Ann Thorac Surg 2004;78:1836-1838
© 2004 The Society of Thoracic Surgeons
Case report
Prandial Atrial Fibrillation: Off-Pump Pulmonary Vein Isolation With Hiatal Hernia Repair
A. Marc Gillinov, MDa,*,
Thomas W. Rice, MDa
a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Accepted for publication July 10, 2003.
* Address reprint requests to Dr Gillinov, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation/F24, 9500 Euclid Ave, Cleveland, OH 44195, USA
gillinom{at}ccf.org
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Abstract
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Frequent palpitations with eating developed in a 62-year-old man with a history of typical gastroesophageal reflux successfully treated by Nissen fundoplication 5 years previously. A Holter monitor demonstrated paroxysmal atrial fibrillation associated with eating. Barium swallow showed a slipped Nissen fundoplication with herniation into the chest. Under a single anesthetic, the patient had median sternotomy and off-pump pulmonary vein isolation with a bipolar radiofrequency clamp and transabdominal redo-Nissen fundoplication. A 24-hour Holter monitor performed 6 weeks after operation demonstrated a normal sinus rhythm with no atrial fibrillation. Barium swallow demonstrated an intact infradiaphragmatic repair.
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Introduction
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Paroxysmal atrial fibrillation (AF) usually arises from foci located in the pulmonary veins, and isolation of all 4 pulmonary veins successfully cures paroxysmal AF in 80% to 90% of patients [1]. Recent development of a bipolar radiofrequency clamp that includes a mechanism for transmurality assessment facilitates off-pump pulmonary vein isolation [2]. Atrial tachyarrhythmias have been associated with swallowing and gastroesophageal reflux (GERD) [3, 4]. We report a case in which paroxysmal AF was associated with eating in a patient with a slipped Nissen fundoplication. Under a single anesthetic, the pulmonary veins were isolated, and the Nissen fundoplication was reconstituted. A Holter monitor obtained 6 weeks after operation confirmed the elimination of paroxysmal AF.
A 62-year-old man with typical GERD had a Nissen fundoplication 5 years previously for control of reflux and regurgitation. He presented with a 3-month history of palpitations associated with eating. A Holter monitor demonstrated frequent runs of paroxysmal AF corresponding to ingestion of food. Barium swallow showed a slipped Nissen fundoplication with herniation into the chest (Fig 1).
Esophageal manometry showed normal esophageal peristalsis with incomplete relaxation of the lower esophageal sphincter. Twenty-four–hour pH monitoring demonstrated no acid exposure. Esophagogastroduodenoscopy demonstrated a slipped supradiaphragmatic repair. Insufflation of the stomach at esophagogastroduodenoscopy resulted in supraventricular tachycardia, and Holter monitoring during a barium swallow was accompanied by bursts of AF.
On echocardiogram, the patient had normal left and right ventricular function, no valvular heart disease, and a left atrial diameter of 3.9 cm. Cardiac catheterization revealed a 90% stenosis in a small posterior ventricular branch of the right coronary artery; this lesion was treated by percutaneous angioplasty without stenting. The patient received clopidogrel for 4 weeks and was scheduled for operation.
The patient presented to the operating room in normal sinus rhythm at 70 beats per minute. A median sternotomy was performed and the pericardium was opened. The right pulmonary veins were dissected free of pericardial reflections. A bipolar pacing electrode was placed on the right pulmonary veins, and the atrium was paced at 100 beats per minute; the pacing threshold was 2 mA. The Atricure bipolar radiofrequency clamp (Atricure Inc, West Chester, OH) was then placed on the left atrial cuff adjacent to the pulmonary veins with the jaws directed cephalad, and a radiofrequency lesion was created. To ensure a continuous lesion that completely isolated the pulmonary veins, a second overlapping lesion was created with the jaws pointed caudally. The pacing electrode was then placed on the pulmonary veins adjacent to the radiofrequency lesion; the heart could not be entrained by pacing the pulmonary veins, even with the output increased to 20 mA, confirming electrical isolation. A similar protocol of pulmonary vein isolation and testing for conduction block was performed on the left pulmonary veins. Dissection and isolation of each set of pulmonary veins required less than 10 minutes.
The incision was extended, and a redo-laparotomy was performed. The previous Nissen fundoplication was taken down, and the esophagus was mobilized. The esophageal hiatus was closed to its normal size, and a loose, floppy Nissen fundoplication was constructed over the distal 2 cm of the esophagus. Because of concern over the integrity of the vagus nerves, a pyloroplasty was also performed. All incisions were then closed.
The patient had no postoperative AF. He was discharged home on postoperative day 7. At the 6-week follow-up, the patient reported no palpitations or light-headedness—symptoms previously caused by his AF. Twenty-four–hour Holter monitor demonstrated a normal sinus rhythm at an average rate of 83 beats per minute; there was no AF.
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Comment
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Atrial tachyarrhythmias have been reported in patients with hiatal hernia and GERD [3, 4]. These arrhythmias may be induced by a mechanical effect on the left atrial wall that is related to the passage of food [3, 4]. Schilling and Kaye [3] reported suppression of atrial flutter by repair of a large paraesophageal hernia. However, atrial flutter and AF have different mechanisms, and the current patient had symptomatic paroxysmal AF associated with eating. Because we could not be certain that an antireflux procedure alone would cure his AF, we offered pulmonary vein isolation as well.
Paroxysmal AF usually arises from pulmonary vein foci, and pulmonary vein ablation should cure paroxysmal AF in 90% of patients [1]. Development of new surgical tools such as the bipolar radiofrequency clamp enable surgeons to perform off-pump epicardial pulmonary vein ablation [2]. The strategy of hiatal hernia repair and pulmonary vein isolation successfully eliminated paroxysmal AF in this patient.
This case demonstrates the feasibility and success of off-pump epicardial pulmonary vein isolation for paroxysmal AF. Although electrophysiologists can perform endocardial pulmonary vein isolation, this procedure is neither simple nor free of risk [5]. With the development of surgical tools to facilitate epicardial pulmonary vein ablation through small incisions or endoscopes, it is likely that surgeons will be able to offer minimally invasive, curative operations to patients with AF.
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References
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- Haissaguerre M, Jais P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339:659–666[Medline]
- Gillinov AM, McCarthy PM. Atricure bipolar radiofrequency clamp for intraoperative ablation of atrial fibrillation. Ann Thorac Surg. 2002;74:2165–2168[Abstract/Free Full Text]
- Schilling RJ, Kaye GC. Paroxysmal atrial flutter suppressed by repair of a large paraesophageal hernia. Pacing Clin Electrophysiol. 1998;21:1303–1305[Medline]
- Landmark K, Storstein O. Ectopic atrial tachycardia on swallowing. Acta Med Scand. 1979;205:251–254[Medline]
- Gaita F, Riccardi R, Calo L, et al. Atrial mapping and radiofrequency catheter ablation in patients with idiopathic atrial fibrillation. Electrophysiological findings and ablation results. Circulation. 1998;97:2136–2145[Abstract/Free Full Text]
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