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Right arrow Electrophysiology - arrhythmias

Ann Thorac Surg 2001;71:1189-1193
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Efficacy of pulmonary vein isolation for the elimination of chronic atrial fibrillation in cardiac valvular surgery

Taijiro Sueda, MDa, Katsuhiko Imai, MDa, Osamu Ishii, MDa, Kazumasa Orihashi, MDa, Masanobu Watari, MDa, Kenji Okada, MDa

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

Accepted for publication October 30, 2000.

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


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. Haissaguerre and colleagues emphasize the importance of the pulmonary veins as a source of ectopic foci for initiating paroxysmal atrial fibrillation (AF). We hypothesized that ectopic foci from the pulmonary veins could also act as drivers for maintaining chronic AF, and that surgical ablation of the pulmonary vein orifices could terminate chronic AF.

Methods. Using a computerized 48-channel mapping system, we performed intraoperative atrial mapping in 12 patients with chronic AF associated with mitral valve disease. Patient age ranged from 24 to 82 years (mean, 60.4 years). AF duration ranged from 3 to 240 months (mean, 92 ± 84 months). Simple surgical isolation of the pulmonary vein orifices was performed during the mitral valve operation.

Results. Regular and repetitive activation was found in the left atria of 9 out of 12 patients, and irregular and chaotic activation was found in both atria of 3 out of 12 patients. Chronic AF in the 9 patients (75%) with regular and repetitive activation of their left atria was successfully treated by a simple surgical isolation of the pulmonary vein orifices. The other 3 patients did not recover sinus rhythm after this procedure. In 1 case of recurrent AF, the patient recovered sinus rhythm during the follow-up period (AF-free rate, 83%).

Conclusions. Surgical ablation of the pulmonary vein orifices was effective in the treatment of chronic AF associated with mitral valve disease. Intraoperative mapping may be useful in predicting the efficacy of a single pulmonary vein orifice isolation procedure.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Atrial fibrillation (AF) is the most prevalent arrhythmia, and is common in patients with mitral valve disease [1]. The Maze procedure is usually performed to eliminate the AF in cases with mitral valve disease [2]. We postulated that the chronic AF associated with mitral valve disease was caused by a distended left atrium, and that a simple surgical procedure performed on the left posterior wall of the left atrium would be effective in eliminating the chronic AF associated with mitral valve disease [3]. Recently, Haissaguerre and coworkers reported a focal source of paroxysmal AF originating from the pulmonary veins [4], and suggested this to be a focal source in many cases with paroxysmal and persistent AF. We have also reported the regular activation of the left atrium during chronic AF with mitral valve disease [3]. On the basis of the observations by Haissaguerre and associates, we speculated that this regular activation might originate from the pulmonary veins. We therefore modified our previous left atrial procedure, and performed a surgical isolation of the pulmonary vein orifices only in order to eliminate the chronic AF during cardiac valve surgery. In this study, we evaluated the efficacy of this isolation of the pulmonary vein orifices plus simple intraoperative atrial mapping.


   Material and methods
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 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Twelve patients with mitral valve disease and chronic AF were operated on during the past 14 months. The patients consisted of 4 men and 8 women, and ranged in age from 24 to 82 years (average, 60.4 years). The underlying valvular disease, AF duration, left atrial diameter, ejection fraction, and other factors are summarized in Table 1.


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  		Table 1. Characteristics of the Patients With Chronic Atrial Fibrillation Associated With Mitral Valve Disease

 
Before the institution of a cardiopulmonary bypass, intraoperative atrial mapping was performed with two card-type mapping electrodes and a Fukuda electronic mapping system (Fukuda model HPM-7100, Tokyo, Japan). The 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 (33 x 50 mm). Two card-type electrodes were attached to the left atrial epicardial surface (between the left atrial appendage and the left pulmonary vein) and the right 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. All of the differential amplifiers had a frequency response of 10 to 100 Hz. A computer stored and digitized all of the data, and displayed the wave forms. Atrial epicardial wave forms for a 50-millisecond window were produced automatically, and were displayed sequentially. After all of the atrial epicardial electrograms had been recorded for 60 seconds, the local epicardial AF cycle length was calculated by measuring the interval between the steepest deflection of each activation point in a 10-second window. The AF cycle length was averaged to obtain the mean AF cycle length (MAFCL). The epicardial activation wave form for both atria was then divided into two types: irregular and chaotic activation, and regular and repetitive activation. All of the atrial electrophysiological studies were performed in the operating room.

After the initiation of a cardiopulmonary bypass, the body temperature was maintained at 33°C. The aorta was clamped, and cold blood cardioplegia was infused for myocardial protection. A right-sided vertical incision in the left atrium was extended to the left margin of both left pulmonary vein orifices. Complementary cryoablation was then applied to the remnant of the circular incision between the left upper pulmonary vein and the left lower pulmonary vein, instead of to the entire circular incision. Consequently, all of the pulmonary vein orifices were electrically isolated. In those cases where there was a mural thrombus in the left atrial appendage, the mural thrombus was excised and the orifice of the left atrial appendage was closed with a running suture (Fig 1). No further atriotomy procedures were performed on the atrial septum or the right atrium. After the completion of this procedure, mitral valve surgery with or without other valve procedures was performed, and the isolated area around the pulmonary vein orifices was anastomosed using running sutures. Antiarrhythmic drugs (digoxin 0.25 mg/day and disopyramide 300 mg/day) were administered to all patients until the time of discharge.



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  		Fig 1. Schema of the procedure. A right-sided vertical atriotomy on the left atrium was extended to the left margin of the left pulmonary vein orifices. Complementary cryoablation (-60°C, 3 minutes) was then applied to the remnant of the left atrial wall between the left upper pulmonary vein orifice and the left lower pulmonary vein orifice. (SN = sinus node; TV = tricuspid valve; RA = right atrium; RAA = right atrial appendage; MV = mitral valve; LA = left atrium; LAA = left atrial appendage; l.PV = left pulmonary vein; rt. lower PV = right lower pulmonary vein; rt. upper PV = right upper pulmonary vein; PV = pulmonary vein; SVC = superior vena cava; IVC = inferior vena cava; CRYO = cryoablation.)

 
The disappearance of the AF was defined as no detectable AF at discharge, and again at 6 months after the operation. The results were recorded as means ± standard deviation, and statistical significance was calculated using Student’s t test. A p value of less than 0.05 was considered to be statistically significant.

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


   Results
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 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
All of the patients survived without any serious complications. The characteristics of these patients, including the pattern of their atrial epicardial electrograms during the chronic AF, the mean atrial fibrillatory cycle length of both atria, the aortic cross-clamping time, the extracorporeal circulation time, and the results of the AF surgery are summarized in Table 2. The atrial epicardial electrograms seemed to be regular and repetitive at most points in the left atrium, but were irregular and chaotic at most points in the right atrium in 9 out of 12 patients. The mean atrial fibrillatory cycle length ranged from 173 to 319 (mean 237) milliseconds in the right atrium, and 151 to 268 (mean 184) milliseconds in the left atrium. The shortest atrial fibrillatory cycle length of the left atrium was significantly shorter than that of the right atrium in all patients (p < 0.05). The shortest atrial fibrillatory cycle length of the left atrium was observed at the root of the left upper pulmonary vein in most patients. Figure 2 shows the lead II electrocardiograms, and 12 out of 48 bipolar epicardial electrograms, recorded from both atria during chronic AF in a 53-year-old woman with mitral valve stenosis and aortic valve regurgitation (patient 3 in Table 2). In this patient, a regular and repetitive activation sequence was detected at several points in the left atrium, in contrast to the irregular and chaotic activation of the right atrium. This typical activation pattern was observed in 9 out of 12 patients, and the chronic AF in these 9 patients was effectively treated by the simple pulmonary vein orifice isolation. The other 3 patients showed irregular and polymorphic activations in both atria, and 2 of these 3 patients did not recover a normal sinus rhythm.


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  		Table 2. Activation Characteristics of the Atrial Mapping and the Results of the Isolation Surgery

 


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  		Fig 2. Distribution of the surface electrodes (left) and the surface lead II electrocardiogram and 12 representative bipolar epicardial electrograms. The schema represents the distribution of the surface electrodes on both atria. The left atrium showed regular and repetitive activations (points 7, 8, 9, 10). The right atrium showed irregular and chaotic activations (points 3, 4, 5, 6). (SVC = superior vena cava; IVC = inferior vena cava; QRS = ventricular activation; RA = right atrium; RAA = right atrial appendage; SA = sinus node; PV = pulmonary vein; LA = left atrium; LAA = left atrial appendage.)

 
The concomitant valve operations included two mitral valve replacements, six mitral valve replacements plus tricuspid annuloplasties, three mitral valve replacements plus aortic valve replacements, and one mitral valve plasty plus aortic valve replacement plus tricuspid annuloplasty. The extracorporeal circulation time and the aortic cross-clamping time ranged from 115 to 237 minutes (average 168 ± 35 minutes) and 77 to 163 minutes (average 108 ± 30 minutes), respectively. All of the patients recovered their sinus rhythm immediately after the operation. In 9 of the 12 patients (75%), the sinus rhythm continued without paroxysmal AF episodes until the time of discharge. Three patients demonstrated a recurrence of their AF within 3 days after the operation, and this AF did not disappear after cardioversion and the administration of antiarrhythmic drugs (digitalis and disopyramide) until the time of discharge. The disappearance rate of the AF was 75% at discharge. During the postoperative follow-up, 1 patient demonstrated a recovery from AF to a sinus rhythm 3 months after the operation (Table 2). Thus, the overall disappearance rate of AF was 83% during the entire follow-up period. A dual chamber pacemaker was required in 1 of the 12 patients (8.3%) because of sinus bradycardia. Paroxysmal atrial fibrillation or tachycardia occurred in 5 of the 12 patients (42%), but disappeared following the administration of antiarrhythmic drugs. Those patients who demonstrated a sinus rhythm at discharge continued to show a regular sinus rhythm during the entire follow-up period (range, 5 to 14 months; mean, 8 months). The preoperative echocardiograms showed a dilation of the left atrium of 52.3 ± 7.6 mm, which decreased to 50.4 ± 8.0 mm at discharge. This decrease in the left atrial diameter between the pre- and postoperative periods was not significant. Transthoracic echocardiography demonstrated the appearance of apparent transvalvular flow during the atrial systolic phase in both the right (9 of 10, 90%) and the left atria (7 of 10, 70%) of those patients whose AF had disappeared.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Chronic AF associated with mitral valve disease often persists despite the proper repair of the cardiac defect [5, 6]. 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 [5]. Our previous data also revealed that the rate of recovery of a sinus rhythm was much higher in those patients who underwent an AF operation than in those who did not (disappearance rate 27% in the control group versus 86% in the AF operation group at discharge) [7].

The Maze procedure has been used for the surgical ablation of AF in patients with mitral valve disease, and has proven to be effective for conversion to a sinus rhythm [2]. The idea behind the original Maze operation was to separate all possible areas for macroreentry, and to restore atrial contractility [8, 9]. Although various concepts involving reentry and ectopic foci have been proposed to explain the mechanism underlying AF [10–12], the real mechanism underlying chronic AF associated with mitral valve disease remains unknown. Harada and colleagues discovered 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 [13]. Our previous study also demonstrated regular and repetitive activation of the left atrium in 7 out of 11 patients with mitral valve disease [3]. Recently, Haissaguerre and coworkers reported the spontaneous initiation of AF due to ectopic beats [4] originating from the pulmonary veins, and reported the successful application of radiofrequency ablation at these focal sources. We also observed repetitive activation originating from the left pulmonary vein during chronic AF with mitral valvular disease [14]. Moreover, the shortest atrial fibrillatory cycle length was recorded in the left atrium in all cases. Morillo and colleagues [15] devised a canine model of sustained AF, which was induced by chronic rapid atrial pacing. They calculated the atrial fibrillatory cycle length by measuring the interval of the steepest deflection of each monopolar atrial electrogram. They reported that the atrial fibrillatory cycle length represented the refractory time of the atrial contractions and that the atrial fibrillatory cycle length of the left atrium was shorter than that of the right atrium in the canine model. We also measured the atrial fibrillatory cycle length by measuring the steepest deflection of each activation using the bipolar electrogram. These electrodes had narrow intervals of each electrode (2 mm) and the waves were thought to be as similar as those of monopolar electrodes. In our previous study [3], we speculated that a shortened refractory period and conduction depression between both atria might play a role in the maintenance of chronic AF associated with isolated mitral valve disease. In this study, we hypothesized that these regular activations might originate from the pulmonary veins, similar to the activation in cases of paroxysmal atrial fibrillation, and might similarly trigger AF. Therefore, we simplified our previous left atrial procedure [3] and performed a simple pulmonary vein orifice isolation for the treatment of the chronic AF associated with mitral valve disease. Chronic AF was effectively eliminated in most cases. The successfully treated cases showed a regular sinus rhythm following surgery, and recovered their left atrial contraction. There was no evidence of atrial flutter originating in the right atrium postoperatively. This simple procedure has numerous advantages, such as a short surgical time and a reduced risk of coronary artery injury and pacemaker implantation, as compared to the Maze procedure. In our experience, the disappearance rate for chronic AF treated by the Maze procedure was the same as that following this pulmonary vein orifice isolation procedure, in spite of the superior results of the Maze III procedure in a recent report [16]. The extracorporeal circulation time and aortic cross-clamping time of the pulmonary vein orifice isolation procedure was shorter than those of the Maze procedure. In addition, postoperative arrhythmias and pacemaker requirements were less frequent in this pulmonary vein orifice isolation procedure.

Although our atrial mapping did not show the exact mechanisms underlying the chronic AF because of limitations due to a lack of extensive atrial mapping and interelectrode conduction-time data, our clinical experience suggests that the pulmonary vein acts as a driver to maintain the chronic AF, and that the sole isolation of the pulmonary vein orifices is adequate for the elimination of the AF, even in those cases with chronic AF and valvular heart disease. In addition, the atrial fibrillatory cycle patterns were useful in assessing the efficacy of this procedure, and might be useful in predicting the results of AF surgery.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Hirosawa K., Sekiguchi M., Kasanuki H. Natural history of atrial fibrillation. Heart Vessels 1987;2(Suppl):14.
  2. Kosakai Y., Kawaguchi A., Isobe F., et al. Cox Maze procedure for chronic atrial fibrillation associated with mitral valve disease. J Thorac Cardiovasc Surg 1994;108:1049-1055.[Abstract/Free Full Text]
  3. Sueda T., Nagata T., Shikata H., et al. Simple left atrial procedure for chronic atrial fibrillation associated with mitral valve disease. Ann Thorac Surg 1996;62:1796-1800.[Abstract/Free Full Text]
  4. Haissaguerre M., Jais P., Shah D.C., et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. New Engl J Med 1998;339:659-666.[Abstract/Free Full Text]
  5. Sato S., Kawashima Y., Hirose H., et al. Long-term results of direct-current cardioversion atrial fibrillationter open mitral commissurotomy for mitral stenosis. Am J Cardiol 1986;57:629-633.[Medline]
  6. Flugelman MY, Hasin Y, Katznelson N, Kriwiwsky M, Shefer A, Gotsman MS. Restoration and maintenance of sinus rhythm after mitral valve surgery for mitral stenosis. Am J Cardiol 1984;54:17–7.
  7. Sueda T., Nagata H., Orihahsi K., et al. Efficacy of a simple left atrial procedure for chronic atrial fibrillation in mitral valve operations. Ann Thorac Surg 1997;63:1070-1075.[Abstract/Free Full Text]
  8. Cox J.L., Canavan T.E., Schuessler R.B., et al. The surgical treatment of atrial fibrillation. II. Intraoperative electrophysiologic mapping and description of the electrophysiologic basis of atrial flutter and atrial fibrillation. J Thorac Cardiovasc Surg 1991;101:406-426.[Abstract]
  9. Cox J.L., Schuessler R.B., D’Agostino H.J., et al. The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg 1991;101:569-583.[Abstract]
  10. Henry W.L., Morganroth J., Pearlman A.S., et al. Relation between echocardiographically determined left atrial size and atrial fibrillation. Circulation 1976;53:273-279.[Abstract/Free Full Text]
  11. Ten Eick R.E., Singer D.H. Electrophysiological properties of diseased human atrium. I. Low diastolic potential and altered cellular response to potassium. Cir Res 1979;44:545-557.[Free Full Text]
  12. Cosio F.G., Palacios J., Vidal J.M., Cocina E.G., Gomez-Sanchez M.A., Tamargo L. Electrophysiologic studies in atrial fibrillation. Slow conduction of premature impulses: a possible manifestation of the background for reentry. Am J Cardiol 1983;51:122-130.[Medline]
  13. Harada A., Sasaki K., Fukushima T., et al. Atrial activation during chronic atrial fibrillation in patients with isolated mitral valve disease. Ann Thorac Surg 1996;61:104-112.[Abstract/Free Full Text]
  14. Sueda T., Imai K., Watari M., Orihahsi K., Shikata H., Matsuura Y. Possibility of focal activation around the left upper pulmonary vein during chronic atrial fibrillation with mitral valve disease. Ann Thorac Cardiovasc Surg 1999;5:116-120.[Medline]
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J. G. Maessen, J. F.M.A. Nijs, J. L.R.M. Smeets, J. Vainer, and B. Mochtar
Beating-heart surgical treatment of atrial fibrillation with microwave ablation
Ann. Thorac. Surg., October 1, 2002; 74(4): S1307 - 1311.
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 Ann. Thorac. Surg.Home page
Y. Matsumoto, G. Watanabe, M. Endo, H. Sasaki, F. Kasashima, and I. Kosugi
Efficacy and safety of on-pump beating heart surgery for valvular disease
Ann. Thorac. Surg., September 1, 2002; 74(3): 678 - 683.
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 J. Thorac. Cardiovasc. Surg.Home page
F. W. Mohr, A. M. Fabricius, V. Falk, R. Autschbach, N. Doll, U. von Oppell, A. Diegeler, H. Kottkamp, and G. Hindricks
Curative treatment of atrial fibrillation with intraoperative radiofrequency ablation: Short-term and midterm results
J. Thorac. Cardiovasc. Surg., May 1, 2002; 123(5): 919 - 927.
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 Cardiovasc ResHome page
A. Shimizu and O. A. Centurion
Electrophysiological properties of the human atrium in atrial fibrillation
Cardiovasc Res, May 1, 2002; 54(2): 302 - 314.
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T. Sueda
Simple pulmonary vein isolation for atrial fibrillation: Reply
Ann. Thorac. Surg., March 1, 2002; 73(3): 1022 - 1023.
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 Ann. Thorac. Surg.Home page
J. W. Lee, S. J. Choo, K. I. Kim, J. K. Song, D. H. Kang, J. M. Song, H. Song, S. K. Lee, and M. G. Song
Atrial fibrillation surgery simplified with cryoablation to improve left atrial function
Ann. Thorac. Surg., November 1, 2001; 72(5): 1479 - 1483.
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