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Ann Thorac Surg 1998;66:256
© 1998 The Society of Thoracic Surgeons

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Original articles: general thoracic

Invited commentary

^a Division of Cardiothoracic Surgery, Department of Surgery, Hannover Medical School, Carl Neuberg Str 1, 30623 Hannover, Germany

	Invited commentary

Top Invited commentary

 
The case reported by Sankar and Farnsworth concerns a left atrial reduction operation in combination with mitral valve replacement and coronary revascularization that succeeded in converting preoperatively long-lasting atrial fibrillation into sinus rhythm.

The communication focuses on the surgical technique for reduction of left atrial mass in patients with a left atrium that is severely enlarged secondary to mitral valve disease. The operative concept incorporates pulmonary vein isolation by a circumferential incision, the site where a ring of atrial tissue is removed, and amputation of the left atrial appendage.

Not all left-sided incisions of the maze III procedure are included in this approach; therefore, reentrant circuits within the atrial wall remain possible. It appears clinically significant, however, that the common site of atrial reentry around and atrial ectopic activity at the orifices of the pulmonary veins are excluded from the propagation of the atrial wave front.

Pulmonary vein isolation has been shown to decrease the susceptibility to fibrillation in atria of normal size. The tailoring of the left atrium by removal of a ring of atrial tissue at this site extends this approach toward patients with "giant left atria." This represents an especially valuable aspect of this concept, because this subgroup of patients has been reported to exhibit an increased risk for persistence or recurrence of atrial fibrillation after the maze III procedure.

The different surgical options in patients with chronic atrial fibrillation vary not only with regard to electrophysiologic concept and surgical technique, but also with regard to the underlying disease and the patient’s individual characteristics. The complete inhibition of atrial reentry is unique to the maze III procedure and makes it amenable to patients with idiopathic or "lone" atrial fibrillation and patients with valvular disease as well. Limited left-sided approaches are targeted to patients with mitral valve disease and aimed to represent measures of reduced complexity for combination with concomitant surgical procedures.

The important question, which group of patients benefits most from the different approaches, can only be answered by a prospective comparison of the available surgical techniques. This comparison should focus on the clinical outcome, including control of atrial rhythm and procedure-related morbidity. Answers to these questions would also provide additional rationale regarding the general issue of surgical treatment of atrial fibrillation beyond the exclusion of the left atrial appendage for prevention of systemic embolism. Evaluation of their clinical significance and their prognostic impact seems to be necessary for a broadening acceptance and application of these techniques.

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