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Ann Thorac Surg 2007;84:357
© 2007 The Society of Thoracic Surgeons

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Correspondence

Simplified Left Atrial Volume Reduction and Modified Maze Procedure as Treatment for Permanent Atrial Fibrillation During Concomitant Mitral Surgery

Department of Cardiothoracic Surgery, ISMETT, Via Tricomi 1, 30127 Palermo, Italy

(Email: rgea{at}hotmail.com).

To the Editor:

We have read the article by Badhwar and colleagues [1] with interest and we commend the authors for their timely report.

Treatment of permanent atrial fibrillation (AF) should not be limited to simple ablation around the pulmonary veins (PV). More strenuous efforts are needed whenever left atria (LA) are enlarged and when substantial substrate for AF generation and perpetuation exists. In a previous report, Scherer and colleagues [2] proposed an alternative LA reduction technique by closing the LA appendage from inside with a double running suture. The same suture is used to plicate the lateral LA wall to the roof of the left PV inflow and the inferior atrial wall. Finally, the atrial septum is plicated by placing stitches to close the atria across the fossa ovalis. As with Badhwar and colleagues [1], we routinely adopt LA reduction in combination with simple LA radiofrequency ablation in every patient in AF undergoing mitral valve surgery. Unlike the authors, we do not actually resect a portion of the atrium, but adopt a very simple "respect and do not resect" approach to the problem. Although we used to extend the LA incision to the left inferior PV and remove a strip of LA, we now perform LA reduction by simply plicating longitudinally with a single continuous suture along the posterior wall of the atrium in the area between the left and right PVs. The continuous suture not only achieves LA reduction but also guarantees electrical isolation between the right and left PVs radiofrequency ablation lesions. In this fashion, we reduce LA size of even more than 3 cm. The procedure is completed with a monopolar radiofrequency Cox-maze III LA lesion set.

In our experience, LA volume reduction not only increases the rate of sinus rhythm recovery after AF surgery, but also allows for improvement in LA emptying.

In a recent report, the Cox-maze procedure concomitant with LA reduction restored effective LA booster function of the enlarged left atria and overstretched myocardium, as assessed by postoperative cine-magnetic resonance imaging. However, despite sinus rhythm recovery, the Cox-maze procedure alone did not restore LA function [3].

In agreement with Badhwar and colleagues [1], we advocate LA volume reduction in patients undergoing concomitant mitral valve surgery and AF ablation. In our experience, this procedure is expeditiously and safely performed by simply plicating the LA posterior wall without removing atrial tissue. The LA volume reduction may also facilitate sinus rhythm and atrial booster function in cases of permanent AF with the enlarged LA.

	References

Top References

 

1. Badhwar V, Rovin JD, Davenport G, et al. Left atrial reduction enhances outcomes of modified maze procedure for permanent atrial fibrillation during concomitant mitral surgery Ann Thorac Surg 2006;82:1758-1764.[Abstract/Free Full Text]
2. Scherer M, Dzemali O, Aybek T, et al. Impact of left atrial size reduction on chronic atrial fibrillation in mitral valve surgery J Heart Valve Dis 2003;12:469-474.[Medline]
3. Marui A, Nishina T, Tambara K, et al. Impact of left atrial volume reduction on the restoration of booster function of enlarged left atrium after the Cox-maze procedure: assessment by magnetic resonance imaging. Presented at the 20^th EACTS meeting, Stockholm, Sweden, September 2006.

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				V. Badhwar Reply Ann. Thorac. Surg., July 1, 2007; 84(1): 357 - 358. [Full Text] [PDF]

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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Gianluca Santise Sergio Sciacca Francesco Pirone Michele Pilato Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by D’Ancona, G. Articles by Pilato, M. Search for Related Content PubMed PubMed Citation Articles by D’Ancona, G. Articles by Pilato, M. Related Collections Electrophysiology - arrhythmias Related Article