冠状动脉搭桥术并发阵发性心房颤动的手术治疗:肺静脉隔离还是迷宫V?

A. Revishvili, V. Popov, V. V. Aminov, G. Plotnikov, E. Malyshenko, M. M. Anishchenko, M. Svetkin
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Propensity score-matched (PSM) analysis with a 1:1 nearest-neighbor matching was done. 30 patients were selected from each group. The exclusion criteria were as follows: emergent CABG, concomitant valvular heart disease, non-paroxysmal AF, decompensation of chronic diseases, and cancer. On-pump CABG was performed at normothermia with warm blood hyperkalemia cardioplegia. RFA for PVI and Maze V were performed before CABG under parallel perfusion without aortic cross-clamping. The primary and secondary endpoints included recurrent AF/atrial flutter, sinus rhythm at discharge and in the long-term period, permanent pacemaker implantation, major cardiovascular and cerebrovascular events.Results. 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引用次数: 0

摘要

高光。与双极RFA治疗PVI相比,Maze V在短期和中期显著减少房颤复发。目的:比较肺静脉隔离术(PVI)与Maze V治疗阵发性心房颤动(AF)合并冠状动脉搭桥术(CABG)的有效性和安全性。回顾性分析139例冠心病合并阵发性房颤患者的病历。所有患者分为两组:第一组(n = 71)行冠脉搭桥+双极射频消融治疗PVI,第二组(n = 68)行Maze V +冠脉搭桥。采用1:1的最近邻匹配进行倾向得分匹配(PSM)分析。每组各取30例。排除标准如下:急诊冠脉搭桥、合并瓣膜性心脏病、非阵发性房颤、慢性疾病失代偿和癌症。无泵冠脉搭桥是在正常体温和温血高钾心脏骤停时进行的。在无主动脉交叉夹持的情况下,在冠脉搭桥前对PVI和Maze V行RFA。主要和次要终点包括房颤/心房扑动复发、出院时和长期窦性心律、永久性起搏器植入、主要心脑血管事件。经PSM分析,CABG+Maze V组和CABG+RFA治疗PVI的手术时间有显著差异(330 [310;375] vs. 255 [225;270] min, p = 0.0001)、体外循环时间(131 [113;[144] min vs. 89 [74;98] min, p = 0.0001),房颤治疗持续时间(53 [44;59] min vs. 10 [9;12] min, p = 0.0001)。两组并发症的结构和发生率具有可比性。没有住院病人死亡。与CABG+RFA治疗PVI组相比,CABG+Maze V组复发性房颤/心房扑动显著减少(分别为13.3%和33.3%;P = 0.044)。所有病例均恢复窦性心律。一过性窦结功能障碍(不超过5天)的发生率在1组为6.7%,在2组为16.6%。差异无统计学意义(p = 0.128)。与CABG+RFA治疗PVI组相比,未经抗心律失常药物治疗的CABG+Maze V组12个月累计房颤/心房扑动自由度显著高于CABG+RFA治疗PVI组(分别为97%和83.5%;P = 0.020)。两组MACE的自由度均为96.7%。Maze V治疗伴发性阵发性心房颤动可延长体外循环时间和手术时间,但不影响术后时间,提示其安全性和有效性。与RFA相比,Maze V手术合并冠脉搭桥在短期和中期都能显著减少房颤的复发。因此,对于阵发性房颤和疾病进展风险高的患者,行Maze V+CABG是合理的。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Surgical treatment of paroxysmal atrial fibrillation concomitant to coronary artery bypass grafting: pulmonary vein isolation or maze V?
Highlights. Maze V significantly reduces the recurrence of AF compared to bipolar RFA for PVI in the short and mid-term period.Aim. To assess the effectiveness and safety of pulmonary vein isolation (PVI) in comparison with Maze V for treating paroxysmal atrial fibrillation (AF) concomitant to coronary artery bypass grafting (CABG).Methods. Medical records of 139 patients with coronary artery disease and concomitant paroxysmal AF were retrospectively analyzed. All patients were divided into two groups: Group 1 patients (n = 71) underwent CABG + bipolar radiofrequency ablation for PVI, and Group 2 patients (n = 68) underwent Maze V + CABG. Propensity score-matched (PSM) analysis with a 1:1 nearest-neighbor matching was done. 30 patients were selected from each group. The exclusion criteria were as follows: emergent CABG, concomitant valvular heart disease, non-paroxysmal AF, decompensation of chronic diseases, and cancer. On-pump CABG was performed at normothermia with warm blood hyperkalemia cardioplegia. RFA for PVI and Maze V were performed before CABG under parallel perfusion without aortic cross-clamping. The primary and secondary endpoints included recurrent AF/atrial flutter, sinus rhythm at discharge and in the long-term period, permanent pacemaker implantation, major cardiovascular and cerebrovascular events.Results. After the PSM analysis, the CABG+Maze V group and CABG+RFA for PVI differed significantly in the duration of surgery (330 [310; 375] vs. 255 [225; 270] min, p = 0.0001), cardiopulmonary bypass time (131 [113; 144] min vs. 89 [74; 98] min, p = 0.0001), duration of AF treatment (53 [44; 59] min vs. 10 [9; 12] min, p = 0.0001). The structure and rate of complications in both groups were comparable. There were no in-patient deaths. Recurrent AF/atrial flutter significantly reduced in the CABG+Maze V group compared to the CABG+RFA for PVI group (13.3% vs. 33.3%, respectively; p = 0.044). Sinus rhythm was restored in all cases. The rate of transient sinus node dysfunction (no more than 5 days) was 6.7% in the Group 1 and 16.6% in the Group 2. The difference did not reach statistical significance (p = 0.128). The 12-months cumulative freedom from AF/atrial flutter without antiarrhythmic drug therapy was significantly higher in the CABG+Maze V group compared to the CABG+RFA for PVI group (97% vs. 83.5%, respectively; p = 0.020). The freedom from MACE in both groups was 96.7%.Conclusion. Maze V for treating concomitant paroxysmal AF prolonged the duration of cardiopulmonary bypass and the surgery itself, but did not affect the postoperative period, indicating its safety and effectiveness. Maze V procedure concomitant to CABG significantly reduced the recurrence of AF compared to RFA for PVI both in the short- and mid-term period. Thus, it is reasonable to perform Maze V+CABG in patients with paroxysmal AF and a high risk of disease progression.
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