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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.