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Ann Thorac Surg 1997;63:1070-1075
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Efficacy of a Simple Left Atrial Procedure for Chronic Atrial Fibrillation in Mitral Valve Operations

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

Accepted for publication October 31, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. We have devised a simple surgical procedure to be performed on the posterior wall of the left atrium for the treatment of chronic atrial fibrillation (AF) associated with mitral valve disease. The effectiveness of this procedure for serial mitral valve operations was then evaluated. We postulated that chronic AF associated with mitral valve disease could be attributable to a distended left atrium. The refractory period of the distended left atrium was significantly shorter in the left posterior atrial wall, especially at the base of the left atrial appendage and at the orifice of the left posterior pulmonary vein. We hypothesized that the left posterior atrial wall with its shorter fibrillatory cycle length would act as a driver for maintaining the AF, and therefore, surgical ablation of this critical area in the left atrium could terminate the chronic AF.

Methods. The surgical patients were divided into two groups. In group 1 (control group), 15 patients with chronic AF were operated on by the mitral valve procedure only. In group 2, 36 patients underwent this procedure in combination with a concomitant mitral valve operation. The disappearance rate of the AF was estimated by electrocardiography, and atrial function was estimated by transthoracic and transesophageal echocardiography.

Results. The chronic AF had been reduced significantly or eliminated at discharge in 4 of 15 patients (26.7%) in the group 1, versus 31 of 36 patients (86%) in group 2 (p < 0.05). In group 2, 29 of the 31 patients (94%) whose AF had disappeared recovered the atrial kick of their right atrium, and 21 patients (22/31; 71%) recovered the atrial kick of their left atrium.

Conclusions. Surgical ablation of the posterior wall of the left atrium was effective in the treatment of chronic AF associated with mitral valve disease. This simple procedure could restore a sinus rhythm and also recovered atrial systolic function. We conclude that the left atrium may act as a driver for sustaining AF in mitral valve disease.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Atrial fibrillation (AF) is present in the majority of patients with mitral valve disease who require operation [1]. The prevalence of AF increases with the patient's age, functional class, duration of mitral valve disease, and left atrial size [2–4]. The pathogenesis of atrial fibrillation associated with mitral valve disease is still equivocal. Most investigators agree that rheumatic inflammation and an increased hemodynamic burden cause an increase in tissue fibrosis; consequently, a nonhomogenous distribution of diastolic depolarization potentials, refractory periods, and conduction properties occurs within the atrial muscle [5–7]. All of these factors enhance the probability of reentry circuits forming around areas with longer refractory periods. A critical atrial area zone appears to be necessary for the AF to endure, which explains the greater incidence of AF in patients with larger atrial chambers.

Several researchers have reported that after a mitral valve operation, AF recurs in 80% of those patients with long-standing AF [8, 9]. Therefore, combined treatment for both mitral valve disease and AF has been performed by the maze procedure [10], which has been reported to eliminate idiopathic AF. However, the real mechanisms responsible for AF associated with mitral valve disease are still unknown. Harada and colleagues [11] recently reported atrial activation during chronic AF in patients with isolated mitral valve disease, and suggested that in the majority of these patients, the chronic AF associated with isolated mitral valve disease might be caused by electrical discharges in the left atrium. Our previous electrophysiologic study performed on patients with isolated mitral valve disease and chronic AF showed a shortened refractory period of the posterior left atrial wall, and a surgical procedure performed only on the posterior wall of the left atrium was adequate in eliminating the AF associated with isolated mitral valve disease [12]. We then decided to perform this simple surgical procedure for chronic AF during mitral valve operation, with or without other valvular regions. This article reports the efficacy of this procedure for the treatment of chronic AF associated with mitral valve disease in serial mitral valve operations.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Fifty-one patients with mitral valve disease and chronic AF were operated on during the past 51 months. The patients included 18 men and 33 women, ranging in age from 46 to 82 years (average, 60.4 years). These patients were divided into two groups: group 1 (15 patients), the control group received the mitral valve operation before February 1993. At that time, the AF operation had not been introduced in our institute. In group 2, 36 patients received a combined operation for both the mitral valve disease and the AF after March 1993. The underlying valvular disease, AF duration, and combined cardiac disorders are summarized in Table 1. The patient's age, AF duration, and underlying valve disease were similar in the two groups. Electrocardiography revealed a fine or coarse shape of the AF wave in the precordial lead (V₁). Preoperative transesophageal echocardiography was also performed to examine both the atrial size and the presence of any left atrial thrombi.

View larger version (27K): [in this window] [in a new window]   Fig 1. . Schema of the left atrial procedure. A left vertical atriotomy was extended to the left margin of the left pulmonary veins. After the excision of the left atrial appendage, cryoablation was delivered at -60°C for 2 minutes to the posterior wall of the left atrium. The cryoablation was directed toward the incision edges 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. (black areas = cryoablation; dashed lines and hatched areas = incision and suture line; CS = coronary sinus; IVC = inferior vena cava; LAA = left atrial appendage; MV = mitral valve; PV = pulmonary vein; RAA = right atrial appendage; SA = sinus node; SVC = superior vena cava; TV = tricuspid valve.)

View larger version (28K): [in this window] [in a new window]   Fig 2. . Schema of the concomitant right atrial procedure for tricuspid regurgitation. A typical right vertical atriotomy was performed, and cryoablation was delivered at -60°C for 2 minutes to the posterior isthmus between the tricuspid annulus and the orifice of the inferior vena cava to prevent a postoperative atrial flutter. (black areas = cryoablation; dashed line and hatched areas = incision and suture line; CS = coronary sinus; IVC = inferior vena cava; LAA = left atrial appendage; MV = mitral valve; PV = pulmonary vein; RAA = right atrial appendage; SA = sinus node; SVC = superior vena cava; TV = tricuspid valve.)

Postoperative transthoracic and transesophageal echocardiography was also performed to measure the size of the atria, and to confirm the presence of an atrial kick for the assessment of the atrial transport function at 1 month after the operation. All echocardiograms were recorded by a Toshiba GGH-65A ultrasound system with a 2.5-MHz precordial transducer and a 2.5-MHz transesophageal transducer. An electrocardiogram was taken every 3 months after operation for prognostic analysis. The follow-up period ranged from 2 to 51 months (average, 18 months).

The results were recorded as means ± standard deviation, and statistical significance was calculated using Student's t test for unpaired observations and by the ² test. A p value less than 0.05 was considered to be statistically significant.

The left atrial procedure was performed after informed consent had been obtained from each patient, and was approved by the institutional review board for human studies.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
All patients survived without serious complications. The concomitant valve operations included 11 mitral valve replacements, 5 mitral valve repairs, 19 mitral valve replacements + tricuspid valve annuloplasties, 8 mitral valve replacements + aortic valve replacements, and 8 mitral valve replacements + aortic valve replacements + tricuspid valve annuloplasties. Another cardiac procedure was also performed in some patients (Table 2).

In group 1 (without AF operation), only 5 patients (35%) showed a sinus rhythm immediately after operation. Three of these 5 patients (60%) returned to the AF rhythm within 7 days after operation, and multiple attempts at cardioversion were delivered during their hospital stay. Four of the 15 patients (27%) had a sinus rhythm restored at discharge. During the follow-up period, 1 patient returned to AF and only 3 patients (20%) had a sinus rhythm restored postoperatively. One patient required a VVI pacemaker because of bradycardia with the AF. In group 2 (with AF operation), all of the patients showed an electrocardiogram with a normal sinus or nodal rhythm immediately after operation. In 26 patients (72%), this sinus rhythm continued without any paroxysmal AF episodes. The other 10 patients demonstrated a recurrence of their paroxysmal AF within 7 days after operation. In 5 of these patients (50%), the AF disappeared after cardioversion or an antiarrhythmic agent (disopyramide or quinidine), or a combination of treatments. Five patients (5 of 36; 14%) were resistant to two attempts of electrical cardioversion, and had demonstrated a return to sustained AF (4 patients) or atrial flutter (1 patient) at discharge. The overall disappearance rate for the AF and atrial flutter (31 of 36 patients) was 86% at discharge; the disappearance rate was significantly higher in group 2 (p < 0.05). During the postoperative follow-up, 2 patients demonstrated a return to AF by 6 months after operation, and 1 patient demonstrated paroxysmal AF and an atrial flutter despite the administration of antiarrhythmic drugs (Table 3). The other 28 patients (78%) maintained their sinus rhythm or a regular nodal rhythm despite episodes of atrial tachycardia or supraventricular premature beating. A dual chamber pacemaker (DDD mode) was implanted in 2 patients (6%) with sinus or nodal bradycardia postoperatively. Preoperative and postoperative echocardiograms showed a mean dilation of the left atrium of 54.6 ± 5.9 mm in group 1, which decreased in diameter to 50.7 ± 8.5 mm postoperatively. In group 2, the diameter decreased from 53.8 ± 9.9 mm preoperatively to 43.7 ± 7.2 mm (p < 0.05) postoperatively (Table 3).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Atrial fibrillation is one of the most prevalent arrhythmias, and is observed at some stage in up to 79% of surgical patients with mitral valve disease [1]. Although the surgical correction of mitral valve lesions reduces the left atrial size and improves the hemodynamic status once the chronic AF has developed, the mitral valve operation itself rarely stops the arrhythmia [13, 14]. Our data also revealed that the rate of recovery of a sinus rhythm was much higher in those patients who underwent AF operation than in those who did not (disappearance rate 27% in the control group versus 86% in the AF operation group at discharge). Patients with mitral valve disease usually have other factors predisposing to AF, such as old age [2], cardiomegaly, increased atrial size, especially of the left atrium [4], and tissue fibrosis [5]. These factors tend to result in persistent AF even after a successful mitral valve operation. Except for those patients with a recent onset of AF [15], specific surgical intervention is mandatory to reverse the AF resulting from mitral valve disease. Because the restoration of an atrial rhythm and an improved long-term prognosis are desirable, we initiated this surgical intervention for patients with chronic AF undergoing mitral valve operations.

Recently, several attempts at eliminating AF have been reported. The corridor operation is one method for a surgical cure for AF [16]. Theoretically, fibrillatory impulses are separated from sinus impulses after this operation, and the AF no longer influences the ventricular rate. However, a major portion of the atrium is excluded from sinus impulses and thus remains fibrillatory or silent and provides no synchronous atrial contraction. When the atrial kick is lost, cardiac hemodynamic function is compromised.

The maze procedure is the newest procedure for the surgical cure of atrial fibrillation [17, 18]. This method is effective in both converting the sinus rhythm and in regaining atrial contractility in the majority of patients. Although this procedure has been devised for the surgical cure of idiopathic AF, such as AF with Wolff-Parkinson-White syndrome, it has proven to be effective for chronic AF associated with mitral valve disease [10]. According to the multiple wavelets theory described by Moe [19] and Allesie and colleagues [20], this method should be ideal for eliminating AF in both atria. However, the maze procedure is meticulous and time consuming, and takes a longer extracorporeal circulation time, especially when other cardiac procedures are required simultaneously. Therefore, we attempted to devise a simpler procedure for eliminating AF and attempted to examine the mechanisms responsible for chronic AF associated with mitral valve disease.

Although various concepts of reentry and ectopic foci have been proposed to explain the mechanisms underlying idopathic AF [3–8], the real mechanisms underlying chronic AF associated with mitral valve disease are still unknown. Recently, atrial activation during chronic AF was demonstrated by Harada and co-workers [11] in patients with isolated mitral valve disease. They 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, the chronic AF associated with isolated mitral valve disease might be caused by electrical discharges in the left atrium. Our electrophysiologic study [12] also demonstrated the regular and repetitive activation of the left atrium in 7 of the 11 patients (64%) with isolated 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 in all patients, and that the areas with the shortest cycle length were the base of left atrial appendage and the posterior wall lateral to the left pulmonary veins. In addition, there was a tendency in patients with larger left atria to have a shorter atrial fibrillatory cycle length of the left atrium. Morillo and colleagues [21] devised a new canine model of sustained AF, which was induced by chronic rapid atrial pacing. They reported that the atrial fibrillatory cycle length of the left atrium was shorter than that of the right atrium, and demonstrated that cryoablation to the left posterior wall of the left atrium significantly prolonged the atrial fibrillatory 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 wall of the left atrium, which had the shortest fibrillatory cycle length of either atria, and thus restored a sinus rhythm in most patients. These findings suggest that the maintenance of the chronic AF associated with mitral valve disease may be related to an area localized to the left atrium that can sustain rapid atrial rates. We speculate that a shortened refractory period and conduction depression between both atria may play a role in the maintenance of the chronic AF associated with mitral valve disease. Although we have operated on very few patients with idiopathic AF, this procedure was also effective for chronic AF in 3 patients with hypertrophic cardiomyopathy and aortic insufficiency without mitral valve disease. This procedure might also be effective in eliminating idiopathic AF.

Atrial fibrillation can be treated by a left atrial procedure alone, but there is a risk of initiating an atrial flutter after this procedure as Brodman and colleagues [22] pointed out. Therefore, we used an additional cryoablation at the inferior vena cava-tricuspid annulus isthmus to protect the origin of the atrial flutter in those patients who required a right atriotomy and tricuspid annuloplasty for tricuspid regurgitation. A recent study on atrial flutter showed that the inferior vena cava-tricuspid annulus isthmus was critical in maintaining the atrial flutter, and that catheter ablation of this site was successful in eliminating atrial flutter [23]. We postulated that cryoablation of this isthmus alone might be sufficient to protect against atrial flutter, instead of the meticulous incision of the right atrium and atrial septum used in the maze procedure. Postoperatively, we encountered 2 patients (5.6%) with atrial flutter in 36 patients. In 1 patient, the atrial flutter disappeared after the administration of an antiarrhythmic drug, whereas the other patient had a sustained, slow atrial flutter (4:1 conduction rate) that subsequently required the insertion of a ventricular pacemaker because of bradycardia. Therefore, the reappearance of an atrial flutter was rare after this procedure and was easy to manage using medication or pacemaker implantation.

This study has certain limitations. Insight into the mechanisms leading to the chronic AF associated with mitral valve disease in this series was limited by a lack of extensive electrophysiologic data. Nonetheless, the left atrial procedure was adequate in eliminating AF in the majority of mitral valve patients.

In conclusion, it was possible to restore and maintain a normal sinus rhythm and dual atrial function in a large percentage of patients with long-standing AF secondary to mitral valve disease. Our preliminary observations are encouraging for using this new approach in eliminating 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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