心房颤动的外科治疗策略

阵发性心房颤动（房颤）需要“局灶触发”，其触发灶一般位于肺静脉开口附近，持续或永久性房颤同时需要“局灶触发”和心房的“异常基质”两个因素。也有人认为持续或永久性房颤根本不需要触发灶。因此，可靠的肺静脉隔离可以治愈绝大部分阵发性房颤的患者，而持续或永久性房颤则需要进行迷宫手术或与其相似的肺静脉隔离基础上的心房附加隔离线。近年来外科消融发展很快，其原因是该方法可达到与迷宫手术相似的高成功率，而并发症低以及手术时间短则明显优于迷宫手术。外科消融可采用的能量很多，有射频、微波、冷冻等。因为外科一般为永久性房颤的患者，肺静脉开口加左房后壁消融是其基本的消融线。考虑到没有心脏器质性疾病的房颤本身是一种良性心律失常，同时外科消融可能出现的某些重并发症，例如左房食管漏、冠状动脉损伤等，不推荐广泛应用外科消融来治疗孤立的房颤。但对需要进行心脏外科手术的患者合并房颤，无论是永久或阵发性房颤，均应常规进行外科治疗。

Surgical Strategies in the Management of Atrial Fibrillation

The initiation of intermittent AF requires a ＂trigger＂, often, though not always, located near the orifices of pulmonary veins. In contrast, continuous or permanent AF does not need a ＂trigger＂ to be re-in,riced repetitively and does not depend on the pulmonary veins or other abnormal automatic foci for its induction or perpetuation. Simple pulmonary vein encircling confines the trigger to the pulmonary veins and, if expertly performed, will cure the majority of the patients with intermittent AF. On the other hand, continuous or permanent AF requires a Maze procedure or variant thereof to eliminate atrial macro-- reentry while allowing sinus rhythm to activate the entire atrial myocardium. Surgical ablation, which originated with the favorable results of the Maze procedure, has an important role in the cure of AF associated with heart diseases that require cardiac surgery. This is due to the high success rate and to the simplification of the procedure now used which has resulted in reduction of the procedural time and complications. Various techniques have been pro- posed, however, it is noteworthy that the posterior part of the left atrium and the ostia of pulmonary veins are involved in all approaches despite the different energy sources used （radiofrequency, microwave and cryo energy）. Considering the rel- atively benignity of AF in absence of associated cardiopathy, the risk of complications （atrioesophagus fistula, coronary artery damage, etc. ） should discourage widespread application of surgical ablation in patients with lone AF. On the contrary it should be routinely proposed in most patients with permanent or paroxysmal AF undergoing cardiac surgery.