THE RHYTHM IN LIFE THE SEASONS DO NOT PUSH ONE ANOTHER; NEITHER DO CLOUDS RACE THE WIND ACROSS THE...
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THE RHYTHM IN LIFE THE SEASONS DO NOT PUSH ONE ANOTHER; NEITHER DO CLOUDS
RACE THE WIND ACROSS THE SKY. ALL THINGS HAPPEN IN THEIR OWN GOOD TIME.
Chronic AF in patients with Mitral Valve Disease
• Its prevalence might reach up to 75%.• An important marker of more advanced
cardiovascular disease. • The onset of AF is now considered a
relative indication for mitral valve surgery.
• Persistence of postoperative AF is linked to increased mortality & morbidity
• Surgical correction of the valve rarely eliminates the arrhythmia.
Surgical treatment of atrial fibrillation
– Left atrial isolation procedure– Corridor procedure– Cox- Maze procedure– The radial approach– Mini- Maze procedures
• Since the Cox- maze III procedure showed that AF can be definitely eradicated, efforts were made to achieve alternative & particularly
less complex methods using surgical catheter ablation techniques during
cardiac surgery.
Rationale for RF ablation• Based on the hypothesis that the
pulmonary veins and surrounding areas frequently house focal triggers and re-entrant circuits critical to the genesis and perpetuation of AF, it was postulated that circumferential isolation of pulmonary veins eliminates or isolates the arrhythmogenic activity that perpetuates chronic AF within the pulmonary veins
An ideal lesion pattern should combine:
• Slight invasiveness• Simplicity• High reproducibility• Saving of time• With excellent success rate.• Radiofrequency ablation
techniques must guarantee lesion transmularity & continuity without cardiac tissue injury.
• The purpose of this study is to assess the feasibility, safety , &efficacy of circumferential isolation of each pulmonary vein using endocardial radiofrequency pulses to restore stable sinus rhythm during mitral valve surgery.
• Also, to identify the clinical predictors to sinus rhythm restoration and left atrial mechanical contraction in this group of patients.
• This is a prospective randomized controlled study. It had been conducted on sixty patients known to have rheumatic mitral valve disease and chronic atrial fibrillation, referred to the National Heart Institute, for mitral valve surgery between November 2001 and November 2004.
• They were divided into two groups according to being subjected to surgical ablation of chronic atrial fibrillation using radiofrequency energy in addition to the mitral valve surgery.
• Exclusion criteria:• Patients with associated aortic valve disease
are excluded from the study due to expected elongation of cross clamp time needed for double valve replacement.
• All patients were subjected to the following:
• Clinical assessment• Electrocardiography• Echocardiography• Surgical procedure
• Surgical procedure :• Tricuspid valve repair on a beating heart
.• Warm cardioplegia .• Normothermia ( core temperature
36°C ) . • Mitral valve surgery .• Lastly, RF endocardial ablation was
performed under temperature control.
• RF pulses were delivered under temperature control not exceeding 70 °C for a period of 2 min. aiming to produce continuous lesion lines to encircle each pulmonary vein without any interconnecting lines. The duration of ablation for each point was not less than 8-10 seconds.
Scheme of the procedure : circumferential isolation of each pulmonary vein
• Antiarrhythmic medications : all patients were started on a loading dose of amiodarone in the early post-operative period, followed by a maintenance dose of 200 mg/day for 3 months.
• In case of postoperative AF prior to hospital discharge, electric cardioversion was attempted either alone or in combination with the administration of amiodarone.
Postoperative management
Follow-up• Follow - up was performed on post-
operative days 1, 7, & 14 and after 1, 3 & 6 months.
• At each follow- up visit, clinical history, ECG, and echocardiogram were obtained.
Anticoagulation regimen
• The anticoagulation regimen was started on the second postoperative day by IV heparin administered to each patient in the two groups, with the activated partial thromboplastin time kept between 1.5 & 2 times that of the control time for 7-14 days until the targeted INR was reached.
• This study included 60 patients referred for elective mitral valve surgery +/- tricuspid valve repair.
• The patients included 19 men & 41 women, ranging in age from 18 to 65 years (average 35.5 ± 11.9 y).
• Patients were subdivided into two groups :• Group (A): thirty patients who were subjected
to circumferential pulmonary vein isolation using RF ablation in addition to the mitral valve surgery (RF group).
• Group (B): another thirty patients were subjected to mitral valve surgery alone without any ablative procedures for the atrial fibrillation and served as the control group.
Clinical dataClinical dataRFRF groupgroupGroup AGroup A
N=30N=30
Control groupControl group Group BGroup B
N=30N=30
p p valuevalue
Age (yrs)Age (yrs)35.535.5++12.912.9(18-65)(18-65)
34.734.7++11.011.0(18-55)(18-55)NSNS
GenderGenderMaleMale
FemaleFemale1010( ( 33.3%33.3%))2020((66.7%66.7%))
99((30%30%))2121((70%70%))NSNS
Duration of AFDuration of AF(years)(years)
2.3±12.3±1(1-5)(1-5)
2.02.0++0.800.80(0.5-4)(0.5-4)NSNS
Duration of Duration of rheumatic historyrheumatic history
((yearsyears))18.418.4++8.88.816.316.3++5.065.06NSNS
Clinical characteristics of the patients
Clinical characteristics of the patients
34.7 35.5
16.318.4
2 2.3
0
5
10
15
20
25
30
35
40
year
s
Age Rheum. H. dura AF Duration
Contol gp RF gp
Echocardiographic dataEchocardiographic dataGroup AGroup A((RF groupRF group))
Group BGroup B(control group )(control group )p valuep value
LVEDD (mm)LVEDD (mm)5757++0.450.4555.955.9++0.50.5NSNS
LVESD(mm)LVESD(mm)40.540.5++0.50.538.638.6++0.60.6NSNS
FSFS%%3030++443131++55NSNS
EFEF% % 5959++666060++66NSNS
LA. Antero-posterior diameter. (mm)LA. Antero-posterior diameter. (mm)57.457.4++5.75.7((48-6848-68))
55.755.7++5.35.3(46-67)(46-67)NSNS
LA. Medio-lateral diameter. (mm)LA. Medio-lateral diameter. (mm)57.557.5++7.37.3((45-7545-75))
56.556.5++6.46.4(45-75)(45-75)NSNS
LA. Superior-inferior diameter. (mm)LA. Superior-inferior diameter. (mm)73.573.5++11.111.1((58-9758-97))
72.572.5++9.59.5((58-9258-92))NSNS
Echocardiographic data
Echocardiographic data
55.7 57.4 56.557.5
72.5 73.5
0
1020
30
4050
60
7080
mm
.
Ant-post diam Medio-lat diam Sup-inf diam
Contol gp RF gp
Postoperative RhythmPostoperative RhythmGroup AGroup A
))RF groupRF group(( N=30N=30
Group BGroup B))control groupcontrol group( (
N=30N=30p valuep value
Immediately postoperativeImmediately postoperativeAFAFSRSRJRJR
2(6.7%)2(6.7%)20(66.7%)20(66.7%)8(26.6%)8(26.6%)
20(66.7%)20(66.7%)10(33.3%) 10(33.3%)
00<0.001*<0.001*
At hospital dischargeAt hospital dischargeAFAFSRSRJRJR
4(13.3%)4(13.3%)25(83.3%)25(83.3%)
1(3.3%)1(3.3%)
20(66.7%)20(66.7%)10(33.3%)10(33.3%)
00<0.001*<0.001*
33 month postoperativemonth postoperativeAFAFSRSR
9(30%)9(30%)21(70%)21(70%)
24(80%)24(80%)6(20%)6(20%)<0.001*<0.001*
66 month postoperativemonth postoperativeAFAFSRSR
12(40%)12(40%)18(60%)18(60%)
27(90%)27(90%)3(10%)3(10%)<0.001*<0.001*
Postoperative Cardiac Rhythm
Postoperative Cardiac Rhythm
2
2020
10 8
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
control gp RF group
AF SR JR
•Immediately postoperative
• 6 month postoperative
12
27
18
3
0%10%
20%
30%
40%50%
60%
70%
80%90%
100%
control gp RF group
AF SR
Postoperative Cardiac Rhythm
Percentage of SR restoration in both RF and control groups
percentage of SR restoration in both the RF and the control group
0102030405060708090
100
follow-up period
% o
f SR
rest
orat
ion
RF groupcontrol group
Surgical procedure RF groupRF group(group A)(group A)
Control groupControl group(group B)(group B)p valuep value
CPB (min.)CPB (min.)86± 7.786± 7.769.8± 5.969.8± 5.9<0.001<0.001
ACC (min.)ACC (min.)64.2± 8.764.2± 8.752.4± 6.2552.4± 6.25<0.001<0.001
MVRMVR28283030
MV repairMV repair1100
MV redoMV redo1100
Associated TV Associated TV repair repair 23232121
Early Early complicationscomplications
Cardiac tamponadeCardiac tamponademediastinitismediastinitisCardiac tamponadeCardiac tamponade
Echocardiographic data of the patients in RF group: preoperatively, immediately
postoperative, & after 6 monthsEchocardiographic Echocardiographic
datadataPreoperativePreoperativeImmediate Immediate postoperativepostoperative
6months 6months postoperativepostoperative
LVEDD ( mm)LVEDD ( mm)5757++0.450.4557 ± 0.4657 ± 0.4656.4 ± 0.2856.4 ± 0.28
LVESD (mm)LVESD (mm)40.540.5++0.50.540.6 ± 0.4940.6 ± 0.4938.4 ± 0.3238.4 ± 0.32
FS %FS %3030++4428 ± 428 ± 432 ± 332 ± 3
EF %EF %5959++6656 ± 656 ± 661 ± 561 ± 5
LA. Antero-LA. Antero-posterior diameter. posterior diameter. (mm)(mm)
57.457.4++5.75.750.4 ± 6.850.4 ± 6.851.1 ± 7.251.1 ± 7.2
LA. Medio-lateral LA. Medio-lateral diameter. (mm)diameter. (mm)57.557.5++7.37.351.6 ± 5.551.6 ± 5.550.5 ± 6.550.5 ± 6.5
LA. Superior-inferior LA. Superior-inferior diameter.(mm)diameter.(mm)73.573.5++11.111.165.965.9 ± ± 7.97.964.9 ± 9.464.9 ± 9.4
• Biatrial contraction was documented by the presence of A wave transmitral and tricuspid flow using transthoracic Doppler echocardiography in 83.6% of patients in SR in the RF group within six months of the operation.
Echocardiographic data of patients in control group: preoperatively, immediately
postoperative, & after 6 monthsEchocardiographiEchocardiographi
c datac dataPreoperativePreoperativeImmediate Immediate postoperativepostoperative
6 months 6 months postoperativepostoperative
LVEDD ( mm)LVEDD ( mm)55.955.9+ + 0.520.5256.1 ± 0.4656.1 ± 0.4655.2 ± 0.3655.2 ± 0.36
LVESD (mm)LVESD (mm)38.638.6++0.60.639.9 ± 0.4939.9 ± 0.4937.4 ± 0.3737.4 ± 0.37
FS %FS %3131+ + 5529 ± 429 ± 432 ± 332 ± 3
EF %EF %6060+ + 6657 ± 657 ± 662 ± 562 ± 5
LA. Antero-LA. Antero-posterior posterior diameter. (mm)diameter. (mm)
55.755.7++5.35.350.1 ± 5.050.1 ± 5.052.5 ± 4.852.5 ± 4.8
LA. Medio-lateral LA. Medio-lateral diameter. (mm)diameter. (mm)56.556.5++6.46.451.1 ± 4.551.1 ± 4.550.4 ± 4.550.4 ± 4.5
LA. Superior-LA. Superior-inferior diameter.inferior diameter.(mm)(mm)
72.572.5++9.59.565.5 ± 6.465.5 ± 6.463.8 ± 5.363.8 ± 5.3
Factors that might be influencing recurrence of atrial fibrillation
Preoperative variables • Age• Duration of AF• Type of MV disease• Left atrial diameters • Left ventricular EF
Intraoperative variables• Duration of CPB• Duration ACC• Diameter of dilated of
pulmonary vein orifices.
CharacteristicCharacteristicSinus rhythmSinus rhythmAtrial Atrial fibrillationfibrillationp value p value
No of patientsNo of patients18181212AgeAge32±12.232±12.240±12.840±12.8NS NS
Duration of rheumatic Duration of rheumatic process (yrs) process (yrs)
15 ± 515 ± 522 ± 1122 ± 11NS NS
AF duration(yrs)AF duration(yrs)1.8±0.71.8±0.73±1.143±1.14<.002 <.002
Comparison of patients' clinical characteristics with and without AF
in the RF group
CharacteristicCharacteristicSinus rhythmSinus rhythmAtrial Atrial fibrillationfibrillationp valuep value
No of patientsNo of patients18181212
LSPV (mm)LSPV (mm)16.3±2.516.3±2.518.8±2.318.8±2.3<.017<.017
LIPV (mm)LIPV (mm)17.4±4.317.4±4.319.2±2.319.2±2.3<.011<.011
RSPV(mm)RSPV(mm)15.5±3.315.5±3.319.3±4.119.3±4.1<.004<.004
RIPV(mm)RIPV(mm)15.3±2.315.3±2.318.2±4.218.2±4.2<.043<.043
CPB(min)CPB(min)86.4± 886.4± 885± 7.585± 7.5NSNS
Patients' Intraoperative Findings in RF subgroups ( with and without AF )
16.318.8
17.419.2
15.5
19.3
15.3
18.2
02468
101214161820
mm
LSPV LIPV RSPV RIPV
Sinus Rhy. Atrial Fibrill.
Patients' Intraoperative Findings in RF subgroups ( with and without AF )
Comparison of patients' echocardiographic data with and without
AF in the RF groupCharacteristicCharacteristic
RF group RF group p valuep value
Sinus rhythmSinus rhythmAtrial fibrillationAtrial fibrillation
No of patientsNo of patients18181212Preoperative LA diameterPreoperative LA diameter
[antero-post.] mm[antero-post.] mm54.9±4.754.9±4.761±5.161±5.1<.005<.005
Postoperative LA diameter Postoperative LA diameter [antero-post.] mm[antero-post.] mm46.2±446.2±458.4±5.758.4±5.7<0.001<0.001
% change in LA diameter% change in LA diameter [anter-post.][anter-post.]15%15%5%5%<0.001<0.001
Preoperative LA diameterPreoperative LA diameter [med.-lat.] mm[med.-lat.] mm54.5±5.254.5±5.262±7.762±7.7<.01<.01
Postoperative LA diameterPostoperative LA diameter [med.-lat.] mm[med.-lat.] mm46.8±2.746.8±2.755.9±6.755.9±6.7<.001<.001
Preoperative LA diameterPreoperative LA diameter [sup.-inf.] mm[sup.-inf.] mm68.6±8.768.6±8.780.1±10.580.1±10.5<.002<.002
Postoperative LA diameterPostoperative LA diameter [sup.-inf.] mm[sup.-inf.] mm6o.6±5.06o.6±5.071.4±10.971.4±10.9<.001<.001
Echocardiographic Findings (pre & postoperative) in the RF subgroups (with and without AF )
54.961
54.562
68.6
80.1
0
10
20
30
40
50
60
70
80
90
mm
Pre AP Pre ML Pre SI
Sinus Rhy. Atrial Fibrill.
Percentage of SR restoration of patients in RF group according to their left atrial
antero-posterior diameters
Postoperative RhythmPostoperative RhythmRF GroupRF Group
Group (1)Group (1)≤≤54mm (n= 12)54mm (n= 12)
Group (2)Group (2)55-59mm (n=8)55-59mm (n=8)
Group (3)Group (3) ≥ ≥60mm (n=1060mm (n=10))
Immediately postoperativeImmediately postoperativeSRSRAFAF
1212((100%100%))((0%0%))
7(87.5%)7(87.5%)1(12.5%)1(12.5%)
9(90%)9(90%)1(10%)1(10%)
At hospital dischargeAt hospital dischargeSRSRAFAF
11(91.6%)11(91.6%)1(8.3%)1(8.3%)
77((87.5%87.5%))11((12.5%12.5%))
8(80%)8(80%)2(20%)2(20%)
33 month postoperativemonth postoperativeSRSRAFAF
11(91.6%)11(91.6%)1(8.3%)1(8.3%)6(75%)6(75%)
2(25%)2(25%)4(40%)4(40%)6(60%)6(60%)
66 month postoperativemonth postoperativeSRSRAFAF
11(91.6%)11(91.6%)1(8.3%)1(8.3%)
4(50%)4(50%)4(50%)4(50%)3(30%)3(30%)
7(70%)7(70%)
Percentage of SR restoration of patients in control group according to their left atrial antero-
posterior diametersPostoperative Postoperative RhythmRhythm
Group (1)Group (1)≥≥54mm54mm(n= 15)(n= 15)
Group (2)Group (2)55-59mm55-59mm
(n=8)(n=8)
Group (3)Group (3)≤ ≤ 60mm60mm
(n=7)(n=7)
Immediately Immediately postoperativepostoperative
SRSR AFAF
99((60%60%))66((40%40%))
11((12.5%12.5%))7(87.5%)7(87.5%)
0(0%)0(0%)7(100%)7(100%)
Immediately Immediately postoperativepostoperative
SRSR AFAF
7(46.6%)7(46.6%)8(53.3%)8(53.3%)
22((25%25%))6(75%) 6(75%)
1(14.3%)1(14.3%)6(85.7%)6(85.7%)
33 month month postoperativepostoperative
SRSR AFAF
6(40%)6(40%)9(60%)9(60%)0(0%)0(0%)
8(100%)8(100%)0(0%)0(0%)
7(100%)7(100%)
66 month month postoperativepostoperative
SRSR AFAF
3(20%)3(20%)12(80%)12(80%)0(0%)0(0%)
8(100%)8(100%)0(0%)0(0%)
7(100%)7(100%)
Percentage of SR restoration in RF group according to the left atrial
diameters
0
20
40
60
80
100
120
immediate at hospital 3 months 6 months
follow-up period
% o
f SR
rest
orat
ion
<54 mm
55-59mm
>60mm
• Data in this study are encouraging for using this new approach in eliminating AF associated with mitral valve disease.
• Simple "circumferential isolation of each pulmonary vein" ablation lines met the essential requirements to eliminate AF; is simple, easy, and quick to perform; effectively eliminated AF
• It helped in restoration and maintenance of a normal sinus rhythm in a considerable percentage of patients with long standing AF secondary to mitral valve disease at an average follow-up period of six months.
• Atrial transport function was restored in 83.6% of the patients in SR.
• It is effective and does not require either new technical resources or additional training of surgical teams.
• The preoperative left atrial diameter and preoperative AF duration are important determinant that might be influencing the sinus conversion rate.