2023 年第 10 期 第 18 卷

瓣膜置换术同期射频消融和左心耳闭合对心脏瓣膜病合并心房颤动患者预后的影响

Effect of radiofrequency ablation and left atrial appendage closure during valve replacement on prognosis of patients with valvular heart disease and atrial fibrillation

作者：陈兴华1韩露2王丽媛1王宁1张继倬1贡鸣3

英文作者：Chen Xinghua1 Han Lu2 Wang Liyuan1 Wang Ning1 Zhang Jizhuo1 Gong Ming3

单位：1首都医科大学附属北京世纪坛医院心脏外科，北京100038；2首都医科大学附属北京朝阳医院医学研究中心，北京100043；3首都医科大学附属北京安贞医院心外科，北京100029

英文单位：1Department of Cardiac Surgery Beijing Shijitan Hospital Capital Medical University Beijing 100038 China; 2Medical Research Center Beijing Chao-Yang Hospital Capital Medical University Beijing 100043 China; 3Department of Cardiac Surgery Beijing Anzhen Hospital Capital Medical University Beijing 100029 China

关键词：瓣膜病；心房颤动；瓣膜置换术；射频消融；左心耳闭合

英文关键词：Valvulardisease;Atrialfibrillation;Valvereplacement;Radiofrequencyablation;Leftatrialappendageclosure

• 摘要：

• 目的  评价瓣膜置换术同期射频消融和左心耳闭合治疗心脏瓣膜病（VHD）合并心房颤动患者的疗效及预后。方法  选取2016年1月至2020年5月首都医科大学附属北京世纪坛医院和首都医科大学附属北京朝阳医院收治的157例VHD合并心房颤动患者作为研究对象，根据治疗方式分为瓣膜置换组（n=77）和联合组（n=80，瓣膜置换联合射频消融和左心耳闭合治疗）。比较2组手术相关指标，术前、术后1年心功能指标、肺动脉压，炎性因子及同型半胱氨酸（Hcy）水平；所有患者均随访至2022年11月，比较2组生存期及主要不良事件发生情况。结果  联合组即刻窦性心律恢复率高于瓣膜置换组［91.2%(73/80)比23.4%（18/77）］（P＜0.001）。术后1年，2组左心房内径（LAD）、左心室舒张末期内径（LVEDD）、肺动脉收缩压（PASP）均低于术前，左心室射血分数(LVEF)均高于术前，且联合组术后1年LAD、LVEDD、PASP低于瓣膜置换组，LVEF高于瓣膜置换组（均P＜0.05）。术后1年，2组白细胞介素6（IL-6）、肿瘤坏死因子α（TNF-α）水平均低于术前，且联合组术后1年IL-6、TNF-α、Hcy水平低于瓣膜置换组（均P＜0.05）。术后1年联合组纽约心脏病协会心功能分级优于瓣膜置换组，差异有统计学意义（P=0.044）。联合组随访中位生存时间长于瓣膜置换组（P=0.022），不良事件发生率低于瓣膜置换组［20.0%(16/80)比35.1%(27/77)］（P=0.034）。结论  瓣膜置换术同期射频消融和左心耳闭合可提高VHD合并心房颤动患者即刻窦性心律恢复率，进一步改善患者术后心功能，降低炎性反应指标和Hcy水平，降低因心力衰竭再入院、全因死亡等不良事件发生率，延长生存时间。

• Objective  To evaluate the efficacy and prognosis of patients with valvular heart disease (VHD) complicated with atrial fibrillation treated with radiofrequency ablation and left atrial appendage closure during valve replacement. Methods  A total of 157 patients with VHD combined with atrial fibrillation from January 2016 to May 2020 admitted to Beijing Shijitan Hospital, Capital Medical University and Beijing Chao-Yang Hospital, Capital Medical University were selected. They were divided into valve replacement group (n=77) group and combination group (n=80, valve replacement combined with radiofrequency ablation and left auricular closure) according to treatment methods  . Surgical indicators, preoperative and 1-year postoperative cardiac function indexes, pulmonary artery pressure, inflammatory factors and homocysteine (Hcy) levels were compared between the two groups. All patients were followed-up until November 2022, and the survival time and major adverse events were compared between the two groups. Results  The rate of immediate sinus rhythm recovery in the combination group was higher than that in the valve replacement group ［91.2%(73/80) vs 23.4%(18/77)］(P<0.001). One year after surgery, the left atrial diameter (LAD), left ventricular end diastolic diameter (LVEDD) and pulmonary artery systolic pressure (PASP) in both groups were lower than those before surgery, and the left ventricular ejection fraction (LVEF) was higher than that before surgery; the LAD, LVEDD and PASP in the combination group were lower than those in the valve replacement group, and LVEF was higher than that in the valve replacement group (all P＜0.05). One year after surgery, interleukin-6 (IL-6) and tumor necrosis factor α(TNF-α) levels of two groups were lower than those before surgery, and the levels of IL-6，TNF-α, Hcy in combination group were lower than those in the valve replacement group (all P＜0.05). One year after surgery, the New York Heart Association cardiac function grading of the combination group was superior than that of the valve replacement group(P=0.044). The median follow-up survival time of the combination group was longer than that of the valve replacement group (P=0.022), and the incidence of adverse events was lower than that of the valve replacement group ［20.0%(16/80) vs 35.1%(27/77)］(P=0.034). ConclusionsRadiofrequency ablation and left atrial appendage closure during valve replacement can greatly improve the immediate sinus rhythm recovery rate in patients with VHD and atrial fibrillation, further improve postoperative cardiac function, reduce inflammatory response indicators and Hcy levels, reduce the incidence of adverse events such as hospitalization and death of heart failure, and prolong survival time.