Analysis Of The Clinical Effect Of Intraoperative Suture Of Left Atrial Appendage On Patients With Atrial Fibrillation And Mitral Valve Replacement

Objective: To study whether simultaneous suture of left atrial appendage during mitral valve replacement in patients with atrial fibrillation is related to the reduction of postoperative stroke risk and mortality,and summarize its clinical effect.Method: A total of 507 patients with atrial fibrillation who underwent mitral valve replacement in the Department of Cardiovascular surgery of affiliated Hospital of Qingdao University from January 2014 to July 2018 were retrospectively analyzed.The inclusion criteria:(1)Mitral valve disease was diagnosed according to clinical manifestation,physical examination and imaging examination(cardiac ultrasound,X-ray,CT),and mitral valve replacement was performed;(2)age> 18 years old;(3)Paroxysmal or persistent or permanent atrial fibrillation was diagnosed by echocardiography,12-lead electrocardiogram or 24-hour dynamic electrocardiogram before operation.Exclusion criteria:(1)patients with congenital heart disease,ventricular aneurysm,aortic dissection(including type A and B),aneurysms;(2)under cardiac function,left ventricular ejection fraction,LVEF<40%;(3)patients with cardiomyopathy,infective endocarditis,malignant tumor,severe cerebral infarction sequelae;(4)patients with previous cardiac surgery,Leonardo da Vinci robot surgery,patients undergoing radiofrequency ablation;(5)patients with severe coronary atherosclerotic heart disease(three coronary arteries disease or single coronary arteries severe stenosis diagnosed by coronary angiography within 2 weeks before operation)or previous history of myocardial infarction;(6)patients who lost follow-up or refused to return visit after operation.According to the different treatment of LAA during operation,the patients were divided into LAA suture group(n=209)and control group(n=298).Under the condition of fully clearing atrial thrombus in the two groups,the left atrial appendage was closed through endocardial suture during mitral valve replacement in the left atrial appendage suture group,while the left atrial appendage was not treated in the control group.SPSS24.0 software was used for statistical analysis.The operation-related data,perioperative indexes and follow-up data of the two groups were compared.COX case risk model was used to analyze the risk factors affecting prognosis,and the cumulative survival curve of Kaplan-Meier without stroke events was drawn.Result: The operation time,cardiopulmonary bypass time and ascending aorta blocking time in the left atrial appendage closure group were significantly longer than those in the control group(P<0.05).One month after operation,the echocardiographic results showed that the left atrial diameter and left ventricular diastolic diameter in the left atrial appendage closure group were lower than those in the control group,and the difference was statistically significant(P< 0.05).The postoperative hospital stay in the left atrial appendage closure group was significantly shorter than that in the control group(P<0.05).There was no significant difference in postoperative ICU stay,perioperative stroke,hospital mortality and other major complications.The incidence of cerebral embolism(0.54% / person-year vs.1.84% / person-year,p=0.029)and all-cause mortality(0.7% /person-year vs.1.99% / person-year,p=0.032)in the left atrial appendage suture group were lower than those in the control group within a median follow-up period of 32(20,45)months.Kaplan-Meier curve showed that the cumulative stroke-free survival rate in the left atrial appendage suture group was better than that in the control group(Log-Rank test p < 0.001).The inclusion of multiple subvariables in COX analysis showed that suturing the left atrial appendage could significantly reduce the risk of stroke(HR=0.260,95%[CI]:0.059-0.728,p=0.014)and death(HR=0.403,95% [CI]:0.108-0.958,p=0.042)in patients with atrial fibrillation.Age(> 65 years old),left atrial thrombus,internal carotid artery or vertebral artery stenosis were independent risk factors for postoperative stroke,while diabetes,alcoholism and previous history of cerebral infarction were independent risk factors for death.Conclusion:1.Intraoperative suture of left atrial appendage is a protective factor for postoperative stroke and mortality.Intraoperative suture of left atrial appendage can effectively reduce the risk of stroke and death in patients with atrial fibrillation and mitral valve replacement,and has good safety.it is worth popularizing in clinical work.2.In mitral valve replacement patients with atrial fibrillation,although intraoperative suture of left atrial appendage will increase part of the operation time,CPB time and ascending aortic occlusion time,it will improve hemodynamics and reduce left atrium diameter after operation.there is no significant increase in the risk of postoperative complications or traumatic procedures.3.Intraoperative suture of the left atrial appendage in patients with preoperative atrial fibrillation after mitral valve replacement,a better stroke-free survival state can be obtained after operation.Patients with advanced age(> 65 years old),history of diabetes,stenosis of internal carotid artery or vertebral artery,left atrial thrombus and previous history of cerebral infarction should actively suture the left atrial appendage during mitral valve replacement to improve the prognosis.