Rhythmic and haemodynamic determinants of long-term survival after radiofrequency ablation of atrial fibrillation in mitral valve surgery

Aims

The aim of the present study was to evaluate the effects of sinus rhythm recovery on long-term survival after radiofrequency (RF) ablation in patients with permanent atrial fibrillation (AF) undergoing surgery for mitral valve disease.

Methods and results

This study included 173 consecutive patients (101 men and 72 women, age 67 ± 9 years) with AF and mitral valve disease who underwent RF ablation procedure associated with mitral valve surgery. Four patients died during hospitalization. At the 6-year follow-up, sinus rhythm was present in 68% of the surviving patients. Thirty-nine patients remained in persistent AF after hospital discharge. In patients with stable sinus rhythm, mortality (10 vs. 30%) and recurrent hospitalization were significantly lower than in patients with persistent AF, but functional capacity improved. The incidence of stroke was also lower in patients with stable sinus rhythm. A pre-operative higher right and left atrial area, pulmonary hypertension, and rheumatic disease were associated with the persistence of AF despite RF ablation. At multivariate analysis, only age and concomitant tricuspid valve repair were independently associated with mortality, whereas the right atria area and tricuspid valve repair were associated with persistent AF.

Conclusion

Although the re-establishment of sinus rhythm by unipolar RF ablation is associated with a higher survival rate after mitral valve surgery, our data suggest that a more severe haemodynamic impairment, in particular in patients with rheumatic valve disease, may be responsible both for higher long-term mortality and lower rate of sinus rate maintenance.

Sinus Rhythm Restoration after Radiofrequency Ablation Improves Survival in Patients Undergoing Mitral Valve Surgery : A Eight Year Single Center Study

Background

The usefulness of radiofrequency (RF) ablation in restoring sinus rhythm in patients with permanent atrial fibrillation (AF) undergoing surgery for mitral valve has been demonstrated. But whether sinus rhythm recovery affects long-term survival is less clear.

Methods

This study included 301 consecutive patients (126 men and 175 women, age 69±6 years) undergoing radiofrequency ablation of persistent atrial fibrillation along with mitral valve surgery. Radiofrequency ablation was performed using unipolar probe in 55.3%, bipolar probe in the remaining 44.7% of cases.

Results

Four patients died during hospitalization. At follow-up, sinus rhythm was present in 76% of the surviving patients. 71 patients never recovered sinus rhythm after hospital discharge. Mortality and recurrent hospitalization were significantly lower in patients with sinus rhythm at the end of follow-up in comparison to permanent AF. The incidence of stroke was also lower in patients with stable sinus rhythm. Larger atria, pulmonary hypertension and history of rheumatic disease were associated with the persistence of AF despite radiofrequency ablation. Although survival and functional capacity were significantly lower in patients with permanent AF at multivariate analysis only age and pulmonary artery pressure before surgery were independently associated with mortality.

Conclusion

Sinus rhythm restoration by RF ablation in patients undergoing mitral valve surgery is associated with an improved long-term survival. However our results suggest that a more severe hemodynamic impairment, expressed by higher pulmonary artery pressure, and increasing age are the only independent factors related to long-term survival.

Maze permutations during minimally invasive mitral valve surgery

Surgical ablation for atrial fibrillation is most frequently done in the concomitant setting, and most commonly with mitral valve surgery. Minimally invasive surgical techniques for the treatment of atrial fibrillation have developed contemporaneously with techniques for minimally invasive mitral valve surgery. As in traditional surgery for atrial fibrillation, there are many different permutations of ablations for the less invasive approaches. Lesion sets can vary from simple pulmonary vein isolation (PVI) to full bi-atrial lesions that completely reproduce the traditional cut-and-sew Cox Maze III procedure with variable efficacy in restoring sinus rhythm. Additionally, treatment of the atrial appendage can be done through minimally invasive approaches without any ablation at all in an attempt to mitigate the risk of stroke. Finally, hybrid procedures combining minimally invasive surgery and catheter-based ablation are being developed that might augment surgical treatment of atrial fibrillation at the time of minimally invasive mitral valve repair. These various permutations and their results are reviewed.