Abstract
Background and Objectives: Surgical atrial fibrillation (AF) ablation concomitant to minimally invasive mitral valve repair has been proven to offer improved short- and long-term sinus rhythm (SR) maintenance compared to mitral valve surgery only. The objective of the present study was to explore, by thorough echocardiographic assessment, long-term morphological and functional left atrial (LA) outcomes after this combined surgical procedure. Materials and Methods: From October 2006 to November 2015, 48 patients underwent minimally invasive mitral valve repair and concomitant surgical AF cryoablation. Results: After 3.8 ± 2.2 years, 30 (71.4%) of those completing the follow-up (n = 42, 87.5%) presented SR. During follow-up, four (9.5%) patients suffered from cerebrovascular accidents and two of these subjects had a long-standing persistent AF relapse and were in AF at the time of the event, while the other two were in SR. An echocardiographic study focused on LA characteristics was performed in 29 patients (69.0%). Atrial morphology and function (e.g., maximal LA volume indexed to body surface area and total LA emptying fraction derived from volumes) in patients with stable SR (60.6 ± 13.1 mL/mq and 25.1 ± 7.3%) were significantly better than in those with AF relapses (76.8 ± 16.2 mL/mq and 17.5 ± 7.4%; respectively, p = 0.008 and p = 0.015). At follow-up, patients who suffered from ischemic cerebral events had maximal LA volume indexed to body surface area 61 ± 17.8 mL/mq, with total LA emptying fraction derived from volumes 23.6 ± 13.7%; patients with strokes in SR showed very enlarged LA volume (>70 mL/mq). Conclusions: AF cryoablation concomitant with minimally invasive mitral valve repair provides a high rate of SR maintenance and this relates to improved long-term morphological and functional LA outcomes. Further prospective studies are needed to define the cut-off values determining an increase in the risk for thromboembolic complications in patients with restored stable SR.
Highlights
At follow-up, patients who suffered from ischemic cerebral events had maximal left atrial (LA) volume indexed to body surface area 61 ± 17.8 Max LA volume (mL)/mq, with total LA emptying fraction derived from volumes 23.6
From October 2006 to November 2015, 48 patients were submitted to minimally invasive mitral valve repair and concomitant Atrial fibrillation (AF) cryoablation
As stated in a previous study of our group [12] we suggest that, at least within patients with severely enlarged left atrium, previous cardiac surgery and catheter or surgical AF ablation, especially if repeated, the assessment of atrial contractility by transthoracic echocardiography should be performed before discontinuing oral anticoagulants (OAC), in patients who maintain sinus rhythm (SR), despite confirmation by serial ECG or Holter monitorings
Summary
Atrial fibrillation (AF) prevalence in patients with indication for mitral valve surgery is about30–54% [1], it has a strong impact on hemodynamics [2], and it has been demonstrated to significantly affect the mortality rate [3,4].Concomitant surgical AF ablation to video-assisted minimally invasive mitral valve surgery (MIMVS) [5,6,7] has been proven to offer improved short- and long-term sinus rhythm (SR) maintenance compared to patients undergoing mitral valve surgery only (73% versus 43% of SR maintenance at 12 months’ follow-up) [8] without increasing complications [9,10].SR maintenance seems achievable, but does this reflect in an improved atrial function?It has been demonstrated that SR maintenance is related to reduced left atrial volumes [11], but little is known about left atrial (LA) functional properties in this clinical setting. Concomitant surgical AF ablation to video-assisted minimally invasive mitral valve surgery (MIMVS) [5,6,7] has been proven to offer improved short- and long-term sinus rhythm (SR) maintenance compared to patients undergoing mitral valve surgery only (73% versus 43% of SR maintenance at 12 months’ follow-up) [8] without increasing complications [9,10]. In patients with underlying mitral valve diseases, atrial remodeling is remarkable: longstanding volume overload to the LA results in chronic stretching and atrophy of atrial myocytes, interstitial fibrosis, overall thinning, and dilatation of the LA wall, which may relate to functional alterations despite the underling electrical activity. Surgical atrial fibrillation (AF) ablation concomitant to minimally invasive mitral valve repair has been proven to offer improved short- and long-term sinus rhythm (SR).
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