vestarВестник аритмологииJournal of Arrhythmology1561-86412658-7327НАО «Инкарт»vestar-614Research ArticleОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯORIGINAL ARTICLESКОМПЛЕКСНАЯ ОЦЕНКА РЕЗУЛЬТАТОВ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ПЕРСИСТИРУЮЩЕЙ ФИБРИЛЛЯЦИИ ПРЕДСЕРДИЙ ВО ВРЕМЯ ОПЕРАЦИИ АОРТОКОРОНАРНОГО ШУНТИРОВАНИЯCOMPLEX ASSESSMENT OF OUTCOMES OF SURIGICAL TREATMENT OF PERSISTENT ATRIAL FIBRILLATION DURING AORTOCORONARY BYPASS GRAFTING SURGERYЧернявскийА. М.ChernyavskyA. M.noemail@neicon.ruКареваЮ. Е.KarevaYu. E.noemail@neicon.ruПакИ. А.PakI. A.noemail@neicon.ruРахмоновС. С.RakhmonovS. S.noemail@neicon.ruРомановА. Б.RomanovA. B.noemail@neicon.ruПокушаловЕ. А.PokushalovE. A.noemail@neicon.ruФГБУ «Новосибирский научно-исследовательский институт патологии кровообращения им. Е.Н.Мешалкина» Министерства здравоохранения и социального развития Российской ФедерацииRussian Federation2013220920200713544Copyright © Чернявский А.М., Карева Ю.Е., Пак И.А., Рахмонов С.С., Романов А.Б., Покушалов Е.А., 20202020Чернявский А.М., Карева Ю.Е., Пак И.А., Рахмонов С.С., Романов А.Б., Покушалов Е.А.Chernyavsky A.M., Kareva Y.E., Pak I.A., Rakhmonov S.S., Romanov A.B., Pokushalov E.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://vestar.elpub.ru/jour/article/view/614

С целью изучения эффективности радиочастотной аблации (РЧА) фибрилляции предсердий (ФП) у больных ишемической болезнью сердца (ИБС) во время операции аортокоронарного шунтирования (АКШ), оценки свободы от аритмии в отдаленном периоде, проаритмогенных эффектов и качества жизни (КЖ) пациентов после операции обследовано и прооперировано 95 пациентов, мужчин 74 (78%), средний возраст 62,8±8,8 лет. В первую группу включен 31 пациент, которым выполнялась радиочастотная изоляция устьев легочных вен (РИ УЛВ ); во вторую -30 пациентов, которым выполнялась радиочастотная процедура лабиринт (РПЛ); в третью - 34 пациента, которым выполнялась только операция АКШ. По данным эхокардиографии фракция выброса менее 35% была выявлена у 8 пациентов, умеренная митральная недостаточность - у 22 пациентов, наличие аневризмы ЛЖ - у 9 пациентов. РИ УЛВ включала в себя нанесение аблационных линий на единые коллекторы УЛВ. РПЛ включала изоляцию УЛВ, резекцию ушка левого предсердия (ЛП), а также создание аблационных линий из отсеченного ушка ЛП к левым верхней и нижней ЛВ и к фиброзному кольцу митрального клапана и по крыше ЛП. Для непрерывного длительного мониторинга ЭКГ в отдаленном послеоперационном периоде мы использовали имплантируемые устройства Reveal XT. Операции АКШ в сочетании с различными вариантами аблации ФП проходили в стандартном режиме без каких-либо технических сложностей. Во время нанесения аблационных линий не замечено никаких технических сложностей, связанных с позиционированием бранш. В раннем послеоперационном периоде все пациенты после выполнения аблации ФП получали антиаритмическую и антикоагулянтную терапию для профилактики ятрогенных аритмий. Достоверной разницы во времени пребывания пациентов трех групп в палате реанимации не получено, не наблюдалось различий между основными и контрольной группами, как по характеру послеоперационного течения, так и частоте развития осложнений в раннем послеоперационном периоде. При выписке синусовый ритм (СР) регистрировался у всех пациентов из первой и контрольной группы, при этом по одному пациенту в каждой из этих групп имел ритм ЭКС, который был планово имплантирован во время операции. В отдаленные сроки после операции в первой группе СР имели 26 из 30 обследованных пациентов, что составляет 86,7%. Во второй группе через 1 год после операции 28 из 29 наблюдавшихся пациентов имели СР, что составляет 96,5%. В контрольной группе через один год наблюдения только 18 из 34 пациентов имели СР, т.е. свобода от ФП в данной группе составила 53%. Таким образом РЧА персистирующей ФП во время операции АКШ является высокоэффективным и безопасным методом лечения ФП. РИ УЛВ во время АКШ позволяет восстановить СР на у 100% больных, РПЛ - у 96,7% больных. РПЛ обладает более низким проаритмогенным эффектом по сравнению с РИ УЛВ. Эффективное устранение ФП во время АКШ улучшает КЖ пациентов по всем шкалам опросника SF-36. Имплантируемые устройства непрерывного длительного мониторирования ритма обеспечивают высокую эффективность в выявлении пароксизмов ФП, позволяют своевременно корригировать и отменять антиаритмическую и антикоагулянтную терапию. РИ УЛВ во время АКШ позволяет сохранить СР в отдаленном периоде у 80% пациентов с персистирующей ФП, РПЛ - у 86,2%, изолированное АКШ - у 44,1%.

To study effectiveness of radiofrequency ablation (RFA) of atrial fibrillation (AF) in patients with coronary artery disease (CAD) during the aortocoronary bypass grafting surgery (ACBG), to assess freedom from arrhythmia in the late post-operation period, pro-arrhythmic effects, and quality of life of patients after the surgery, 95 patients (74 men; 78%), aged 62.8±8.8 years were examined and surgically treated. Group I included 31 patients, in whom radiofrequency ostial pulmonary vein isolation (ROPVI) was performed. The radiofrequency procedure Cox-Maze was performed in 30 patients of Group II. In 34 patients of Group III, only the ABCG surgery was performed. According to the echocardiography data, ejection fraction lower than 35% was found in 8 patients, moderate mitral insufficiency, in 22 patients, and the left ventricular aneurysm, in 9 subjects. ROPVI included application of ablation lines on common collectors of pulmonary vein ostia. The radiofrequency procedure Cox-Maze included the ostial pulmonary vein isolation, resection of the left auricle, as well as application of ablation lines from the resected left auricle towards the left upper and lower pulmonary veins, as well as the fibrous ring of the mitral valve, and on the left atrial roof. For persistent long-term ECG monitoring in the late post-operation period, implantable devices Reveal XT were used. The ACBG surgery in combination with different types of AF ablation took place in the study subjects without technical issues. During the application of ablative lines, no issues related to the branch positioning were noted. All patients after AF ablation received antiarrhythmic and anticoagulant therapy in early post-operation period to prevent iatrogenic arrhythmias. No significant difference was observed in the duration of stay in ICU in all three groups; no differences between both study and control group in the clinical course of the post-operation period and incidence of complications developed in the early post-operation period were revealed, as well. At the discharge from hospital, the sinus rhythm was documented in all patients from Group I and control group excluding one patient from both above groups apiece who had the pacemaker rhythm after the planned pacemaker implantations occurred during the surgery. In the late post-operation period, the sinus rhythm was detected in 26 patients of 30 (86.7%). In Group II, 28 patients of 29 (96.5%) had the sinus rhythm one year after the operation. In the control group after one year of follow-up, only 18 patients of 34 had the sinus rhythm, i.e. the freedom from arrhythmia was 53%. Thus, RFA of persistent AF during the ACBG procedure is a highly effective and safe method of treatment of AF. Radiofrequency isolation of pulmonary vein ostia during the ACBG surgery permits one to restore the sinus rhythm in 100% of patients and radiofrequency procedure Cox-Maze, in 96.7% of patients. The radiofrequency procedure Cox-Maze is associated with a less pro-arrhythmic effect than the radiofrequency isolation of pulmonary vein ostia. The effective AF elimination during the ACBG surgery improves the quality of life of the patients according to all scales of the SF 36 questionnaire. Insertable cardiac monitors are highly effective in detection of AF paroxysms and permit one to correct or discontinue antiarrhythmic and/or anticoagulant therapy in proper time. Radiofrequency isolation of pulmonary vein ostia during the ACBG surgery maintains the sinus rhythm in the late post-operation period in 80% of patients with persistent AF, the radiofrequency procedure Cox- Maze, in 86.2% of patients, and the ACBG surgery alone, in 44.1% of subjects.

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The authors declare that there are no conflicts of interest present.