Ann Thorac Surg 2001;71:1044-1045
© 2001 The Society of Thoracic Surgeons
How to do it
Left atrial reduction and mitral valve surgery: the "functional-anatomic unit" concept
Ovidio A. García-Villarreal, MDa,
Humberto Rodríguez, MDa,
Alfonso Treviño, MDa,
Amadeu B. Gouveia, MDa,
Rubén Argüero, MDb
a Department of Cardiothoracic Surgery, Hospital Regional No. 34, Centro Médico Nacional del Norte, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, Mexico
b Department of Cardiac Surgery, Hospital de Cardiología, Centro Médico Nacional "Siglo XXI," Instituto Mexicano del Seguro Social, México DF, Mexico
Accepted for publication August 25, 2000.
Address reprint requests to Dr. García-Villarreal, Colón 301 sur, 66350, Santa Catarina, Nuevo León, México
e-mail: abelardog{at}sis.net.mx
 |
Abstract
|
|---|
The desired outcome for patients undergoing mitral valve surgery includes both good function of the mitral valve, and preservation and restoration of sinus rhythm. To achieve such an outcome, we evolved the concept of the left atrium and mitral valve as a "functional anatomic unit." In this report, we describe a technique for reduction in left atrial size, isolation of the pulmonary veins, and amputation of the left atrial appendage in combina-tion with mitral valve repair. We performed such a procedure in 4 patients, with rheumatic mitral valve disease and chronic atrial fibrillation, with restoration of good valve function and sinus rhythm at 16 to 20 months after surgery.
|
Introduction
|
|---|
Many patients undergoing mitral valve (MV) surgery also have atrial fibrillation (AF), particularly when the left atrium (LA) is significantly enlarged. MV repair or replacement often does not result in restoration of sinus rhythm. Moreover, recurrence of AF months or years after MV surgery may compromise an otherwise excellent functional result. Although other techniques have been described for the surgical treatment of atrial fibrillation [1–3], with or without concomitant MV surgery, many surgeons feel these operations are technically difficult and time-consuming. To address the combination of MV dysfunction and AF, we have considered the MV and the LA as a "functional anatomic unit" and have used an approach that is less complex than those previously described. Simply stated, it consists of MV repair or replacement combined with LA reduction, isolation of the pulmonary veins, and amputation of the LA appendage.
|
Technique
|
|---|
Median sternotomy was done. The aorta and inferior vena cava were cannulated using standard techniques. A right-angled cannula was placed into the superior vena cava (SVC) through a purse string suture well cephalad to the caval-atrial junction. We used normothermic cardiopulmonary bypass and continuous, warm, retrograde blood cardioplegia. The interatrial groove was developed and the SVC divided at least 3 cm cephalad to its entry into the right atrium. The LA was incised in the interatrial groove and extended across the roof of the LA and encircling the pulmonary veins (Fig 1A). The MV procedure was done and a second atrial encircling incision was made about 3 cm outside the first one and including the base of the LA appendage (Fig 1B). A circumferential band of LA tissue that included the LA appendage was obtained. The LA was reapproximated with continuous suture of 3-0 monofilament material (Fig 1C). The SVC anastomosis was performed with 5-0 monofilament running suture.
View larger version (47K):
[in this window]
[in a new window]
|
Fig 1. The left atrial reduction procedure. (A) Superior vena cava is sectioned and the first incision is performed surrounding all the pulmonary vein holes. (B) The dotted line indicates the second incision, around the mitral valve. (C) A strip of left atrial tissue with the left atrial appendage is excised, and the left atrium is closed.
|
|
|
Results
|
|---|
We have operated on 4 patients with rheumatic MV disease using this technique, 2 male and 2 female, with a mean age of 35.7 years (±12.8) at operation. All patients had chronic AF. Preoperative and postoperative LA measurements (by echocardiography) are shown in Table 1 and reflect a significant reduction in LA size from the procedure. Three of the patients had MV repair and 1 had MV replacement with a St. Jude prosthesis. Normal sinus rhythm was restored quickly after removal of the aortic cross-clamp in all cases. The mean times for cardiopulmonary bypass was 119 ± 15.8 minutes, and for aortic clamping was 97.5 ± 16.1 minutes. There were no hospital deaths or reoperations for bleeding. No A-V dissociation, sinus node dysfunction, or recurrence of AF were seen. All patients were extubated within 6 hours of surgery and the mean postoperative hospital stay was 6.5 ± 0.58 days. Antiarrhythmic therapy was discontinued 6 weeks after surgery. At a follow-up period of 16 to 20 months, all patients are New York Heart Association class I and all remain in sinus rhythm.
|
Comment
|
|---|
In many instances, MV surgery does not result in long-term relief of AF. The surgical techniques that have been proposed for the treatment of AF [1–3] are considered by many surgeons to be difficult and time-consuming, particularly when combined with a MV procedure. Additionally, these procedures are not designed to reduce LA size, a concept that has been felt to be important by Isobe and Kawashima [4]. They felt that an LA diameter of more than 80 mm was the most important factor in the recurrence of AF. Similarly, Kawaguchi and coworkers [5] have stratified patients with AF as being "maze-amenable" or "maze-refractory" based on their LA size, those having larger LA requiring some supplementary procedure at the time of MV surgery for effective treatment of their AF.
We have employed a simple concept in our 4 cases: reduction in LA size, and isolation of the entrance of the pulmonary veins and atrial appendage in combination with MV repair or replacement. In this limited experience, the procedures proved to be effective in alleviating AF and was not associated with mortality or significant morbidity. Two principles have been considered in the evolution of the described procedure: first, the orifices of the pulmonary veins and the atrial appendage are larger than normal, and, second, the LA itself is larger than normal. Cox and associates [3] felt that the size of the orifices leading into the LA were an important factor in the development, persistence, and recurrence of AF. These orifices have been isolated in the procedure described, thereby preventing the development of reentrant macrocircuits at these sites. Additionally, LA size has been significantly reduced.
In our limited experience, we have found this technique to be technically simple, quick to accomplish, and, most importantly, effective in relieving AF without adding to the mortality or morbidity of MV surgery alone. We encourage others to try this method.
|
Acknowledgments
|
|---|
We thank Mrs Rosalva García for her expert secretarial assistance, and Dr Luis I. Soto Montano for his assistance in translation of this manuscript. We are indebted to William Gay, MD, as Language Editor, for his expert help in the final version of this article.
|
References
|
|---|
-
Cox J.L. The surgical treatment of atrial fibrillation. IV. Surgical technique. J Thorac Cardiovasc Surg 1991;101:584-592.[Abstract]
-
Defauw J.J., Guiraudon G.M., van Hemel N.M., Vermeulen F.E., Kingma H., de Baker J.M. Surgical therapy of paroxysmal atrial fibrillation with the "corridor" operation. Ann Thorac Surg 1992;53:564-571.[Abstract/Free Full Text]
-
Cox J.L., Boineau J.P., Schuessler R.B., Kater K.M., Lappas D.G. Five-year experience with the maze procedure for atrial fibrillation. Ann Thorac Surg 1993;56:814-824.[Abstract/Free Full Text]
-
Isobe F., Kawashima Y. The outcome and indications of the Cox maze III procedure for chronic atrial fibrillation with mitral valve disease. J Thorac Cardiovasc Surg 1998;116:220-227.[Abstract/Free Full Text]
-
Kawaguchi A.T., Kosakai Y., Isobe F., et al. Surgical stratification of patients with atrial fibrillation secondary to organic lesions. Eur J Cardiothorac Surg 1996;10:983-989.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
O. A. Garcia-Villarreal and R. Gonzalez-Oviedo
eComment: The eternal dilemma of the left atrial appendage in the atrial fibrillation surgery
Interact CardioVasc Thorac Surg,
February 1, 2010;
10(2):
311 - 311.
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. O. Barbukhatti, S. Y. Boldyrev, G. N. Antipov, and V. A. Porhanov
First experience of cardiac autotransplantation for giant left atrium treatment
Interact CardioVasc Thorac Surg,
January 1, 2009;
8(1):
173 - 175.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Apostolakis and J. H. Shuhaiber
The surgical management of giant left atrium
Eur J Cardiothorac Surg,
February 1, 2008;
33(2):
182 - 190.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Zou, J. Kneller, L. J. Leon, and S. Nattel
Substrate size as a determinant of fibrillatory activity maintenance in a mathematical model of canine atrium
Am J Physiol Heart Circ Physiol,
September 1, 2005;
289(3):
H1002 - H1012.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. Kutay, K. Kirali, H. Ekim, and C. Yakut
Effects of Giant Left Atrium on Thromboembolism after Mitral Valve Replacement
Asian Cardiovasc Thorac Ann,
June 1, 2005;
13(2):
107 - 111.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. A. Romano, D. S. Bach, F. D. Pagani, R. L. Prager, G. M. Deeb, and S. F. Bolling
Atrial reduction plasty Cox maze procedure: extended indications for atrial fibrillation surgery
Ann. Thorac. Surg.,
April 1, 2004;
77(4):
1282 - 1287.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
O. A Garcia-Villarreal
Left Atrial Reduction: Isolation of the Pulmonary Veins
Asian Cardiovasc Thorac Ann,
June 1, 2002;
10(2):
198 - 198.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
