Transcript Presentation1 - The Egyptian Cardiac Rhythm Association

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 reentrant 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
Postoperative management
•
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.
Follow-up
• Follow - up was performed on postoperative 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 characteristics of the
patients
Clinical data
RF group
Group A
N=30
Control
group
Group B
N=30
p
value
Age (yrs)
35.5+12.9
)65-18(
34.7+11.0
)55-18(
NS
Gender
Male
Female
10 (33.3%)
20(66.7%)
9(30%)
21(70%)
NS
Duration of AF
(years)
1±2.3
)5-1(
2.0+0.80
)4-0.5(
NS
Duration of
rheumatic history
(years)
18.4+8.8
16.3+5.06
NS
Clinical characteristics of the patients
Contol gp
RF gp
40
34.7
35.5
35
years
30
25
18.4
20
16.3
15
10
5
2
2.3
0
Age
Rheum. H. dura
AF Duration
Echocardiographic data
Echocardiographic data
Group A
(RF group)
Group B
(control group )
p value
LVEDD (mm)
0.45+57
55.9+0.5
NS
LVESD(mm)
0.5+40.5
38.6+0.6
NS
FS%
4+30
31+5
NS
EF %
6+59
60+6
NS
LA. Antero-posterior diameter. (mm)
57.4+5.7
(48-68)
55.7+5.3
)67-46(
NS
LA. Medio-lateral diameter. (mm)
57.5+7.3
(45-75)
56.5+6.4
)75-45(
NS
LA. Superior-inferior diameter. (mm)
73.5+11.1
(58-97)
72.5+9.5
(58-92)
NS
Echocardiographic data
Contol gp
RF gp
72.5 73.5
80
70
60
55.7
57.4
56.5
57.5
mm.
50
40
30
20
10
0
Ant-post diam
Medio-lat diam
Sup-inf diam
Postoperative Cardiac Rhythm
Postoperative Rhythm
Immediately postoperative
AF
SR
JR
At hospital discharge
AF
SR
JR
3 month postoperative
AF
SR
6 month postoperative
AF
SR
Group A
(RF group)
N=30
Group B
(control group )
2(6.7%)
20(66.7%)
8(26.6%)
20(66.7%)
10(33.3%)
4(13.3%)
25(83.3%)
1(3.3%)
20(66.7%)
10(33.3%)
0
<0.001*
9(30%)
21(70%)
24(80%)
6(20%)
<0.001*
12(40%)
18(60%)
27(90%)
3(10%)
<0.001*
p value
N=30
<0.001*
0
Postoperative Cardiac
Rhythm
•Immediately postoperative
AF
SR
JR
100%
90%
10
8
80%
70%
60%
50%
40%
20
20
30%
20%
10%
2
0%
control gp
RF group
Postoperative Cardiac
Rhythm
• 6 month postoperative
AF
100%
90%
SR
3
80%
18
70%
60%
50%
27
40%
30%
12
20%
10%
0%
control gp
RF group
Percentage of SR restoration in both RF and
control groups
100
90
80
70
60
50
40
30
20
10
0
RF group
th
s
on
6
m
on
3
ch
ho
sp
ita
ld
is
m
ia
te
ar
ge
th
s
control group
im
m
ed
% of SR restoration
percentage of SR restoration in both
the RF and the control group
follow-up period
Surgical procedure
RF group
(group A)
Control group
(group B)
p value
CPB (min.)
86± 7.7
69.8± 5.9
<0.001
ACC (min.)
64.2± 8.7
52.4± 6.25
<0.001
MVR
28
30
MV repair
1
0
MV redo
1
0
Associated TV
repair
23
21
Early
complications
Cardiac tamponade
mediastinitis
Cardiac tamponade
Echocardiographic data of the patients in RF
group: preoperatively, immediately
postoperative, & after 6 months
Echocardiographic
data
Preoperative
Immediate
postoperative
6months
postoperative
LVEDD ( mm)
57+0.45
57 ± 0.46
56.4 ± 0.28
LVESD
40.5+0.5
40.6 ± 0.49
38.4 ± 0.32
(mm)
FS
%
30+4
28 ± 4
32 ± 3
EF
%
59+6
56 ± 6
61 ± 5
LA. Anteroposterior diameter.
(mm)
57.4+5.7
50.4 ± 6.8
51.1 ± 7.2
LA. Medio-lateral
diameter. (mm)
57.5+7.3
51.6 ± 5.5
50.5 ± 6.5
LA. Superior-inferior
diameter.(mm)
73.5+11.1
65.9 ± 7.9
64.9 ± 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 months
Echocardiograph
ic data
Preoperative
Immediate
postoperative
6 months
postoperative
LVEDD ( mm)
55.9 + 0.52
56.1 ± 0.46
55.2 ± 0.36
38.6+0.6
39.9 ± 0.49
37.4 ± 0.37
LVESD
(mm)
FS
%
31 + 5
29 ± 4
32 ± 3
EF
%
60 + 6
57 ± 6
62 ± 5
LA. Anteroposterior
diameter. (mm)
55.7+5.3
50.1 ± 5.0
52.5 ± 4.8
LA. Medio-lateral
diameter. (mm)
56.5+6.4
51.1 ± 4.5
50.4 ± 4.5
LA. Superiorinferior
diameter.(mm)
72.5+9.5
65.5 ± 6.4
63.8 ± 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.
Comparison of patients' clinical
characteristics with and without AF
in the RF group
Characteristic
Sinus rhythm
Atrial
fibrillation
No of patients
18
12
Age
32±12.2
40±12.8
NS
Duration of rheumatic
process (yrs)
15 ± 5
22 ± 11
NS
AF duration(yrs)
1.8±0.7
3±1.14
<.002
p value
Patients' Intraoperative Findings in RF
subgroups ( with and without AF )
Characteristic
Sinus rhythm
No of patients
18
12
16.3±2.5
18.8±2.3
<.017
LIPV (mm)
17.4±4.3
19.2±2.3
<.011
RSPV(mm)
15.5±3.3
19.3±4.1
<.004
RIPV(mm)
15.3±2.3
18.2±4.2
<.043
CPB(min)
86.4± 8
85± 7.5
NS
LSPV (mm)
Atrial fibrillation p value
Patients' Intraoperative Findings in RF
subgroups ( with and without AF )
mm
Sinus Rhy.
20
18
16
14
12
10
8
6
4
2
0
18.8
19.2
19.3
18.2
17.4
16.3
LSPV
Atrial Fibrill.
15.5
LIPV
RSPV
15.3
RIPV
Comparison of patients'
echocardiographic data with and without
AF in the RF group
RF group
Characteristic
p value
Sinus rhythm
Atrial fibrillation
No of patients
18
12
Preoperative LA diameter
[antero-post.] mm
54.9±4.7
61±5.1
<.005
Postoperative LA diameter
[antero-post.] mm
46.2±4
58.4±5.7
<0.001
% change in LA diameter
[anter-post.]
15%
5%
<0.001
Preoperative LA diameter
[med.-lat.] mm
54.5±5.2
62±7.7
<.01
Postoperative LA diameter
[med.-lat.] mm
46.8±2.7
55.9±6.7
<.001
Preoperative LA diameter
[sup.-inf.] mm
68.6±8.7
80.1±10.5
<.002
Postoperative LA diameter
[sup.-inf.] mm
6o.6±5.0
71.4±10.9
<.001
Echocardiographic Findings
e & postoperative) in the RF subgroups
(with and without AF )
Sinus Rhy.
Atrial Fibrill.
90
80.1
80
68.6
70
mm
60
62
61
54.9
54.5
50
40
30
20
10
0
Pre AP
Pre ML
Pre SI
Percentage of SR restoration of patients in RF
group according to their left atrial
antero-posterior diameters
RF Group
Postoperative Rhythm
Group (1)
≤54mm (n= 12)
Group (2)
55-59mm (n=8)
Group (3)
≥ 60mm (n=10)
Immediately postoperative
SR
AF
12(100%)
(0%)
7(87.5%)
1(12.5%)
9(90%)
1(10%)
At hospital discharge
SR
AF
11(91.6%)
1(8.3%)
)%87.5(7
)%12.5(1
8(80%)
2(20%)
6(75%)
2(25%)
4(40%)
6(60%)
3 month postoperative
SR
AF
11(91.6%)
1(8.3%)
6 month postoperative
SR
AF
11(91.6%)
1(8.3%)
4(50%)
4(50%)
3(30%)
7(70%)
Percentage of SR restoration of patients in
control group according to their left atrial anteroposterior diameters
Postoperative
Rhythm
Immediately
postoperative
SR
AF
Immediately
postoperative
SR
AF
3 month
postoperative
SR
Group (1)
≤54mm
(n= 15)
Group (2)
55-59mm
(n=8)
9(60%)
6(40%)
1(12.5%)
7(87.5%)
7(46.6%)
8(53.3%)
2(25%)
6(40%)
9(60%)
6(75%)
0(0%)
8(100%)
Group (3)
≥ 60mm
(n=7)
0(0%)
7(100%)
1(14.3%)
6(85.7%)
0(0%)
7(100%)
AF
6 month
postoperative
SR
3(20%)
12(80%)
0(0%)
8(100%)
0(0%)
7(100%)
Percentage of SR restoration in RF
group according to the left atrial
diameters
% of SR restoration
120
100
80
<54 mm
60
55-59mm
>60mm
40
20
0
immediate
at hospital
3 months
follow-up period
6 months
• 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.