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Ann Thorac Surg 2003;75:1680
© 2003 The Society of Thoracic Surgeons

Correspondence

Pulmonary vein isolation and left atrial reduction for chronic atrial fibrillation secondary to mitral valve disease

N.Madhu Sankar, MS, PhDa, Keshavamurthy Suresh, MS, MCha, Ravi Agarwal, MS, MCha, Kotturathu M. Cherian, MS, FRACSa

a Institute of Cardiovascular Diseases, Madras Medical Mission, 4A Dr J.J. Nagar, Mogappair, Chennai 600 050, India; icvd@eth.net

To the Editor:

We read with interest the article by Kalil and colleagues [1] on pulmonary vein isolation for treating secondary atrial fibrillation in mitral valve disease. The authors have presented a simple solution to the complex problem posed by atrial fibrillation in mitral valve disease. Pulmonary vein isolation alone in their series has achieved a 92.3% conversion to sinus rhythm at 6 months, which is commendable. The authors have suggested based on their past experience[2] that reversion to normal sinus rhythm was likely in those patients with a left atrial size less than 52 mms. During the postoperative course in their series antiarrhythmic therapy was used in as many as 40% of patients and 1 patient required a pacemaker implant.

The technique of left atrial reduction and pulmonary vein isolation for chronic atrial fibrillation with mitral valve disease has been described by one of us[3]. The operation involves division of the superior vena cava, extending the left atriotomy to encircle the pulmonary veins, and excision of a rim of left atrial wall and the left atrial appendage. We have performed this procedure in 44 cases. The procedure is safe and 10 of our patients were redo procedures and 6 had double valve replacement.

Patients in our study were selected for left atrial reduction when the left atrial size exceeded 60 mms. Thirty-eight of 44 patients (86%) came back to normal sinus rhythm and 34 are maintaining the same at 1-year follow-up. Transesophageal echocardiography has demonstrated left atrial contractility in 30 patients. No patient required pacemaker implantation and 8 patients required antiarrhythmic therapy with amiodarone.

We subscribe to the view that a critical mass of left atrial tissue appears necessary to sustain atrial fibrillation and that left atrial size has been identified as the key factor differentiating maze-amenable and maze-refractory atrial fibrillation[4]. We would like to stress, based on our experience, that LA reduction is an important contributory factor in addition to pulmonary vein isolation to convert this subset of patients to normal sinus rhythm. We believe LA reduction in addition to pulmonary vein isolation is highly effective in restoring normal sinus rhythm as well as the geometry of the LA in patients with mitral valve disease.

References

  1. Kalil R.A.K., Lima G.G., Leira T.L., et al. Simple surgical isolation of pulmonary veins for treating secondary atrial fibrillation in mitral valve disease. Ann Thorac Surg 2002;73:1169-1173.[Abstract/Free Full Text]
  2. Kalil R.A.K., Maratia C.B., D’Avila A., et al. Predictive factors for persistence of atrial fibrillation after mitral valve operation. Ann Thorac Surg 1999;67:614-617.[Abstract/Free Full Text]
  3. Madhu Sankar N., Farnsworth A.E. Left atrial reduction for chronic atrial fibrillation associated with mitral valve disease. Ann Thorac Surg 1998;66:254-256.[Abstract/Free Full Text]
  4. 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;10:983-990.[Abstract]




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