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.

• 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.

• 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

• 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.

• 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.

• 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

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.

• 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 managementPostoperative 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.

• 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 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.

• 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).

• 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.

• 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

FemaleFemale

1010( ( 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

Clinical characteristics of the patientsClinical characteristics of the patients

34.7 35.5

16.318.4

2 2.3

0

5

10

15

20

25

30

35

40

ye

ars

Age Rheum. H. dura AF Duration

Contol gp RF gp

34.7 35.5

16.318.4

2 2.3

0

5

10

15

20

25

30

35

40

ye

ars

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

Echocardiographic data Echocardiographic data

55.7 57.4 56.557.5

72.5 73.5

0

10

20

30

40

50

60

70

80

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 RhythmPostoperative Cardiac Rhythm

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•Immediately postoperative

• 6 month 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

12

27

18

3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

control gp RF group

AF SR

Postoperative Cardiac Rhythm

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

res

tora

tion

RF group

control group

Surgical procedure 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 months

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.

• 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

Factors that might be influencingrecurrence of atrial fibrillation

Preoperative variables • Age• Duration of AF• Type of MV disease• Left atrial diameters • Left ventricular EF

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.

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 patients18181212

AgeAge32±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

Comparison of patients' clinicalcharacteristics 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 )

Patients' Intraoperative Findings in RF subgroups ( with and without AF )

16.3

18.817.4

19.2

15.5

19.3

15.3

18.2

02

4

6

8

10

12

14

16

18

20

mm

LSPV LIPV RSPV RIPV

Sinus Rhy. Atrial Fibrill.

Patients' Intraoperative Findings in RF subgroups ( with and without AF )

Patients' Intraoperative Findings in RF subgroups ( with and without AF )

Comparison of patients' echocardiographic data with and without

AF in the RF group

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 patients18181212

Preoperative 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 )

Echocardiographic Findings in the RF (pre & postoperative)

subgroups (with and without AF )

54.961

54.5

62

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

Percentage of SR restoration of patients in RF group according to their left atrial

antero-posterior diameters

Postoperative RhythmPostoperative Rhythm

RF 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 diameters

Postoperative 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

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 S

R r

esto

rati

on

<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

• 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 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.

• 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.