电复律治疗风湿性心脏病瓣膜置换术后持续性心房颤动的疗效观察

Cardioversion for treatment of persistent atrial fibrillation in rheumatic cardiac disease patients after valve replacement

摘要:

目的探讨电复律治疗风湿性心脏病瓣膜置换术后伴左房明显增大的持续性心房颤动的疗效。方法将164例风湿性心脏病瓣膜置换术后持续性心房颤动的患者(左房内径均>50 mm)随机分为3组:胺碘酮组20例;胺碘酮+雷米普利组76例;胺碘酮+厄贝沙坦组68例。所有患者在经静脉应用胺碘酮后,房颤如未转复,则行电复律治疗。复律成功者胺碘酮改为口服200 mg/d,联合雷米普利及厄贝沙坦组同时口服雷米普利5 mg/d、厄贝沙坦150 mg/d,3～6个月后停用。结果即时成功率92.7%(152/164例)。平均随访(1.8±0.4)年,128例(78.0%)保持窦性心律。联合雷米普利组窦律维持率为86.8%(66/76例),联合厄贝沙坦组窦律维持率为75.0%(51/68例)无统计学差异,单独口服胺碘酮组55.0%(11/20例)维持窦性心律,与联合雷米普利组、厄贝沙坦组比较,有显著差异。末次随访,胺碘酮组左房内径较复律前明显增加〔(60.5±3.8)mm vs(57.7±4.5)mm;P=0.04〕;联合雷米普利组〔(58.2±4.3)mmvs(57.3±5.8)mm,P=0.28〕和联合厄贝沙坦组〔(57.2.±5.5)mmvs(56.4±4.9)mm,P=0.37〕前后对照无显著差异。三组患者心功能均改善,两两比较无显著差异。结论对于房颤时间长,左房增大的患者只要正确掌握电复律的指征及方法,并予以辅助药物维持治疗,电复律的成功率较高,转复后维持率亦高,并能改善患者心功能。胺碘酮联合雷米普利或厄贝沙坦能延缓左房增大,提高窦律维持率。

Abstract:

Objective To approach the clinical effects of cardioversion for treatment of atrial fibrillation(AF) in the rheumatic cardial disease patients with large left atrium after valve replacement.Methods All 164 patients with persistent AF after valve replacement(left atrial diameter exceeded 50mm)were randomly divided into 3 groups: amiodarone group(n=20),combination of amiodarone and ramipril group(n=76),and combination of amiodarone and irbesartan group(n=68).Amiodarone was administrated iv in all patients,and cardioversion was used if AF was not returned.Amiodarone was administrated 200mg every day after successful cardioversion,ramipril was used 5mg every day at the same time in ramipril group,irbesartan was used 150mg every day in irbesartan group for 3-6 months.Results Immediate effective ratio was 92.7%(152/164 cases).Mean follow-up was(1.8±0.4) years;128 cases(78.0%) maintained sinus rhythm.Rate of sinus rhythm was 86.8%(66/76 cases) in ramipril group and it was 75.0%(51/68 cases)in irbesartan group with no significant difference between the two groups.It was 55.0%(11/20 cases)in amiodarone group,also without significant difference compared with ramipril or irbesartan group.Left atrial diameter detected in last follow-up significantly exceeded than before cardioversion in amiodarone group((60.5±3.8)mm vs(57.7±4.5)mm,P=0.04);but there was no significant difference between ramipril group((58.2±4.3)mm vs(57.3±5.8)mm,P=0.28)and irbesartan group((57.2.±5.5)mm vs(56.4±4.9)mm,P=0.37).Cardiac function was improved in 3 groups without conspicuous difference among them.Conclusion If methods of cardioversion and combined medicine approach are correct,the effective ratio is high in patients who had long time AF and large left atrium,the rate of maintenance of sinus rhythm is also high,and the cardiac function is improved.Amiodarone combined with ramipril or irbesartan can delay augmentation of left atrium and improve rate of maintenance of sinus rhythm.