中国组织工程研究

中国组织工程研究 ›› 2019, Vol. 23 ›› Issue (22): 3562-3569.doi: 10.3969/j.issn.2095-4344.1753

• 材料生物相容性 material biocompatibility • 上一篇    下一篇

瓣膜置换或瓣环置入同期迷宫Ⅲ手术治疗老年二尖瓣病变合并持续性或长期持续性心房颤动

韩  冰1，2，王辉山2，韩劲松2，尹宗涛2，谢赛旗2 
  

  1. 1大连医科大学研究生院，辽宁省大连市  116044；2中国人民解放军北部战区总医院心血管外科，辽宁省沈阳市  110016
  • 收稿日期:2019-03-04
  • 通讯作者: 韩劲松，博士，副主任医师，硕士生导师，中国人民解放军北部战区总医院心血管外科，辽宁省沈阳市 110016
  • 作者简介:韩冰，男，1990年生，河南省驻马店市人，汉族，大连医科大学在读硕士，现规培于中国人民解放军北方战区总医院，主要从事心脏瓣膜病和迷宫手术方面的研究。
  • 基金资助:

    2017年辽宁省自然基金计划重点项目(20170540977)，项目负责人：韩劲松

Valve replacement or valve ring implantation and Cox-Maze III procedure for older adults with mitral valve disease complicated by persistent or long-standing persistent atrial fibrillation

Han Bing1, 2, Wang Huishan2, Han Jinsong2, Yin Zongtao2, Xie Saiqi2
  

  1. 1Graduate School of Dalian Medical University, Dalian 116044, Liaoning Province, China; 2Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
  • Received:2019-03-04
  • Contact: Han Jinsong, MD, Associate chief physician, Master’s supervisor, Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
  • About author:Han Bing, Master candidate, Graduate School of Dalian Medical University, Dalian 116044, Liaoning Province, China; Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
  • Supported by:

    the Major Project of Natural Foundation of Liaoning Province in 2017, No. 20170540977 (to HJS)

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摘要：

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文题释义：
心房颤动：简称房颤，是临床上最常见的心律失常之一，是指规则有序的心房电活动丧失，代之以快速无序的颤动波，是严重的心房电活动紊乱，其几乎见于所有的器质性心脏病，非器质性心脏病也可发生，常引起严重并发症，如心力衰竭和动脉栓塞。根据房颤的发作特点，临床上将房颤分为首诊房颤(首次发作或首次发现)、阵发性房颤(持续时间≤7 d，能自行终止)、持续性房颤(持续时间>7 d，非自限性)、长期持续性房颤(持续时间≥1年，患者有转复愿望)、永久性房颤(持续时间>1年，不能终止或终止后有复发，无转复愿望)。
迷宫手术：Cox等于1991年开始对房颤的机制展开研究，发现房颤的心房肌存在多个大折返环，围绕着上下腔静脉开口、界嵴及左右肺静脉开口，而且路径转瞬即变，无法根据电生理标测的线路指导手术，因而设计了心房多个切口，应用“切开和缝合”的方式来阻断心房内及心房周围的折返环，并保留特定的心房传导路径，使窦性激动能够传至房室结，这一手术方式称为“迷宫手术”。目前常见的迷宫术式主要是迷宫Ⅲ型和Ⅳ型手术，因迷宫Ⅲ型手术对心房进行切开和缝合，保证了确切的透壁性，使电信号确切隔离，远期疗效较好，被认为是治疗房颤的“金标准”，但因其切口多、创伤大，限制了其广泛开展。Damiano等应用各种能源如冷冻、射频、微波等代替“切和缝”的方法，开创了迷宫Ⅳ型手术，因其操作简单，成为目前流行治疗房颤的手术方法。
 
 
背景：前期研究证实，迷宫Ⅲ手术是治疗二尖瓣病变合并持续性或长期持续性心房颤动安全且有效的方法，但老年患者手术耐受性差，有关老年患者行迷宫Ⅲ手术安全性及有效性的相关报道较少。
目的：评价迷宫Ⅲ手术治疗老年二尖瓣病变合并持续性或长期持续性房颤患者的安全性和有效性。  
方法：纳入2013年5月至2017年11月中国人民解放军北部战区总医院(原中国人民解放军沈阳军区总医院)收治的二尖瓣病变合并持续性或长期持续性房颤患者166例，依据WHO发展中国家公民年龄≥60周岁为老年人的定义，分为老年组(年龄≥60岁，n=70)和非老年组(年龄<60岁，n=96)，对两组实施迷宫Ⅲ手术，同期行瓣膜置换或瓣膜成形手术。对比两组术中指标、术后安全性指标及术后早期疗效。试验已通过中国人民解放军北部战区总医院(原中国人民解放军沈阳军区总医院)伦理委员会审核，伦审k(2015)33号。
结果与结论：①术中指标：两组主动脉阻断时间、体外循环时间、出血量、二尖瓣手术类型比较差异无显著性意义(P > 0.05)，老年组冠状动脉旁路移植术和生物瓣使用多于非老年组(P < 0.05)；②术后安全性指标：两组间二次开胸止血、低心排综合征、脑卒中、肝肾功能不全、再次气管插管、主动脉内球囊反搏植入、起搏器应用及早期死亡等不良事件发生率比较差异无显著性意义(P > 0.05)，ICU停留时间及术后住院时间比较差异无显著性意义(P > 0.05)；老年组呼吸机使用时间长于非老年组(P < 0.05)；③术后早期疗效：两组出院时、术后6个月、术后1年的心功能分级均较术前明显改善，但两组间比较差异无显著性意义(P > 0.05)；两组间出院时、术后6个月、术后1年的窦性心律恢复率比较差异无显著性意义(P > 0.05)，均在85%以上；④结果表明：迷宫Ⅲ型手术治疗老年二尖瓣病变合并持续性或长期持续性心房颤动是安全的，近期疗效满意。

关键词: 迷宫手术, 老年患者, 心脏瓣膜病, 心房颤动, 长期持续性心房颤动, 人工瓣膜, 二尖瓣病变

Abstract:

BACKGROUND: Preliminary studies have shown that the Cox-Maze III procedure is safe and effective method to treat persistent or long-standing persistent atrial fibrillation. As the surgical tolerance of elderly patients is poor, the safety and effectiveness of Cox-Maze III for elderly patients are rarely reported.
OBJECTIVE: To evaluate the safety and efficacy of Cox-Maze III procedure in elderly patients with mitral valve disease complicated by persistent or long-standing persistent atrial fibrillation.
METHODS: One hundred and sixty-six patients with mitral valve disease complicated by persistent or long-standing persistent atrial fibrillation admitted at General Hospital of Northern Theater Command (General Hospital of Shenyang Military Region of Chinese PLA) from May 2013 to November 2017 were included. According to the World Health Organization definition of the elderly people, they were divided into elder group (≥ 60 years, n=70) and young group (< 60 years, n=96), followed by undergoing Cox-Maze III procedure and valvular replacement or valvuloplasty. The intraoperative indexes, postoperative safety indexes and early-term and efficacy were compared between two groups. The study was approved by the Ethics Committee of General Hospital of Northern Theater Command (General Hospital of Shenyang Military Region of Chinese PLA), approval number: k(2015)33.
RESULTS AND CONCLUSION: (1) Intraoperative safety indexes: there was no significant difference in the time of aortic clamping, cardiopulmonary bypass time, blood loss and surgical type between two groups (P > 0.05). The elderly group had more patients to conduct the coronary artery bypass grafting and the use of biological valve than the young group (P < 0.05). (2) Postoperative safety indexes: the incidence of adverse events such as the re-thoratomy for hemaostsis, low cardiac output syndrome, stroke, hepatic and renal dysfunction, secondary tracheal intubation, intra-aortic balloon pump implantation, temporary pacemaker application and early-term mortality were insignificant differences between two groups (P > 0.05). There were no significant differences in the intensive care unit stay time and postoperative hospitalization time (P > 0.05) between two groups. The time of ventilator use in the elderly group was significantly longer than that in the young group (P < 0.05). (3) Postoperative efficacy: the New York Heart Association classes at discharge and postoperative 6 and 12 months were significantly improved in all patients compared with the baseline, and there was no significant difference between two groups (P > 0.05). The rate to achieve sinus rhythm at discharge and postoperative 6 and 12 months showed no significant difference between two groups (P > 0.05), which reached above 85%. (4) These results indicate that Cox-Maze III procedure possesses safety for elderly patients with mitral valve disease complicated by persistent or long-standing persistent atrial fibrillation, and the short-term efficacy is satisfactory.

Key words: Cox-Maze procedure, elderly patients, heart valve disease, atrial fibrillation, long-standing persistent atrial fibrillation, artificial valve, mitral valve disease

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