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外科手术治疗是预防房颤复发的有效手段，其中以Cox迷宫术的效果较好。Cox迷宫术目前已发展到Ⅲ型。多个临床研究证实，接受Cox迷宫术的患者，窦性心律的维持率达90％，远高于药物治疗和射频消融治疗。但经典外科手术技术难度大、体循环时间长、创伤大，开展比较困难，现在的趋势是心脏外科手术时应用各种消融能量治疗房颤，消融经线与以往手术切口相似。目前对于合并房颤的外科手术患者，尤其是二尖瓣手术患者，同时行心内膜或心外膜消融治疗房颤已被广泛接受。
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（三）起搏治疗房颤
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起搏治疗用于预防房颤发作尚处于研究阶段。心房起搏可以阻止心脏停搏或心动过缓导致的心房不应期改变、缩短房内传导时间、降低心房不应期的弥散或减少心房异位兴奋点，从而预防折返或颤动样传导所引起的房颤。右房单部位、多部位起搏或双房同步起搏都具有这种治疗作用。但临床试验的结果没有提供足够的支持，房颤还不是永久性起搏的指征，对无心动过缓、不需要植入起搏器的患者不建议用起搏的方法预防房颤。
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【思考题】
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1．房颤发生的机制有哪些？
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2．房颤的药物治疗策略？
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3．房颤的非药物治疗方法有哪些？
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参考文献
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[1] Levy S, Camm AJ, Saksena S, et al. Intenational consensus on nomenclature and classification of atrial fibrillation: A collaborative project of the Working Group on Arrhythmias and the Working Group of Cardiac Pacing of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. J Cardiovasc Electrophysiol, 2003, 14
:443-445.
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[2] Wyse D G, Gersh B J. Atrial fibrillation: a perspective: thinking inside and outside the box. Circulation, 2004, 109
:3089-3095.
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[3] V Fuster, LE Rydén, DS Cannom, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for practice guidelines. J Am Coll Cardiol, 2006, 48
:854-906.
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[4] Healey JS, Baranchuk A, Crystal E, et al. Prevent of atrial fibrillation with angiotensin-converting enzyme inhibiters and anglotensin receptor blockers. J Am Coil Cardiol, 2005, 45
:1832-1839.
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[5] Dernellis J, Panaretou M. Effect of C-reactive protein reduction on paroxysmal atrial fibrillation. Am Heart J, 2005, 150(5)
:1064.
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[6] Carlsson J, Miketic S, Windeler J, et al. Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation（STAF）Study. J Am Coll Cardiol, 2003, 41
:1690-1696.
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[7] Nadernanee K, Schwab M, Porath J, et al. How to perform electrogram-guided atrial fibrillation ablation. Heart Rhythm, 2006, 3
:981-984.
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[8] Oral H, chugh A, Good E, et al. Radiofequency catheter ablation of chrenie atrial fibrillation guided by complex electrograms. Circulation, 2007, 115
:2606-2612.
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[9] Pappone C, Santineli V, Manguso F, et al. Pulmonary vein denervation enhances long-term benefit after eircumfercntial ab lation for paroxysmal atrial fibrillation. Circulation, 2004, 109
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[10] O’Neill M, Jais P, Takahashi Y, et al. The stepwise ablation approach for chronic atrial fibrillation. Evidence for a cumldative efect. J Intev Card Electrophysiol. 2006, 16
:153. 167.
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（钱安斌 胡申江）
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内科学新进展 第三节 心脏性猝死与心电信息改变
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摘 要 心脏性猝死是影响全球公众健康的重大问题。心脏性猝死发病复杂，常发生于以往有基础心脏疾病患者，但也见于无器质性心脏疾病患者。猝死患者最常见的基础疾病是冠状动脉粥样硬化性心脏病。发生心脏骤停患者最有效的抢救措施是及时呼叫急救系统，早期心肺复苏，早期除颤和早期高级生命支持。然而院外复苏的成功率不高，美国低于30％，我国低于10％。尽管随着诊断和治疗技术的迅速发展，对心脏性猝死高危因素进行检测和分级，并在其指导下选择有效的预防性措施，可减少恶性心律失常事件或心脏性猝死的发生。一些无创技术如心电生理检查对恶性室性心律失常和心脏性猝死的预测有较肯定的价值。而把这些无创性检查技术结合使用，则有更高的临床价值。
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Abstract Sudden cardiac death is a major globle public health problem. SCD is a heterogeneous condition and may be caused in patients with structural abnormalities of the heart usually as coronary artery disease. Less commonly, SCD happens in patients who may not have apparent structural heart disease. People are more likely to survive cardiac arrest when activation of the Emergency Medical Service（EMS）system, basic cardiopulmonary resuscitation（CPR), defibrillation and advanced care occur as rapidly as possible. But survival after out-of-hospital cardiac arrest remains poor, as less than 30% in America and 10% in our country. However, major developments in risk stratification and therapy have now made it possible to identify many of those at risk and to provide effective prophylactic treatment and reduce the incidence of fatal ventricular tachyarrhythmias or SCD. Several ninvasive risk stratification techniques has been proven to identify fatal ventricular tachyarrhythmias or SCD from total mortality, and it is important to combine and use these techniques in clinical practice.
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一、心脏性猝死
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