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Ann Thorac Surg 2001;71:577-581
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Clinical analysis of results of a simple left atrial procedure for chronic atrial fibrillation

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

Accepted for publication June 6, 2000.

Address reprint requests to Dr Imai, First Department of Surgery, Hiroshima University School of Medicine 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
e-mail: kimai{at}mcai.med.hiroshima-u.ac.jp

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Background. We have performed a simple left atrial procedure for eliminating chronic atrial fibrillation (AF) associated with mitral valve disease. This article analyzes the midterm results of this procedure.

Methods. Thirty-two patients were enrolled in this study concomitant with mitral valve operations. Patients were divided into two groups (AF- and AF+). We examined the efficacy of this operation and atrial function for more than 12 months of follow-up.

Results. In a total of 98.5 patient years of follow-up, AF was absent 3 years after operation in 74%. Of preoperative and intraoperative variables, only long duration of AF was a predisposing factor for recurrence of AF (p < 0.05). In the AF- group, 5 patients (21%) showed atrial tachycardia or flutter and 5 (21%) needed postoperative pacemaker implantation. An A wave was detected in 60% across the mitral valve and 100% across the tricuspid.

Conclusions. A simple left atrial procedure is effective for chronic AF with mitral valve disease and restores atrial transport function during midterm follow-up. However, other atrial arrhythmias occur in some patients postoperatively.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia in the adult population [1], and is especially common in patients with mitral valve disease. Operations on the atria aimed to prevent or interrupt AF have been developed in several institutes: left atrial isolation [2, 3], corridor operation [4, 5], Cox’s maze procedure [6] and its modification [7–9], with satisfactory results in short-term follow-up. For lone AF, the long-term results of these treatments have been evaluated sufficiently [10–12]. Similarly, atrial and sinus node function after surgical procedures against AF associated with organic heart diseases should be determined as well as the late postoperative phase probably because of the late recovery of these functions [13, 14]. However, it has not been fully evaluated, especially in cases with valvular heart disease.

Since 1993 we performed simple left atrial procedures in patients with chronic AF combined with mitral valve disease and have described its initial outcome [15]. The purpose of this study is to present the midterm results of this procedure for at least a 1-year follow-up.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Patient population
Since February 1993 we underwent the simple left atrial procedure combined with mitral valve repair and replacement for the patients with chronic AF associated with mitral valve disease. Postoperative follow-up for longer than one year was available in 32 of those patients in whom the analysis hereafter was done. Table 1 shows the profiles of these patients. There were 17 men (53%) and 15 women (47%) with an average age of 64 years (range, 47 to 82 years). All patients had chronic AF refractory to medical treatments for 5 months to 25 years (average, 9.3 years). Fourteen of these patients had rheumatic mitral stenosis with or without mitral regurgitation, and 18 had mitral regurgitation secondary to degenerative valvular disease. In eight patients (25%), concomitant surgical intervention was only mitral valve replacement, whereas in other patients it involved nine tricuspid annuloplasty (TAP, 28%), six aortic valve replacements (19%), one coronary artery bypass grafting (3%), one closure of patent foramen ovale-closure (PFO-closure, 3%), five TAPs with aortic valve replacements (16%), one TAP with coronary artery bypass grafting (3%), one TAP with PFO-closure (3%), one TAP with ligation of patent ductus arteriosus (3%), and one TAP and aortic valve replacements with coronary artery bypass grafting (3%). Two patients with AF already had permanent pacemaker implantation because of symptomatic bradycardia before the operation.

View larger version (30K): [in this window] [in a new window]   Fig 1. Schema of the simple left atrial procedure. The four pulmonary veins with a part of the left atrium were isolated with surgical incision and cryoablation (gray line), and the left atrial appendage was excised. The other two ablation lines between the encircling line of pulmonary veins and the posterior mitral valvular annulus were added. (CR = cryoablation; IVC = inferior vena cava; LAA = left atrial appendage; MV = mitral valve; PVs = pulmonary veins; SVC = superior vena cava.)

After discharge, all patients were followed up every 3 to 6 months. Antiarrhythmic agents of class I or IV of Vaughan Williams classification and digitalis were given in all patients postoperatively, and discontinued at 3 to 6 months after the operation. Patients with atrial arrhythmia continued these medications. The patients were divided into sinus rhythm (SR) group and recurred AF group, based on cardiac rhythms of the latest follow-up. The SR group was without AF and regained sinus rhythm postoperatively. The AF group had recurred AF postoperatively or during the follow-up period. The patients that received pacemaker implantation for sinus bradycardia or paroxysmal atrial tachycardia, or both, were divided into the SR group. Between these two groups, the preoperative profiles and intraoperative variables were compared. The following data were collected at the latest follow-up: cardiothoracic ratio and echocardiographic indices including Doppler flow studies (left atrial diameter, ejection fraction, and atrial kick on transmitral and transtricuspid flow). Patients were questioned about their medications and any postoperative occurrences of supraventricular arrhythmia at the latest follow-up.

Informed consent and statistical analysis
The informed consent for this surgical procedure eliminating AF and postoperative follow-up study was obtained from each patient. All values are expressed as means ± standard deviation. All collected data were entered into a database. Continuous variables were compared using the nonparametric Mann-Whitney U test. Proportions were compared with Fischer’s exact test. A p value less than 0.05 was considered to be statistically significant. Time-dependent morbidity was tabulated univariately by a Kaplan-Meier life-table with the end points of recurrence of sustained atrial fibrillation. The statistical analysis was performed using the StatView J-4.5 software package (Abacus Concepts, Inc, Berkeley, CA).

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Operative procedure, mortality, and morbidity
Simple left atrial procedure for chronic AF was completed in every patient. Duration of cardiac arrest ranged from 74 to 172 minutes (124 ± 27 minutes) and that of cardiopulmonary bypass from 120 to 268 minutes (191 ± 33 minutes). No patient required postoperative circulatory support such as intraaortic balloon pumping, and there was no reexploration for postoperative hemostasis.

There was no postoperative mortality. The follow-up period ranged from 13 to 66 months (36.9 ± 14.1 months) with a total of 98.5 patient-years. No patient had any cerebral thromboembolic complications postoperatively.

Recurrence of atrial fibrillation
Five of 32 patients had persistent AF after the operation. Three of 32 patients developed AF at a later time (1 patient, 6 months after the operation and 2 patients, 17 months after the operation); however, they did not have AF immediately after the operation. At final follow-up, 24 of 32 patients (75%) remained free from chronic atrial fibrillation. The actuarial proportion of patients without recurrence of AF at 3 years after the operation was 74.5% (59.2% to 89.8%: 95% confidence intervals) (Fig 2).

View larger version (12K): [in this window] [in a new window]   Fig 2. Midterm freedom from atrial fibrillation (AF). Results of midterm follow-up on patients with successful simple left atrial procedures displaying the actuarial proportion of patients freedom from AF (95% confidence intervals). The box at the bottom of the figure indicates the number of patients studied.

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
A simple surgical procedure [15] was developed in our institute to ablate only the left atrium against chronic AF. The concept of this procedure is based on the electrophysiological evidence that chronic AF associated with mitral valve disease might be caused by the shortened refractory period of the distended left atrium [16] and the left atrium might act as an electrical driving chamber for chronic AF with mitral valve disease [17]. The purpose of this study was to clarify the midterm results of simple left atrial procedure for chronic AF.

The actuarial eliminating rate of AF was 74% at 3 years after this operation in a total follow-up of 98.5 patient- years. Chua and colleagues [18] described their experience with 97 patients for chronic AF and mitral valve insufficiency, with approximately 20% of these patients having regained sinus rhythm after successful valve repair. Though our study did not have matched set of patients from a single institution, the AF eliminating rate of this study was higher than that without procedures against AF. Late results of other surgical procedures against AF with organic valvular disease have seldom been reported. Graffigna and colleagues [3] reported their experience with eighty-eight left atrial isolation procedures for chronic AF combined with mitral valve operations, with 72% of patients in sinus rhythm after an average follow-up of 14 months. Kosakai and colleagues [9] described their outcomes with sixty-two modified Cox maze procedures; 84% of patients regained atrial rhythm in a total of 65 patients per year followed-up. In the small series of patients (n = 30) treated with the original cut and suture Cox maze III procedure, Isobe and colleagues [19] reported restoration in sinus rhythm from AF with mitral valve disease in 90% of their patients after a mean follow-up of 25 months.

Although the Cox maze procedure and its modification procedures have been adopted by many surgeons because of their excellent outcomes, there might arise an elongation of aortic cross-clamp time and postoperative hemostasis [9] because they have numerous incision lines especially on the right atrium and atrial septum. We did not have any intraoperative or postoperative complications in our series because of the ease in performing the mitral valve operations with only one incision line.

New supraventricular arrhythmias occurred postoperatively in more than 20% of the SR group even after AF was eliminated. We supposed that progression of preexisting tissue abnormalities might lead to the advent and transition to atrial tachycardia or flutter from chronic atrial fibrillation. van Hemel and coworkers [12] reported after corridor operation against lone AF that new atrial arrhythmia such as atrial flutter or tachycardia appeared in 8 of 26 patients (31%) without recurrence of AF during 4 years follow-up. They speculated that the atrial substrate for chronic AF could also be a precipitating factor for the onset of new atrial arrhythmias. Isolated atrial hypertrophy or degenerative changes have been documented in diseased patients with AF [20]. Furthermore, we assume that fibrotic and calcific degeneration of the atrial myocardium as a result of marked dilatation or rheumatic change is more severe in cases with overt valvular heart disease.

We perfomed a postoperative electrophysiologic study and subsequent radiofrequency catheter ablation on 2 patients in our series. Atrial flutter was refractory to cardioversion or antiarrhythmic agents. Endocardial mapping in one patient demonstrated rapid atrial activation around the tricuspid annulus; it was responsible for atrial flutter since catheter ablation for the isthmus eliminated atrial flutter. In the other patient, the atrial mapping showed rapid reentrant activation around the mitral annulus. Incomplete cryoablation can be responsible for this reentrant tachycardia. Because catheter ablation failed to ablate the circuit around the mitral valve annulus, modification of atrioventricular node and implantation of a permanent pacemaker were performed to keep regular rhythm.

Because atriotomies in the original maze procedure [6] transect all major variations of the human sinus node arteries, Cox [7] and other surgeons [9, 18] modified atriotomies or used cryoablation, or both, to avoid disrupting the arterial blood supply to the sinus node. In their series, the incidence of sick sinus syndrome, which necessitated the implantation of a pacemaker, was 3.2% to 25%. On the other hand, after left atrial isolation there were no patients of sinus bradycardia or sinus arrest that required pacemaker implantation [3]. In our series, 5 patients needed a pacemaker (21%), although 3 of 5 were not symptomatic. We implanted a dual-chamber pacemaker to increase cardiac output in these 5 patients, even in patients without symptoms of bradycardia (vertigo, palpitation).

Restoration of atrial contribution to ventricular filling is another important purpose of this operation. In the SR group, atrial contraction was detected in 60% of the left atria and in 100% of the right atria. In addition, atrial kick became detectable at the transmitral flow in 3 of 5 patients with continuous atrial pacing. According to the study from healthy patients [21], the difference between transmitral A/E ratio and transtricuspid A/E ratio was not significant; however, the transmitral A/E ratio was still lower than the transtricuspid in our series. The ablation to the left atrium was limited to the orifice of four pulmonary veins and around the left atrial appendage and there were no incisions added toward the right atrium and atrial septum. This could be responsible for better preservation of right atrial function then that of left atrial function. We suppose that the difference between two atria might be due to more severe injury of the left atrial myocardium as a result of the mitral valve disease.

Prevention of thromboembolic events is another important aim of the procedures for AF. In our study, no patient had any thromboembolic complications postoperatively, even without anticoagulant therapy, although, most patients had warfarin because of combined mitral valve replacement. It is necessary to examine the effect of avoiding thromboembolism in a larger series of mitral valve repair associated with simple left atrial procedure.

A limitation of this study is the small sample size and the associated low statistical power. In particular there is not much statistical power to evaluate the association between the variables in Table 2 and whether AF persists after an operation. This means that important predictors may have turned out to be nonsignificant in the large sample size.

In conclusion, midterm results of simple left atrial procedure for chronic AF with mitral valve disease shows efficacy for elimination of AF associated with mitral valve disease in most cases at the midterm follow-up period. Some patients necessitated pacemaker implantation or catheter ablation procedures. Most patients free from AF could escape from thromboembolic events and regain the transport function of both atria. A further investigation is mandatory, including a longer-term follow-up and electrophysiological studies to determine more accurately the indication for this procedure.

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/section/atsdiscussion/

	References

Top Footnotes Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Online Discussion Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kazumasa Orihashi Yuichiro Matsuura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Imai, K. Articles by Matsuura, Y. Search for Related Content PubMed PubMed Citation Articles by Imai, K. Articles by Matsuura, Y. Related Collections Electrophysiology - arrhythmias