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Ann Thorac Surg 1996;62:1796-1800
© 1996 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Simple Left Atrial Procedure for Chronic Atrial Fibrillation Associated With Mitral Valve Disease

First Department of Surgery, Hiroshima University School of Medicine, Hiroshima, Japan

Accepted for publication June 27, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. A computerized 48-channel mapping system was used to investigate the characteristics of an atrial epicardial electrogram during chronic atrial fibrillation (AF) in patients with solitary mitral valve disease. We have devised a simple left atrial procedure to eliminate the chronic AF during a mitral valve operation.

Methods. Using this mapping system, we performed intraoperative atrial mapping in 11 patients with chronic AF associated with mitral valve disease. The AF duration ranged from 0.4 to 15 years (mean, 8.0 ± 4.5 years). A simple surgical ablation of the AF on the left atrium only was performed during the mitral valve operation.

Results. The mean AF cycle length of the atria ranged from 129 to 169 milliseconds in the right atrium and from 114 to 139 milliseconds in the left atrium. The mean AF cycle length of the left atrium was shorter than that of the right atrium. Regular and repetitive activation was found in the left atria of 7 of 11 patients. The AF disappeared in all patients immediately after the operation, and 10 of these patients continued to have a sinus rhythm postoperatively (AF-free rate, 91%).

Conclusions. Computerized intraoperative mapping revealed a shorter mean AF cycle length in the left atrium. A simple left atrial procedure was effective in eliminating chronic AF associated with solitary mitral valve disease.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Atrial fibrillation (AF) is one of the most prevalent arrhythmias, and is especially common in patients with mitral valve disease [1]. Cox and colleagues [2] described a maze procedure to correct for irregular heart beat, and produced a normal sinus rhythm. Although this maze procedure was designed for idiopathic AF, it has also proved effective for the treatment of chronic AF with mitral valve disease [3] and atrial septal defects [4]. However, there have been few detailed studies of chronic AF associated with mitral valve disease. Harada and colleagues [5] recently reported an atrial activation pattern in patients with chronic AF and isolated mitral valve disease. They postulated that the left atrium might act as an electrical driving chamber for AF in the majority of patients with mitral valve disease. We postulated that chronic AF associated with mitral valve disease might be caused by the shortened refractory period of the distended left atrium [6], and developed a simple surgical procedure to be performed on the left atrium only for the ablation of chronic AF. This study examines atrial activity during chronic AF, and demonstrates the efficacy of this procedure for chronic AF associated with isolated mitral valve disease.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Computerized atrial mapping was performed during chronic AF in 11 patients with solitary mitral valve disease who were undergoing mitral valve operations. Patient age ranged from 37 to 71 years, and there were 3 men and 8 women. Eight of these patients had rheumatic mitral stenosis with or without mitral regurgitation, and 3 had mitral regurgitation secondary to degenerative valvular disease. After the induction and maintenance of anesthesia, a median sternotomy followed by a cardiotomy was performed to expose the heart.

Before the institution of the cardiopulmonary bypass, intraoperative atrial mapping was performed with two card-type mapping electrodes and a Fukuda electronic mapping system (model HPM-7100). The large card-type electrode had 24 small bipolar electrodes of 2 mm diameter each, mounted in four rows of six on a flexible plastic rectangular sheet (42 x 65 mm). The small one had 24 bipolar electrodes of 2 mm in diameter each, mounted in four rows of six on a small sheet (33 x 50 mm). All of the signals from both bipolar electrodes were connected to a differential amplifier at a frequency response of 100 to 1,000 Hz. A computer stored and digitized all of the data, and displayed the wave forms. Before the initiation of extracorporeal circulation, the large card-type electrode was attached to the right atrial epicardial surface, and the small electrode was attached to the left atrial epicardial surface. Atrial mapping was then performed for both atria, and bipolar epicardial electrograms were recorded continuously on diskette for off-line signal processing by a computerized mapping system. Atrial epicardial wave forms for a 50-millisecond window were automatically produced and displayed sequentially. After all of the atrial epicardial electrograms were recorded with 60 seconds of acquisition, the local epicardial AF cycle length was calculated by measuring the interval between the steepest negative deflection of each activation point in a 10-second window. The AF cycle length was averaged to obtain the mean AF cycle length (MAFCL). After the MAFCL of 48 points was measured, the average MAFCL was calculated for each atrium and each local point in all 11 patients.

The epicardial activation wave form for both atria was then divided into two types: irregular activation (chaotic) and regular activation. Regular activation was defined as regular and repetitive epicardial electrograms at several points for each atrium. In contrast, irregular activation was defined as electrograms that were irregular in shape and duration at all points.

After the initiation of the cardiopulmonary bypass, a left vertical atriotomy was extended to the left margin of the left pulmonary veins. After excision of the left atrial appendage, cryoablation at -60°C was delivered for 1 minute to the posterior wall of the left atrium. The ablation was directed toward the incision ridge between the upper and lower left pulmonary veins, and to two areas of the posterior left atrial wall: from the left upper atrial incision edge into the posterior mitral valvular annulus, and from the left lower atrial incision edge into the center of the posterior mitral valvular annulus (Fig 1). No further atriotomies were performed on the atrial septum or right atrium. After completion of this procedure, the mitral valve operation was performed.

View larger version (32K): [in this window] [in a new window]   Fig 1. . Schema of the left atrial procedure. The four pulmonary veins (PV) were isolated and the left atrial appendage (LAA) was excised. Cryoablation (CRYO) (-60°C for 1 minute) was delivered to the posterior wall of the left atrium, between the superior and posterior edges of the LAA. (IVC = inferior vena cava; MV = mitral valve; RAA = right atrial appendage; SN = sinus node; SVC = superior vena cava; TV = tricuspid valve.)

The atrial epicardial mapping study and surgical procedure were performed after informed consent had been obtained from all patients, and were approved by the institutional review board for human studies.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
All of the patients survived without any serious complications. The characteristics of these patients and their atrial epicardial electrograms during chronic AF are summarized in Table 1. The pattern of the atrial epicardial electrogram was different in each case. However, the AF cycle seemed to be regular at several points in the left atrium, but was chaotic at all points in the right atrium in 7 of 11 patients. Figure 2 shows the lead III electrocardiograms and 8 of 48 bipolar epicardial electrograms recorded from both atria during chronic AF in a 71-year-old woman with mitral regurgitation (patient 3 in Table 1). In this patient, a regular activation sequence was repeated at several points in the left atrium, in contrast to the irregular and chaotic activation of the right atrium. The other 4 of 11 patients showed irregular activation in both atria. The activation pattern changed during the observation period, especially in the right atrium. The MAFCL ranged from 130 to 163 milliseconds in the right atrium and from 114 to 139 milliseconds in the left atrium. In all patients, the MAFCL of the left atrium was significantly shorter than that of the right atrium (p < 0.05) (Fig 3). Area mapping of the MAFCL revealed that the areas with the shortest cycle length area were the base of the left atrial appendage and the posterior wall lateral to the left pulmonary veins (Fig 4).

View larger version (54K): [in this window] [in a new window]   Fig 2. . Distribution of the epicardial electrodes (top) and surface electrocardiogram lead III and eight bipolar epicardial electrograms. The left atrium (LA) showed frequent, regular, and repetitive activation (points 6 and 8). In contrast, the right atrium (RA) showed irregular activation (points 1–4). (IVC = inferior vena cava; LAA = left atrial appendage; PV = pulmonary veins; RAA = right atrial appendage; SVC = superior vena cava.)

View larger version (22K): [in this window] [in a new window]   Fig 3. . (Top) Schema of the distribution of 48 epicardial electrodes and (bottom) mean atrial fibrillatory cycle length (MAFCL) of both atria. The MAFCL ranged from 130 to 163 milliseconds in the right atrium and from 114 to 139 milliseconds in the left atrium. (LA = left atrium; RA = right atrium.)

View larger version (29K): [in this window] [in a new window]   Fig 4. . Area mapping of the mean atrial fibrillatory cycle length (MAFCL) showed that the areas with the shortest cycle length area were the base of left atrial appendage (LAA) and the posterior wall lateral to the left pulmonary veins (shaded area). (IVC = inferior vena cava; LAA = left atrial appendage; PV = pulmonary veins; RAA = right atrial appendage; SVC = superior vena cava.)

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Although various concepts of reentry and ectopic foci have been proposed to explain the mechanism underlying AF [8–11], the real mechanism underlying chronic AF associated with mitral valve disease is still unknown. Recently, Harada and colleagues [5] demonstrated atrial activation during chronic AF in patients with isolated mitral valve disease, and discovered a regular and repetitive activation pattern in the left atrium and an intricate activation pattern in the right atrium. They also suggested that in the majority of these patients, chronic AF associated with isolated mitral valve disease might be caused by electrical discharges in the left atrium. Our study also demonstrated regular and repetitive activation of the left atrium in 7 of 11 patients with solitary mitral valve disease. Moreover, local epicardial atrial mapping showed that the atrial fibrillatory cycle length of the left atrium was shorter than that of the right atrium. This significant difference in the MAFCL between the left and right atria may be explained by the shorter refractory period of the left atrium, modulated in part by differences in autonomic innervation [12]. However, the exact mechanism of this difference during chronic AF remains unclear.

The use of the atrial fibrillatory cycle length as an index of the refractory period is based on the concept that during fibrillation, a wandering wavelet reexcites the atrial myocytes as soon as they recover their excitability [13, 14]. Morillo and colleagues [15] have devised a model of sustained atrial fibrillation, which was induced by chronic rapid atrial pacing using a canine heart. They reported that the AF cycle length of the left atrium was shorter than that of the right atrium. Furthermore, they demonstrated that cryoablation of this area significantly prolonged the AF cycle length of both atria, and successfully restored a sinus rhythm in most dogs (82%). Our procedure also ablated the electrical activation of the left posterior atrium, which had the shortest fibrillatory cycle length of either atria, and thus restored a sinus rhythm in most patients (91%). These findings suggest that the maintenance of chronic AF associated with isolated mitral valve disease may be related to an area localized to the posterior left atrium that can sustain these rapid atrial rates. Although there are many limitations to these electrophysiologic data, we can speculate that a shortened refractory period and conduction depression between both atria may play a role in the maintenance of chronic AF associated with isolated mitral valve disease.

Our procedure is easy to perform during the isolated mitral valve operation. However, the ablated left atrium could have become asystolic. Thus, we selected the ablation area of the left atrium carefully, and limited it to the four pulmonary veins and around the left atrial appendage. Cryoablation was then applied to the superior and inferior edges of the orifice of the left atrial appendage, and toward the mitral annulus to avoid injury to the posterior sinus nodal and circumflex coronary arteries. No other procedures were performed toward the right atrium or atrial septum; therefore, right atrial function could be preserved in all patients postoperatively, and left atrial function could be restored in most patients.

Although there is a risk of initiating an atrial flutter after this procedure [16], we did not encounter any cases of atrial flutter in this study. Recent studies [17, 18] have shown that the mechanism underlying common atrial flutter is a large reentrant circuit confined to the right atrium. It is unknown whether atrial flutter occurs easily after AF is terminated, but we had no cases of atrial flutter in this study. We believe that the cause of chronic AF is different from that of atrial flutter or paroxysmal AF in mitral valve disease. One problem with this procedure is that atrial flutter might occur in patients with tricuspid regurgitation, in whom an arrhythmogenic right atriotomy is necessary for tricuspid annuloplasty. Next, we applied a complementary cryoablation of the inferior vena cava-tricuspid annulus isthmus to protect the atrial flutter in patients who required a right atriotomy for tricuspid regurgitation.

It was possible to restore and maintain a sinus rhythm and bilateral atrial function in a large percentage of patients with long-standing AF secondary to isolated mitral valve disease. Our observations may facilitate the development of a surgical modality for ablating chronic AF associated with mitral valve disease.

Insight into the mechanisms underlying chronic AF associated with mitral valve disease is limited by the lack of extensive atrial mapping and interelectrode conduction-time data. Nonetheless, our clinical experience suggests that the left atrium acts as a driver to maintain chronic AF associated with mitral valve disease.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Sueda, First Department of Surgery, Hiroshima University, School of Medicine 1-2-3 Kasumi, Minami-ku, Hiroshima 734, Japan.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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