Ann Thorac Surg 2004;78:805-806
© 2004 The Society of Thoracic Surgeons
Invited commentary
Lynda Mickleborough, MD
Department of Cardiac Surgery, University of Toronto1221 Gervais Rd, RR #1, Waubaushene, OntarioCanada L0K 2C0
l.mickleborough{at}on.aibn.com
This study, although limited by its retrospective design, is I believe an important one. The data confirm the excellent results that can be achieved with percutaneous balloon commissurotomy (PBC) with respect to function of the mitral valve, but highlights the important influence of concomitant atrial fibrillation on long-term results (risk of thromboembolism). They compared results achieved in 199 patients with atrial fibrillation (AF), who met their criteria for a Maze procedure but who underwent PBC, to those achieved with an open valve procedure-Maze operation. With respect to the factors examined, the surgical group appears to be at increased risk for embolic events (increased age, increased duration of AF, increased left atrial dimension, and increased history of previous atrial thrombus). It is implied that patients with left atrial thrombus underwent an open procedure; however, it is unclear what echo criteria were used for systematic identification of thrombus. It is also unclear whether cardioversion was attempted in all PBC patients. Possible selection bias may also have influenced the results. All patients who remained in AF were put on long-term anticoagulants, but the target international normalized ratio 1.8 to 2.8 seems a bit low, which could have influenced results. There was one death in the surgical group which may have been related to the cut-and-sew technique used for the Maze.
As expected, the Maze restored sinus rhythm (SR) in 86% of the patients, and the risk of embolism during follow-up was significantly lower in this group. The authors conclude that in patients with mitral stenosis and AF, PBC alone is not effective in restoring SR or preventing emboli. They recommend that in selected patients (those most likely to respond to the Maze) an open approach to the valve with Maze is the treatment of choice.
As surgical techniques for control of AF continue to evolve, there will be great potential for the procedure to impact on results achieved in patients requiring an open surgical approach for concomitant valve or coronary disease. As emphasized in this report, comparison of results achieved with open surgical approaches versus percutaneous interventions will be extremely important if we are to obtain optimal results in our patients.
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Consequence of atrial fibrillation and the risk of embolism after percutaneous mitral commissurotomy: The necessity of the maze procedure
- Hiroyuki Nakajima, Junjiro Kobayashi, Ko Bando, Yoshio Yasumura, Satoshi Nakatani, Kohji Kimura, Kazuo Niwaya, Osamu Tagusari, and Soichiro Kitamura
Ann. Thorac. Surg. 2004 78: 800-805.
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