzed retrospectively. There were 21 males and 24 females, with an average age of (62.3±7.7) years. There were 19 patients with permanent atrial fibrillation, 22 with persistent atrial fibrillation, and 4 with paroxysmal atrial fibrillation.

Results

There was no death during the perioperative period. Eighteen cases underwent valve replacement alone, 12 underwent valve replacement+radiofrequency ablation, and 15 underwent valve replacement+radiofrequency ablation+left atrial appendage clipping. The average operation time of single valve replacement was (241.00±26.55) min, that of valve replacement+radiofrequency ablation was (275.50±12.69) min, and that of valve replacement+radiofrequency ablation+left atrial appendage clipping was (298.33±19.92) min. Thirty-six cases (4/5) had sinus rhythm immediately after operation, and 9 (1/5) had no sinus rhythm. The position of left atrial appendage clipping was good without displacement (15 cases, 100%). There were 1 case of postoperative stroke in the simple valve operation group and 1 case in the valve operation+radiofrequency ablation group. There was no stroke in the valve replacement+radiofrequency ablation+left atrial appendage clipping group. One patient each developed pleural effusion and bleeding in the simple valve operation group. In the valve operation+radiofrequency ablation group, there was 1 patient with bleeding after operation. There were no postoperative complications in the valve replacement+radiofrequency ablation+left atrial appendage clipping operation group.

Conclusion

Cardiac valve surgery combined with atrial fibrillation radiofrequency ablation and left atrial appendage clipping can significantly reduce the incidence of stroke. The incidence of postoperative complications is not affected by the increase of surgical complexity. The combination therapy is safe and efficient.

Key words: Structural heart disease, Atrial fibrillation, Cardiogenic stroke, Left atrial appendage clipping

表1 患者的一般资料

分组	甲组（18例）	乙组（12例）	丙组（15例）
性别（男性/女性）	8/10	4/8	9/6
年龄（岁， $x ¯$ ±s）	62.9±5.6	61.8±9.3	62.3±8.3
心功能指数Ⅱ级	3	6	4
心功能指数Ⅲ级	7	4	9
心功能指数Ⅳ级	5	2	2
房颤类型（永久型）	8	6	5
房颤类型（持续型）	9	6	7
房颤类型（阵发型）	1	0	3

表1 患者的一般资料

分组	甲组（18例）	乙组（12例）	丙组（15例）
性别（男性/女性）	8/10	4/8	9/6
年龄（岁， $x ¯$ ±s）	62.9±5.6	61.8±9.3	62.3±8.3
心功能指数Ⅱ级	3	6	4
心功能指数Ⅲ级	7	4	9
心功能指数Ⅳ级	5	2	2
房颤类型（永久型）	8	6	5
房颤类型（持续型）	9	6	7
房颤类型（阵发型）	1	0	3

表2 3组患者手术资料及术后情况

组别	例数	手术时间（min， $x ¯$ ±s）	术后住院天数（d， $x ¯$ ±s）	脑卒中发生率（%）	手术并发症发生率（%）	窦性转复率（%）
甲组	18	241.00±26.55	14.60±3.21	5.5	11.1	72.2
乙组	12	275.50±12.69^b	17.00±3.37	8.3	8.3	83.4
丙组	15	298.33±19.92^a	14.17±2.40	0	0	86.7
t/χ²值		0.412	0.254
P值		0.026	0.479

表2 3组患者手术资料及术后情况

组别	例数	手术时间（min， $x ¯$ ±s）	术后住院天数（d， $x ¯$ ±s）	脑卒中发生率（%）	手术并发症发生率（%）	窦性转复率（%）
甲组	18	241.00±26.55	14.60±3.21	5.5	11.1	72.2
乙组	12	275.50±12.69^b	17.00±3.37	8.3	8.3	83.4
丙组	15	298.33±19.92^a	14.17±2.40	0	0	86.7
t/χ²值		0.412	0.254
P值		0.026	0.479

表3 3组患者左心房、左心室二维切面测量情况（mm，

x ¯

±s）

组别	左心房二维切面测量		左心室二维切面测量
组别	术前	术后	术前	术后
甲组	56.40±4.83	49.2±2.17^c	61.00±3.32	52.80±5.36^c
乙组	57.25±3.25	44.25±3.40^ab	58.75±2.75	48.5±7.72^c
丙组	53.83±4.40	44.83±3.25^ab	54.00±6.82	45.17±5.64^ac
t值	0.954	0.865	0.479	0.512
P值	0.146	0.030	0.375	＜0.01

表3 3组患者左心房、左心室二维切面测量情况（mm，

x ¯

±s）

组别	左心房二维切面测量		左心室二维切面测量
组别	术前	术后	术前	术后
甲组	56.40±4.83	49.2±2.17^c	61.00±3.32	52.80±5.36^c
乙组	57.25±3.25	44.25±3.40^ab	58.75±2.75	48.5±7.72^c
丙组	53.83±4.40	44.83±3.25^ab	54.00±6.82	45.17±5.64^ac
t值	0.954	0.865	0.479	0.512
P值	0.146	0.030	0.375	＜0.01

图1 3组患者左心房、左心室二维切面测量比较。图a为3组分别在手术前和手术后左心房二维切面测量指标的比较；图b为甲组、乙组、丙组3组自身术前和术后左心房二维切面测量指标的比较；图c为甲组、乙组、丙组3组分别在手术前和手术后左心室二维切面测量指标的比较；图d为甲组、乙组、丙组3组自身术前和术后左心室二维切面测量指标的比较注：*P＜0.05；**P＜0.01

表4 3组患者射血分数恢复情况（%，

x ¯

±s）

组别	术前射血分数	术后射血分数
甲组	52.20±1.30	57.01±2.55^d
乙组	52.00±0.816	61.00±1.83^bd
丙组	49.50±4.89	65.33±2.55^acd
t值	0.784	0.247
P值	0.614	＜0.01

表4 3组患者射血分数恢复情况（%，

x ¯

±s）

组别	术前射血分数	术后射血分数
甲组	52.20±1.30	57.01±2.55^d
乙组	52.00±0.816	61.00±1.83^bd
丙组	49.50±4.89	65.33±2.55^acd
t值	0.784	0.247
P值	0.614	＜0.01

图2 3组分别在手术前和手术后左心室射血分数指标的比较注：^*P＜0.05；^**P＜0.01

图3 3组自身术前和术后左心室射血分数指标的比较注：^**P＜0.01；^***P＜0.001；^****P＜0.0001

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Heart valve surgery combined with atrial fibrillation radiofrequency ablation and left atrial appendage clipping for prevention of cardiogenic stroke

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Heart valve surgery combined with atrial fibrillation radiofrequency ablation and left atrial appendage clipping for prevention of cardiogenic stroke