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Ann Thorac Surg 2006;81:863-867
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Conversion to Sinus Rhythm by Ablation Improves Quality of Life in Patients Submitted to Mitral Valve Surgery

Stefano Forlani, MD, PhD * , Ruggero De Paulis, MD, Lorenzo Guerrieri Wolf, MD, Renata Greco, MD, Patrizio Polisca, MD, Marco Moscarelli, MD, Luigi Chiariello, MD

Division of Cardiac Surgery, University of Rome, Tor Vergata, Rome, Italy

Accepted for publication September 1, 2005.

* Address correspondence to Dr Forlani, Divisione di Cardiochirurgia, Università di Roma Tor Vergata, Policlinico di Tor Vergata, V.le Oxford 81, Rome, 00133 Italy (Email: stefanoforlani{at}gmail.com).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Atrial fibrillation can be successfully treated with surgical ablation, but the effect of restoring sinus rhythm on the quality of life has yet to be established. We evaluate the effects of left atrial ablation combined with mitral valve surgery on health-related quality of life in patients with permanent atrial fibrillation.

METHODS: Ninety-one consecutive patients with permanent atrial fibrillation underwent mitral valve surgery at our division. The last 53 also received left atrial ablation by means of monopolar radiofrequency and excision of the left appendage. The patients were divided into two groups according to the median total score obtained at the Short Form 36 Health Survey used to evaluate their quality of life (ie, the good quality of life group [n = 54] and the poor quality of life group [n = 37]).

RESULTS: Preoperative and intraoperative data of the two groups were similar. In-hospital mortality and morbidity were similar in both groups. Sinus rhythm was obtained in 68% of patients (36 of 53) treated with left atrial ablation and it occurred spontaneously in 10% of patients (4 of 38) treated for the mitral pathology only. At follow-up, there was no difference between the groups in ejection fraction, left atrial diameter, mitral dysfunction, tricuspidal regurgitation, and New York Heart Association functional class. Using stepwise logistic regression, only the presence of sinus rhythm was associated with better quality of life.

CONCLUSIONS: In patients submitted to mitral surgery, conversion to sinus rhythm by left atrial ablation can significantly improve the health-related quality of life.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in the clinical practice today, accounting for approximately one third of hospitalizations for cardiac rhythm disturbance. Atrial fibrillation is a disorder found in about 5 million people in the world, and in United States the number of patients with AF is likely to increase 2.5-fold during the next 50 years, reflecting the growing proportion of elderly individuals [1].

The quality of life (QOL) of patients with AF has been reported to be worse than that of healthy controls, impaired as that of patients submitted to percutaneous transcatheter coronary angioplasty or post-myocardial infarction and similar to that of patients with heart failure [2]. Regardless of the strategy of rhythm control or rate control, the QOL of patients improves if it is medically treated [3–5]. However, the QOL of patients has not been extensively evaluated when sinus rhythm (SR) is obtained by mean of ablation instead of drugs and direct current shock.

The aim of this study, which was conducted on patients with permanent AF and submitted to mitral valve surgery, was to test the hypothesis that the conversion to SR obtained by left atrial ablation could be associated with better QOL.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
Ninety-one patients with permanent (cardioversion failed) AF and mitral pathology underwent surgery at the University of Rome, Tor Vergata, Italy. The first 38 patients received surgical treatment for the mitral valve only and the last 53 patients also received concomitant surgical treatment for AF. All these patients were consecutively followed-up for ≥ 6 months.

All patients underwent cardiopulmonary bypass with double-stage/bicaval and aortic cannulation in normothermia; myocardial protection was assured by antegrade blood warm cardioplegia. A lateral left atriotomy anteriorly to the right pulmonary veins was performed in all patients.

Surgical treatment of permanent AF consisted of left atrial appendage excision, and a set of linear lesions was made by a monopolar radiofrequency irrigated ablation system (Cardioblate, Medtronic, Inc, Minneapolis, MN) following the scheme previously reported [6]. The lines of ablation consisted in two loops to isolate the left and right pulmonary veins respectively, a lesion joining these, a lesion joining the left loop to the base of the excised appendage, and another from here to the mitral annulus in a "P3" position.

Antiarrhythmic treatment was carried out on a routine basis. Amiodarone was the drug of choice. Its administration was begun after the induction of anaesthesia with a 300 mg intravenous bolus, followed by 1,200 mg/24 hours intravenously until the end of the first postoperative day. Beginning on the second postoperative day, oral administration of 200 mg every 24 hours was begun. In 6 patients with contraindications to amiodarone, we administrated sotalol (80 mg twice daily) from postoperative day 1. In patients with early postoperative AF, direct current shock was performed during the hospitalization, and in the case of failure it was repeated 1 to 3 months after discharge.

At the follow-up clinical history visit, a 12-lead electrocardiogram, echocardiography, and QOL were evaluated. The Italian version of the Short Form 36 (SF-36) Health Survey (IQOLA SF-36 Italian Version 1.6, New England Medical Center Hospitals, Inc, 1992) was used to measure QOL.

All patients gave their informed consent to participate in this study, which was approved by the Institutional Board of the University of Rome Tor Vergata.

Statistical analyses were calculated by measuring the mean ± standard deviation for continuous variables, and frequencies were measured for categorical variables. Differences between groups were analyzed by an unpaired Student t test for continuous variables, whereas in the case of categorical variables, group differences were examined by the {chi}2 test or Fisher's exact test as appropriated. A value of p < 0.05 was considered significant. A stepwise logistic regression analysis was performed to select predictors of better QOL; the model was built using variables that demonstrated a p value ≤ 0.10 in the univariate analysis. The significance within the model was evaluated with the Wald statistical test. All tests were performed by StatView for Windows statistical software (SAS Institute Inc).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
On the basis of the median total score obtained in the SF-36 survey (regardless of rhythm) the patients were divided into two groups: (1) the group with good QOL (n = 54; score > 100) and the group with poor QOL (n = 37; score < 100). The demographic characteristics of the two groups of patients are listed in Table 1, and operative and postoperative data are listed in Table 2. At the follow-up, most of the clinical and echocardiographic measurements were similar in both groups (Table 3).


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  		Table 1. Demographic Data
 

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  		Table 2. Operative and Postoperative Data
 

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  		Table 3. Follow-up
 
Of patients treated with left atrial ablation and excision of the appendage, 68% (36 of 53) were in SR at follow-up. In the multivariate analysis, only the presence of SR was significantly associated with a better QOL (p < 0.001).

To evaluate the effect of SR on different domains of the SF-36 survey, we divided the patients into two groups according the presence or not of SR. In 5 of 8 domains of the survey, there were significant differences between groups representing both mental and physical function (Table 4).


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  		Table 4. Results in the Domains of Short Form 36 Survey
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
Our finding shows that in patients with permanent AF submitted to mitral valve surgery, restoring SR by ablation results in a better QOL than is found in patients whose AF is not treated. The total score and the scores of 5 of 8 domains of the SF-36 survey are higher in patients with restored SR in comparison with those of the patients who remained in AF. The differences were observed in both mental and physical functioning scores indicating a general involvement of the person.

Radiofrequency catheter ablation can be effectively used to treat AF [7–11]. In a study on the effects of radiofrequency catheter ablation on health-related QOL in patients with recurrent arrhythmias, all subscales of the SF-36 were improved from 1 to 6 months after the procedure compared with baseline [10]. Pappone and colleagues [9] examined the clinical course of 1,171 consecutive patients with symptomatic AF who underwent catheter ablation or medical therapy. The authors found that the circumferential pulmonary veins ablation for AF reduces mortality and morbidity, and improves QOL as compared with medical therapy.

Surgical treatment of AF, introduced by Cox in 1990, is a curative therapy for AF, but very few studies exist on its effect on the QOL. Lönnerhome and colleagues estimated the impact of the Maze operation in 49 patients with drug-refractory AF. They found that QOL had improved after surgery, at 6 months and at 1 year, and it has reached that of the general population [12]. Also Jessurun and colleauges [13] reported QOL that had markedly improved after surgery in a group of 12 patients with lone, paroxysmal AF. The same authors in a prospective, randomized study found that patients with AF and mitral pathology had a QOL that was markedly improved after valve surgery but was not different between patients with or without maze surgery [14]. The value of this finding is limited by the fact that only 8 patients did not receive surgical treatment for their AF [14].

Among patients undergoing mitral valve surgery those with AF range from 30% to 79% [15, 16]. The probability of spontaneous conversion to SR after isolated mitral valve surgery is less than 10% [16, 17]. Patients who return to SR after mitral valve repair or replacement demonstrate better survival and freedom from adverse events [18–20]. In particular, the improvements are greater for those patients who undergo mitral valve repair or replacement with biological prosthesis in which the anticoagulants were withdrawn 3 months after the operation [21–24]. However, for patients with mechanical valves the maintenance of SR after cardiac surgery is also correlated with a reduced risk of stroke [25].

In recent years, the availability of new techniques and devices has facilitated the surgical treatment of AF during mitral valve surgery. Sinus rhythm can be restored in the majority of patients with permanent AF. Based on the effects we have observed on QOL, we strongly recommend that all patients with permanent AF who undergo mitral valve surgery should receive concomitant treatment for AF.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
Thanks to Dr Hennya Hafsi for her unique and precious contribution. Thanks to Dr Marc M. Gallagher and to Dr Osamah Abdullah for their collaboration during the preparation of the article.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study JAMA 2001;285(18):2370-2375.[Abstract/Free Full Text]
  2. Dorian P, Jung W, Newman D, et al. The impairment of health-related quality of life in patients with intermittent atrial fibrillationimplications for the assessment of investigational therapy. J Am Coll Cardiol 2000;36:1303-1309.[Abstract/Free Full Text]
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  4. Hagens VE, Vermeulen KM, TenVergert EM, et al. Rate control is more cost-effective than rhythm control for patients with persistent atrial fibrillation—results from the RAte Control versus Electrical cardioversion (RACE) study Eur Heart J 2004;25(17):1542-1549.[Abstract/Free Full Text]
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  7. Pappone C, Rosanio S, Oreto G, et al. Circumferential radiofrequency ablation of pulmonary vein ostia Circulation 2000;102:2619-2628.[Abstract/Free Full Text]
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  9. Pappone C, Rosanio S, Augello G, et al. Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation. Outcomes from a controlled nonrandomized long-term study J Am Coll Cardiol 2003;42:185-197.[Abstract/Free Full Text]
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