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Atrial Size Reduction and Right Pulmonary Vein Isolation for Treatment of Atrial Fibrillation in Mitral Valve Surgery
Omer Dzemali,Mirella Scherer,1Sadi Bexheti,Alexandra Miskovic,Gerhard Wimmer-Greinecker,Anton Moritz,Peter Kleine
The Cardiology , 2011,
Abstract: Pulmonary vein focal activity and left atrial size are major factors in the initiation and maintenance of atrial fibrillation. We tested a technically safe and simple method of atrial size reduction and right pulmonary vein exclusion on its effectiveness to restore sinus rhythm. The technique had to be compatible with a minimally invasive approach. From November 2001 to July 2002, 25 patients (mean age 62?12) suffering from chronic atrial fibrillation associated with mitral valve disease were included. Atrial size reduction was achieved by closure of the left atrial appendage, plication of the posterior left atrial wall and septum. The right pulmonary vein was dissected and reanastomosed. Nine of the operations were performed minimally invasive using the Chitwood technique. Mean cardiopulmonary bypass and aortic cross clamp times were 149?37 min and 89?22 min. respectively. There were no peri- or postoperative deaths. Atrial diameter, evaluated by repeated echocardiography, was reduced from 52?9 mm to 44?8 mm. All patients could be converted to sinus rhythm intraoperatively. During hospital stay 80% of patients returned to atrial fibrillation, but conversion rate increased significantly during follow-up. One year after surgery, 83,3 % of patients showed stable sinus rhythm with reduced antiarrhythmic medication. Exclusion of the right pulmonary veins in combination with left atrial size reduction added little complexity and risk to mitral valve surgery. Stable sinus rhythm was present in 83% of patients at one year follow up. Additional radio frequency ablation is currently evaluated and may further improve results.
Atrial Size Reduction and Right Pulmonary Vein Isolation for Treatment of Atrial Fibrillation in Mitral Valve Surgery
Omer Dzemali,Mirella Scherer,1Sadi Bexheti,Alexandra Miskovic
The Cardiology , 2005,
Abstract: Pulmonary vein focal activity and left atrial size are major factors in the initiation and maintenance of atrial fibrillation. We tested a technically safe and simple method of atrial size reduction and right pulmonary vein exclusion on its effectiveness to restore sinus rhythm. The technique had to be compatible with a minimally invasive approach. From November 2001 to July 2002, 25 patients (mean age 62?12) suffering from chronic atrial fibrillation associated with mitral valve disease were included. Atrial size reduction was achieved by closure of the left atrial appendage, plication of the posterior left atrial wall and septum. The right pulmonary vein was dissected and reanastomosed. Nine of the operations were performed minimally invasive using the Chitwood technique. Mean cardiopulmonary bypass and aortic cross clamp times were 149?37 min and 89?22 min. respectively. There were no peri- or postoperative deaths. Atrial diameter, evaluated by repeated echocardiography, was reduced from 52?9 mm to 44?8 mm. All patients could be converted to sinus rhythm intraoperatively. During hospital stay 80% of patients returned to atrial fibrillation, but conversion rate increased significantly during follow-up. One year after surgery, 83,3 % of patients showed stable sinus rhythm with reduced antiarrhythmic medication. Exclusion of the right pulmonary veins in combination with left atrial size reduction added little complexity and risk to mitral valve surgery. Stable sinus rhythm was present in 83% of patients at one year follow up. Additional radio frequency ablation is currently evaluated and may further improve results.
Protein Analysis of Atrial Fibrosis via Label-Free Proteomics in Chronic Atrial Fibrillation Patients with Mitral Valve Disease  [PDF]
Peide Zhang, Wei Wang, Xin Wang, Xu Wang, Yunhu Song, Yong Han, Jing Zhang, Hui Zhao
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0060210
Abstract: Background Atrial fibrosis, as a hallmark of atrial structure remodeling, plays an important role in maintenance of chronic atrial fibrillation, but interrelationship of atrial fibrosis and atrial fibrillation is uncertain. Label-free proteomics can implement high throughput screening for finding and analyzing pivotal proteins related to the disease.. Therefore, we used label-free proteomics to explore and analyze differentially proteins in chronic atrial fibrillation patients with mitral valve disease. Methods Left and right atrial appendages obtained from patients with mitral valve disease were both in chronic atrial fibrillation (CAF, AF≥6 months, n = 6) and in sinus rhythm (SR, n = 6). One part of the sample was used for histological analysis and fibrosis quantification; other part were analyzed by label-free proteomic combining liquid chromatography with mass spectrometry (LC-MS), we utilized bioinformatics analysis to identify differential proteins. Results Degree of atrial fibrosis was higher in CAF patients than that of SR patients. 223 differential proteins were detected between two groups. These proteins mainly had vital functions such as cell proliferation, stress response, focal adhesion apoptosis. We evaluated that serine/threonine protein kinase N2 (PKN2), dermatopontin(DP), S100 calcium binding protein B(S100B), protein tyrosine kinase 2(PTK2) and discoidin domain receptor tyrosine kinase 2(DDR2) played important roles in fibrotic process related to atrial fibrillation. Conclusion The study presented differential proteins responsible for atrial fibrosis in chronic atrial fibrillation patients through label-free proteomic analysis. We assessed some vital proteins including their characters and roles. These findings may open up new realm for mechanism research of atrial fibrillation.
Surgical Treatment of Atrial Fibrillation with Concomitant Mitral Valve Disease: An Asian Review  [PDF]
Mien-Cheng Chen,Jen-Ping Chang,Yung-Lung Chen
Chang Gung Medical Journal , 2008,
Abstract: Atrial fibrillation (AF) is the most common sustained cardiacarrhythmia in patients with mitral valve disease and is presentin up to 50% of patients undergoing mitral valve surgery,contributing to increased risks of systemic embolization, anticoagulant-related hemorrhage and mortality. The Cox maze IIIprocedure, introduced in 1987 by Dr. James Cox, was the firsteffective operation for AF and is recognized as the gold standardtherapy for AF associated with organic heart disease.However, few surgeons have adopted the Cox maze III procedure,as it is a lengthy operation with extensive cutting, suturingand blood loss. Several groups in Asia have successfullydeveloped less invasive approaches using a number of differentenergy sources to create continuous lines of ablation to replacethe surgical incisions. Because high-density real-time intraoperativemapping to define the mechanisms of AF is currentlynot available to guide AF ablation in most surgical groups, an anatomic approach to ablationbased on our understanding of the pathophysiology and empiric results is reasonable. Thepreoperative left atrial size and duration of AF are primary predictors of sinus conversionafter the maze procedure for patients with persistent and permanent AF and mitral valve disease.The maze procedure combined with an atrial volume reduction technique may increasethe sinus conversion rate. Future progress will require a better understanding of the mechanismsof AF, and minimally invasive cardiac surgery with endoscopic AF ablation needs tobe explored in the Asian region.
Effect of β-blockers on the risk of atrial fibrillation in patients with acute myocardial infarction
Pesaro, Antonio Eduardo;Soeiro, Alexandre de Matos;Serrano, Carlos Vicente;Giraldez, Roberto Rocha;Ladeira, Renata Teixeira;Nicolau, José Carlos;
Clinics , 2010, DOI: 10.1590/S1807-59322010000300005
Abstract: introduction: oral β-blockers improve the prognosis of patients with acute myocardial infarction, while atrial fibrillation worsens the prognosis of this population. the reduction of atrial fibrillation incidence in patients treated with β-blockers could at least in part explain the benefits of this drug. objective: to investigate the effect of β-blockers on the incidence of atrial fibrillation in patients with acute myocardial infarction. methods: we analyzed 1401 patients with acute myocardial infarction and evaluated the occurrence or absence of atrial fibrillation, the use of oral β-blockers and mortality during the first 24 hours. results: a) the use of β-blockers was inversely correlated with the presence of atrial fibrillation (ρ = 0.004; or = 0.54). b) correlations with mortality were as follows: 31.5% in patients with atrial fibrillation, 9.2% in those without atrial fibrillation (ρ < 0.001; odds ratio = 4.52), and 17.5% in patients not treated with β-blockers and 6.7% in those who received the drug (ρ < 0.001; or = 0.34). c) adjusted models: the presence of atrial fibrillation was independently correlated with mortality (or = 2.48, ρ = 0.002). the use of β-blockers was inversely and independently correlated with mortality (or = 0.53; ρ = 0.002). the patients who used β-blockers showed a lower risk of atrial fibrillation (or = 0.59; ρ = 0.029) in the adjusted model. conclusion: the presence of atrial fibrillation and the absence of oral β-blockers increased in-hospital mortality in patients with acute myocardial infarction. oral β-blockers reduced the incidence of atrial fibrillation, which might be at least partially responsible for the drug's benefit.
Hipercoagulabilidad en fibrilación auricular y su relación con factores de riesgo para embolia sistémica Hypercoagulable state in atrial fibrillation and its relationship with risk factors for systemic embolism  [cached]
Luis A Pérez P,Ramón Corbalán H,Mónica Acevedo B,Jaime Pereira
Revista médica de Chile , 2002,
Abstract: Background: Atrial fibrillation is associated to a high risk of systemic embolism and to hypercoagulability. Aim: To evaluate the activation of the coagulation cascade through determinations of the thrombin-antithrombin complex in patients with atrial fibrillation and to correlate this data with the clinical and echocardiographic risk factors for systemic embolism. Patients and Methods: In 53 patients with atrial fibrillation plasma levels of the thrombin-antithrombin complex were determined on admission to a coronary care unit and 30 days later. Using a univariate and multiple regression analysis, the association basal thrombin-antithrombin with the duration of the arrhythmia, age over 70 years, previous use of antiplatelet agents, history of hypertension, mitral valve disease, diabetes, heart failure, previous systemic embolism, left atrial diameter and the presence of spontaneous contrast echo or thrombus in the left atrial appendage, was studied. Results: Basal thrombin-antithrombin values were 40.1±69 mg/L (Median 8.34 [3.0-47.5]) compared to 2.7±3.3 mg/L in healthy controls (p <0.001). No significant correlation was found between activation of the coagulation cascade and risk factors for systemic embolism. There were no significant differences in thrombin-antithrombin values between patients with chronic or paroxysmal atrial fibrillation (29.5±43 mg/L and 49.4±83 mg/L respectively). Mean thrombin-antithrombin values in patients under antiplatelet agents were lower than in those without treatment (17.3±43 vs 66.8±127 mg/L; p=0.018). Conclusions: The activation of the coagulation cascade in patients with atrial fibrillation was confirmed. However, no association of this activation with well known clinical and echocardiographic risk factors for systemic embolism, was found. Previous antiplatelet treatment prevented a higher activation of the coagulation cascade (Rev Méd Chile 2002; 130: 1087-94)
Atrial Fibrillation As A Risk Factor For Stroke  [PDF]
Sanela Bozic,Vesna Suknjaja,Jelena Milojkovic,Nemanja Popovic
Aktuelnosti iz Neurologije, Psihijatrije i Grani?nih Podru?ja , 2011,
Abstract: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, occurring in 1–2% of the general population. AF confers a 5-fold risk of stroke, and one in five of all strokes is attributed to this arrhythmia. Ischemic strokes in association with AF are oft en fatal, and those patients who survive are left more disabled by their stroke and more likely to suffer a recurrence than patients with other causes of stroke. The prevalence of AF increases with age. Men are more oft en affected than women. AF is associated with a variety of cardiovascular conditions: valvular heart diseases, cardiomyopathies, including primary electrical cardiac diseases, which carry an increased risk for AF, especially in young patients. Atrial septal defect is associated with AF in 10–15%. This association has important clinical implications for the antithrombotic management of patients with a previous stroke or transient ischemic attack (TIA) and an atrial septal defect. AF may manifest initially as an ischemic stroke or TIA, and it is reasonable to assume that most patients experience asymptomatic, oft en self-terminating, episodes of arrhythmia, before AF is first diagnosed. Most patients with acute AF will require anticoagulation unless they are at low risk of thromboembolic complications (no stroke risk factors) and no cardioversion is necessary. Much earlier detection of the arrhythmia might allow the timely introduction of therapies to protect the patient, not only from the consequences of the arrhythmia, but also from progression of AF from an easily treated condition to an utterly refractory problem.
Combined ablation of atrial fibrillation and minimally invasive mitral valve surgery: a case report
Hironori Izutani, Masahiro Ryugo, Fumiaki Shikata, Masashi Kawamura, Tatsuhiro Nakata, Toru Okamura, Takumi Yasugi, Mitsugi Nagashima, Kanji Kawachi
Journal of Cardiothoracic Surgery , 2010, DOI: 10.1186/1749-8090-5-79
Abstract: Minimally invasive cardiac surgery with partial sternotomy for valvular heart disease has been performed for more than a decade. A partial lower sternotomy and an extended transseptal incision provide excellent exposure for minimally invasive mitral valve surgery [1,2]. We have experienced sixty minimally invasive surgeries with partial sternotomy since 2004. This approach provides excellent results in less pain, less blood loss, lower rate of wound complications, shorter length of hospital stay, and excellent cosmetics. However, there is a challenge in the patient who requires combined ablation of atrial fibrillation because of possible conduction system disturbance caused by the extended transseptal approach. We carried out cryoablation in three patients for chronic atrial fibrillation with good clinical results using a T-shaped cryoprobe with a lesion set of pulmonary vein isolation and ablation of the left and right isthmus in performing minimally invasive mitral valve surgery. We describe our technique for a creation of a lesion set for ablation of atrial fibrillation using the transseptal approach to the mitral valve through a partial lower sternotomy incision.A 72-year-old man with a history of chronic atrial fibrillation recently experienced palpitation and dyspnea on effort. His echocardiography showed an atrial septal defect, moderate mitral regurgitation, moderate tricuspid regurgitation, and slightly reduced left ventricular function with an ejection fraction of 49%. His cardiac catheterization studies showed the Qp/Qs of 3.46 and mean pulmonary pressure of 23 mmHg. The patient was recommended to undergo mitral valve repair, tricuspid valve repair, atrial septal defect closure, and ablation of atrial fibrillation. A seven centimeter midline chest skin incision was made. The sternal saw was used to perform partial sternotomy from the right second intercostal space down to the xyphoid. A 7 mm soft-flow aortic cannula was placed on the ascending aorta. Bica
Clinical and prognostic implications of atrial fibrillation in patients undergoing transcatheter aortic valve implantation  [cached]
Pablo Salinas,Raúl Moreno,Luis Calvo,Santiago Jiménez-Valero
World Journal of Cardiology , 2012, DOI: 10.4330/wjc.v4.i1.8
Abstract: AIM: To study a cohort of consecutive patients undergoing transcatheter aortic valve implantation (TAVI) and compare the outcomes of atrial fibrillation (AF) patients vs patients in sinus rhythm (SR). METHODS: All consecutive patients undergoing TAVI in our hospital were included. The AF group comprised patients in AF at the time of TAVI or with history of AF, and were compared with the SR group. Procedural, echocardiographic and follow-up variables were compared. Likewise, the CHA2DS2-VASC stroke risk score and HAS-BLED bleeding risk score and antithrombotic treatment at discharge in AF patients were compared with that in SR patients. RESULTS: From a total of 34 patients undergoing TAVI, 17 (50%) were allocated to the AF group, of whom 15 (88%) were under chronic oral anticoagulation. Patients in the AF group were similar to those in the SR group except for a trend (P = 0.07) for a higher logistic EuroSCORE (28% vs 19%), and a higher prevalence of hypertension (82% vs 53%) and chronic renal failure (17% vs 0%). Risk of both stroke and bleeding was high in the AF group (mean CHA2DS2-VASC 4.3, mean HAS-BLED 2.9). In the AF group, treatment at discharge included chronic oral anticoagulation in all except one case, and in association with an antiplatelet drug in 57% of patients. During a mean follow-up of 11 mo (maximum 32), there were only two strokes, none of them during the peri-procedural period: one in the AF group at 30 mo and one in the SR group at 3 mo. There were no statistical differences in procedural success, and clinical outcome (survival at 1 year 81% vs 74% in AF and SR groups, respectively, P = NS). CONCLUSION: Patients in AF undergoing TAVI show a trend to a higher surgical risk. However, in our cohort, patients in AF did not have a higher stroke rate compared to the SR group, and the prognosis was similar in both groups.
New Procedure for Treatment of Atrial Fibrillation in Patients with Valvular Heart Disease
Naser Safaie,Nasrollah Maghamipour,Ahmad Reza Jodati,Ata Mahmoodpoor
Acta Medica Iranica , 2010,
Abstract: "nPatients with valvular heart disease suffer from atrial fibrillation for more than 12 months after valve surgery and have a low probability of remaining in sinus rhythm. We performed an intra-operative procedure similar to surgical maze procedure for conversion of this arrhythmia to sinus rhythm. We did this study to evaluate the efficacy of this procedure to restore the sinus rhythm in patients with valvular heart disease. 28 patients with valvular heart disease and chronic persistent atrial fibrillation underwent different combinations of valve surgery and concomitant reduction of left and right atrial size and resection of both atrial auricles in Shahid Madani cardiothoracic center from September 2004 to October 2008. The procedure for atrial fibrillation treatment was performed with cardiopulmonary bypass and after mitral valve replacement. There was one in-hospital death postoperatively because of respiratory failure, but no other complication till 6 months after the operation. Out of 28 patients, 23 were in sinus rhythm one week after the operation, one patient had junctional rhythm after the operation that restored to sinus rhythm and 4 patients had persistent atrial fibrillation. During the 12-month follow up, atrial fibrillation was corrected in 82.14%. Doppler echocardiography in these patients with sinus rhythm demonstrated good atrial contractility. This procedure on both atria is effective and less invasive than the original maze procedure to eliminate the atrial fibrillation, and can be performed in patients with valvular heart disease without increasing the risk of operation.
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