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Ann Thorac Surg 2004;77:381
© 2004 The Society of Thoracic Surgeons
Department of Cardiology and Cardiothoracic Surgery, St. Antonius Hospital, Koekoekslaan 1 Nieuwegein 3435 CM, The Netherlands
e-mail: heme01{at}antonius.net
To the Editor:
We appreciated the review of the rationale for, methods of, and results of operation for atrial fibrillation (AF) presented by Gillinov and associates [1]. However, we do not agree with them about several aspects of operation for AF.
The authors have strong reasons to mention the need of universally accepted rules for uniform collection, analysis, and reporting of AF surgical results. This is presumably the major reason for the disparity in the results of others whom they cited [1, p 2213]. It is clear that assessment of surgical results and definitions of success and failure cannot be discussed without clarifying the reasons for AF surgical procedures. To our surprise, the authors hardly addressed these reasons and selection criteria, and therefore the proposed rules for assessing the success of AF operations remain ambiguous.
The indication for operation for AF remains an important matter of dispute because of the recent publication of two studies demonstrating that rhythm control of AF offers no advantage over rate control in terms of survival [2] and morbidity from cardiovascular causes [3]. Although these findings cannot immediately be applied to all patients with AF undergoing mitral valve operations and other cardiac surgical procedures, the message of these studies will influence the current selection criteria for AF operations as perceived by the referring cardiologist. In addition, we [4] showed in a prospective study that the 12-month quality-of-life outcome did not differ in patients having a mitral valve operation with or without a maze III procedure. We [5] also found that during long-term follow-up of patients operated on for AF without structural heart disease, new atrial tachycardia and incompetent sinus node function frequently emerged. On the basis of this information, one can easily conclude that the reasons for AF operation and corresponding selection criteria should be updated and refined. Certainly this process will influence the assessment and the definitions of surgical results as proposed by the authors.
If we focus on the proposed definition of surgical failure, the description of Gillinov and colleagues does not agree with our experience. They state that when sinus rhythm is maintained and AF suppressed with antiarrhythmic drugs 6 months after operation, this result should be classified as a surgical success. However, such a result depends heavily on the reason for the AF operation. Patients who have an operation for unresponsiveness to drugs or symptomatic AF without other cardiac disorders or other cardiac surgical procedures consider the required antiarrhythmic drugs 6 months after operation as indicative of an unsatisfactory and disappointing result. The obligatory use of antiarrhythmic drugs strongly diminishes quality of life [6]. The same holds for pacemaker dependency after operation for AF in patients without structural heart disease or other cardiac surgical procedure. In our series of patients having a maze III operation for AF without structural heart disease, implantation of a pacemaker (10% of patients) is a disappointment for the patient as well as for the referring cardiologist [6]. In our opinion, postoperative pacemaker dependency can be prevented by better selection of patients using noninvasive methods to establish sufficient chronotropic function of the sinus node and to exclude the bradycardia-tachycardia syndrome before operation. We think that the definition of surgical failure should be changed for these patients.
Finally, the authors state that atrial flutter occurring after an AF operation can easily be ablated with current catheter methods. This is true if classic atrial flutter (so-called type I) emerges after operation, but its incidence is very low because of the design of the maze III procedure. Much more frequent after operation are fast atypical atrial flutter and ectopic atrial tachycardia. Delineating the site of origin of these paroxysmal arrhythmias is very complex and frequently frustrates successful catheter ablation, thus mandating long-term antiarrhythmic drug treatment. These complications should also be incorporated into the final definitions of surgical success and failure.
References
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