Cardiac Autotransplantation for the Treatment of Permanent Atrial Fibrillation Combined with Mitral Valve Disease
DOI:
https://doi.org/10.1532/hsf.545Abstract
Objective: The results of current surgical options for the treatment of permanent atrial fibrillation associated with mitral valve surgery are widely different, particularly for extremely dilated left atria. The aim of this study is to assess the efficacy of cardiac autotransplantation in restoring a normal sinus rhythm via a consistent reduction in the left atrium volume associated with a complete isolation of the pulmonary veins.
Methods: From April 2000 to April 2002, 28 patients (men/women, 5/23) underwent cardiac autotransplantation for the treatment of mitral disease and concomitant permanent atrial fibrillation (>1 year). A modified surgical technique derived from bicaval heart transplantation procedures maintained the connection of the right atrium with the inferior vena cava in all but 3 cases. In 2 patients, the mitral valve was repaired, and it was replaced in 26 patients. Associated procedures were 6 aortic valve replacements, 2 tricuspid valve annuloplasties, and 2 coronary revascularizations.
Results: No hospital deaths were recorded, but 1 patient died of pneumonia 3 months postoperatively. At a mean follow-up period of 17.2 ± 6.7 months (range, 6-30 months), 24 patients (88.9%) were in sinus rhythm, and 3 (11.1%) were in atrial fibrillation. The Santa Cruz Score was 0 for 3 patients, 2 for 1 patient, and 4 for the remaining 23 patients (85.2%). The mean left atrial diameter decreased from 65.4 ± 17.1 mm (range, 50-130 mm) before the operation to 48.4 ± 5.6 mm (range, 37-78 mm) postoperatively (P < .001), and the mean left atrial volume decreased from 119 ± 70.5 mL (range, 60-426 mL) to 69.1 ± 35.1 mL (range, 31-226 mL) (P < .0001). Conclusion: Cardiac autotransplantation is a safe and effective surgical option for the treatment of permanent atrial fibrillation in patients with long-lasting mitral valve disease and severe enlargement of the left atrium.
References
Keren G, Etzion T, Sherez J, et al. 1987. Atrial fibrillation and atrial enlargement in patients with mitral stenosis. Am Heart J 114:1146-55.nKobayashi J, Kosakai Y, Nakano K, Sasako Y, Eishi K, Yamamoto F. 1998. Improved success rate of the maze procedure in mitral valve disease by new criteria for patients' selection. Eur J Cardiothorac Surg 13:247-52.nKopecky SL, Gersh BJ, McGoon MD, et al. 1987. The natural history of lone atrial fibrillation: a population based study over three decades. N Engl J Med 317:669-74.nKosakai Y. 2000. Treatment of atrial fibrillation using the maze procedure: the Japanese experience. Semin Thorac Cardiovasc Surg 12:44-52.nMcCarthy PM, Gillinov MG, Castle L, Chung M, Cosgrove D III. 2000. The Cox-Maze procedure: the Cleveland Clinic experience. Semin Thorac Cardiovasc Surg 12:25-9.nMelo J, Adragao P, Neves J, et al. 2000. Endocardial and epicardial radiofrequency ablation in the treatment of atrial fibrillation with a new intra-operative device. Eur J Cardiothorac Surg 18:182-6.nMelo JQ, Neves J, Adragao P, et al. 1997. When and how to report results of surgery on atrial fibrillation. Eur J Cardiothorac Surg 12:739-44.nOnundarson PT, Thorgeirsson G, Jonmundsson E, Sigfusson N, Hardarson T. 1987. Chronic atrial fibrillation: epidemiologic features and 14 year follow-up: a case control study. Eur Heart J 8:521-7.nSanfilippo AJ, Abascal VM, Sheehan M, et al. 1990. Atrial enlargement as a consequence of atrial fibrillation: a prospective echocardiographic study. Circulation 82:792-7.nSie HT, Beukema WP, Ramdat Misier AR, et al. 2001. Radiofrequency modified maze in patients with atrial fibrillation undergoing concomitant cardiac surgery. J Thorac Cardiovasc Surg 122:249-56nSueda T, Katsuhiko I, Ishii O, Orihashi O, Watari M, Okada K. 2001. Efficacy of pulmonary vein isolation for the elimination of chronic atrial fibrillation in cardiac valvular surgery. Ann Thorac Surg 71:1189-93.nVaturi M, Sagie A, Shapira Y, et al. 2001. Impact of atrial fibrillation on clinical status, atrial size and haemodynamics in patients after mitral valve replacement. J Heart Valve Dis 10:763-6.nYuda S, Nakatani S, Kosakai Y, Yamagishi M, Miyatake K. 2001. Long-term follow-up of atrial contraction after the maze procedure in patients with mitral valve disease. J Am Coll Cardiol 37:1622-7.nGersak B, Sutlic Z. 2002. Aortic and mitral valve surgery on the beating heart is lowering cardiopulmonary bypass and aortic cross clamp time. Heart Surg Forum 5:182-6.nHaines DE. 2000. In atrial fibrillation, size does matter [editorial comment]. J Cardiovasc Electrophysiol 11:1407-8.nHaissaguerre M, Jais P, Shah DC, et al. 1998. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 339:659-66.nHarada A, Konishi T, Fukata M, Higuchi K, Sugimoto T, Sasaki K. 2000. Intraoperative map guided operation for atrial fibrillation due to mitral valve disease. Ann Thorac Surg 69:446-51.nHirosawa K, Sekiguchi M, Kasanuki H, et al. 1987. Natural history of atrial fibrillation. Heart Vessels Suppl 2:14-23.nKannel WB, Abbott RD, Savage DD, McNamara PM. 1982. Epidemiologic features of atrial fibrillation: the Framingham study. N Engl J Med 306:10118-22.nKawaguchi AT, Kosakai Y, Sasako Y, Eishi K, Nakano K, Kawashima Y. 1996. Risks and benefit of combined maze procedure for atrial fibrillation associated with organic heart disease. J Am Coll Cardiol 28:985-90.nAlbirini A, Scalia GM, Murray RD, et al. 1997. Left and right atrial transport function after the maze procedure for atrial fibrillation: an echocardiographic Doppler follow-up study. J Am Soc Echocardiogr 10:937-45.nAllessie MA. 1998. Atrial electrophysiologic remodeling: another vicious circle? J Cardiovasc Electrophysiol 9:1378-93.nBando K, Kobayashi J, Kosakai Y, et al. 2002. Impact of Cox maze procedure on outcome in patients with atrial fibrillation and mitral valve disease. J Thorac Cardiovasc Surg 124:575-83.nBenussi S, Pappone C, Nascimbene S, et al. 2000. A simple way to treat chronic atrial fibrillation during mitral valve surgery: the epicardial radiofrequency approach. Eur J Cardiothorac Surg 17:524-9.nChua YL, Schaff HV, Orszulak TA, Morris JJ. 1994. Outcome of mitral valve repair in patients with preoperative atrial fibrillation: should the maze procedure be combined with mitral valvuloplasty? J Thorac Cardiovasc Surg 107:208-15.nCox JL. 2001. Intraoperative options for treating atrial fibrillation associated with mitral valve disease [editorial comment]. J Thorac Cardiovasc Surg 122:212-5.nCox JL, Schuessler RB, D'Agostino HJ, et al. 1991. The surgical treatment of atrial fibrillation, III: development of a definitive surgical procedure. J Thorac Cardiovasc Surg 101:569-83.n
