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Ann Thorac Surg 2004;77:2094-2095
© 2004 The Society of Thoracic Surgeons

Invited commentary

Department of Cardiothoracic Surgery, Klinikum der Johan Wolfgang Goethe, Universitat, 60 590 Frankfurt am Main, Germany

e-mail: fieguth{at}em.uni-frankfurt.de

Using a prospective randomized clinical trial, the authors of this paper evaluate the treatment of atrial fibrillation (AF) by pulmonary vein isolation in patients undergoing mitral valve surgery.

This patient population differs significantly from that with "lone" atrial fibrillation, since the left-sided origin of AF is well documented in patients with mitral valve disease. Several studies have been able to identify trigger substrates in the pulmonary veins or reentry around them. Therefore, isolation of these regions seems to be justified, although it has to be noted that the atria can fibrillate if a trigger outside the isolated area occurs.

In contrast, the Cox-Maze procedure alters the morphology of both atria in a way that prevents the atria from sustaining fibrillation if the atrial refractory period is normal or prolonged. This approach is, therefore, independent from potential points of origin. This favors its use in patients where trigger points are unknown or variable, like otherwise healthy individuals with paroxysmal vagal-mediated AF, who carry a substantial risk of systemic embolization. The complexity of the procedure, however, has led to limited use in patients with concomitant cardiac disease and initiated a search for alternatives.

The authors conducted a prospective randomized study with a comprehensive three-arm design, comparing the Cox-Maze procedure with pulmonary vein isolation and a control group. Only a few comparable investigations exist in the literature. Despite its limited size, the study provided significant results, demonstrating the superiority of both surgical approaches in comparison to the control group.

In order to establish a valid treatment option for patients with mitral valve disease and atrial fibrillation, the efficacy of a simple left-sided procedure—like pulmonary vein isolation—in prevention of atrial fibrillation should be reproduced in a larger or multicenter study. This would allow for analysis of important secondary end points like freedom from embolic events, and hemodynamic markers like exercise capacity and NYHA stage. The presented study provides important evidence for a simple and safely reproducible procedure, which may lead to a standardized surgical approach.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Fieguth, H. G. Search for Related Content PubMed Articles by Fieguth, H. G. Related Collections Electrophysiology - arrhythmias