Ann Thorac Surg 2003;75:1680
© 2003 The Society of Thoracic Surgeons
Correspondence
Reply
Renato A.K. Kalil, MD, PhDa,
Gustavo G. Lima, MD, MSca,
Tiago L.L. Leiria, MDa,
Rogério Abrahão, MDa,
Leonardo M. Pires, MDa,
Paulo R. Prates, MDa,
Ivo A. Nesralla, MD, PhDa
a Instituto de Cardiologia do Rio Grande do Sul, Av. Princesa Isabel, 395 Santana Porto Alegre-RS 90.620-001 Brazil
(Email: kalil{at}cardnet.tche.br).
To the Editor:
Thank you for the opportunity to comment on this letter from Dr Sankar and coworkers. Their group is to be congratulated for their contribution to this novel field in cardiovascular surgery. Indeed, our previous paper [1] demonstrated a trend to spontaneous postoperative reversion to sinus rhythm in those patients with a left atrial dimension less than 52 mm when associated with mitral regurgitation, but we did not find this trend for mitral stenosis.
In our technique of simple surgical pulmonary vein isolation (IVP) [2], antiarrhythmic therapy with amiodarone is a useful adjunct. This may be related to atrial size, as many of our patients have very large atria, or to other trigger points outside the excluded atrial area. The important point is that previous chronic refractory atrial fibrillation is reversed to sinus rhythm.
Atrial reduction may contribute to a better surgical result by eliminating some critical atrial mass and possible additional trigger points for the arrhythmia. It adds complexity to the procedure, however, and one of the attractions of our procedure is its simplicity which can be reproduced in any cardiac surgical center. For this reason, we do not employ more radical techniques of atrial reduction. Indeed, we may ressect some tissue and use larger bites of suture in large atria.
Finally, we should mention that in very large atria, where the atrial wall has lost its structure and the myocardial layer is very thin, fibrotic, and even calcified, it is not worthwhile to attempt to reverse atrial fibrillation. Even if we succeed in reverting the rhythm, the atrium will not contract, as it has lost this ability. Atrial reduction should be reserved for large atria with preserved wall structure.
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References
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- Kalil RAK, Maratia CB, 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]
- Kalil RAK, Lima GG, Leiria TL, 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]
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