左心房MAZE消融手术有损心房功能

洛杉矶——美国心脏协会(AHA)年会11月6日公布的一项研究结果表明，采用双侧双极射频通过改良Cox MAZE手术进行左心房完全消融治疗房颤，可导致左心房功能显著降低。

在这项研究中，荷兰莱顿大学心脏中心的Marieke G. Compier博士及其同事采用超声心动图评估了31例采用双侧双极射频通过改良Cox-MAZE手术进行左心房完全消融的患者和31例仅进行肺静脉隔离(PVI)的患者的左心房功能。在完全消融组中，25例患者有持续性房颤，6例有阵发性房颤；在PVI组中，25例患者有阵发性房颤，6例有持续性房颤。所有患者均同期接受冠状动脉旁路术和(或)瓣膜手术。

研究者在术后3、6和12个月采用24 h心电监测评估房颤治疗的疗效。此外，还在术后3个月和1年时采用二维超声心动图评估左心房体积和功能。

结果显示，1年后，完全消融组和PVI组分别有68%和81%的患者无房颤且完全停止接受抗心律失常药物治疗；两组的其他患者出现了房颤复发的情况。研究者表示，两组在长期成功维持窦性心律的患者比例方面的差异，可能缘于阵发性和持续性房颤患者比例的不平衡。

1年后，超声心动图检查显示，完全消融组患者的左心房体积和应变显著降低，42%患者的A波恢复。与术前测定值相比，应变率平均降低50%，A波峰值平均降低1/3，左心房射血分数和充盈分数各平均降低20%。与基线值相比，所有这些变化均具有统计学显著性。

在PVI组中，术后应变率和A波峰值均未出现显著变化，平均左心房射血分数和充盈分数各增加10%，与基线值相比无显著差异。PVI组87%患者的A波恢复。

对两组的基线差异进行逐步回归分析发现，随访期间观察到的左心房体积和功能的差异主要是缘于两组消融治疗的不同。

Compier博士声明无经济利益冲突。

专家点评：尽管有损心房功能，但心房消融仍是最佳方案


Pierre Page博士

蒙特利尔大学心脏外科主任Pierre Page博士在接受采访时表示，虽然该研究观察到左心房完全消融可导致左心房功能降低，但这一结果不是放弃心房消融的理由，而且也不应使用肺静脉隔离代替心房消融，除非左心房功能的降低对患者的预后或生存有明确影响。目前而言，与保护完整的心房功能相比，更重要的是要彻底和可靠地解决患者的房性心律失常。用肺静脉隔离代替完全消融会增加房颤复发的风险。

Page博士博士声明无经济利益冲突。
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By: MITCHEL L. ZOLER, Cardiology News Digital Network

LOS ANGELES – Full left-atrial ablation by the modified Cox MAZE procedure to treat atrial fibrillation led to significant reductions in left atrial function, based on a detailed assessment of 31 patients who underwent this treatment using bilateral bipolar radiofrequency.

The damaging effect of complete left-atrial ablation contrasted with the impact of a less extensive procedure, pulmonary vein isolation, which kept left-atrial function intact and even improved it by some parameters. Opinions split on the implications of these findings.

"Our advice is that left-atrial ablation should be restricted to those cases where pulmonary vein isolation will likely be insufficient" to restore and maintain sinus rhythm, Dr. Marieke G. Compier said as she presented the findings at the annual scientific sessions of the American Heart Association on Nov. 6.

But a cardiac surgeon who heard the results disagreed, contending that the top priority is performing the procedure that will result in durable prevention of atrial fibrillation (AF) recurrence.

"Recurrence of atrial fibrillation is a more important determinant of [successful] clinical outcomes than preserved atrial function," said Dr. Pierre Page, chief of cardiac surgery at the University of Montreal. "The data we have today show that left-atrial ablation is very beneficial," Dr. Page said in an interview.

Dr. Compier and her associates used echocardiography to assess left-atrial function in 31 patients who underwent a modified Cox-MAZE procedure for complete left-atrial ablation using bilateral bipolar radiofrequency, and 31 patients who underwent pulmonary-vein isolation (PVI) only. In the full ablation group, 25 patients had persistent AF and 6 had paroxysmal AF; in the PVI group, 25 patients had paroxysmal disease and 6 had persistent AF. All patients also underwent concurrent coronary artery bypass, valve surgery, or both.

The researchers assessed the efficacy of AF treatment using 24-hour ECG monitoring at 3, 6, and 12 months following surgery. They also used two-dimensional echocardiography to assess left atrial size and function at 3 months and 1 year after surgery.