|Year : 2004 | Volume
| Issue : 3 | Page : 62-63
|Date of Web Publication||22-Jun-2010|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Abstract. Heart Views 2004;5:62-3
Surgical Ablation of Chronic Atrial Fibrillation and Atrial Restoration in Patients with Rheumatic Mitral Valve Disease
A. Fahmy El-Watidy, MD, FRCS; A. Ashmeg, MD; FRCS, W. Abukhudair, MD, FRCS
King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
Objective: To evaluate the results of atrial fibrillation (AF) ablation using microwave energy in patients with rheumatic mitral valve (MV) disease who underwent valve surgery at King Fahd Armed Forces Hospital (KFAFH), Jeddah, KSA.
Patients and Methods: From March 2002 until September 2004, 30 patients who were operated upon for mitral valve disease had microwave ablation for chronic atrial fibrillation at KFAFH, Jeddah, KSA. 7 patients (23.3%) had AF ablation alone with mitral valve surgery, and 23 patients (76.7%) had left atrial reduction added to the procedure (Atrial Restoration).
Results: The age of the patients ranged from 24 to 70 years (mean 40.8); 76.5% were female patients. The etiology was rheumatic in 93.4%, degenerative disease 3.3%, and SBE 3.3%. The percentage of patients who had mitral valve repair was 38.4%, biological mitral valve replacement 34.6%, mechanical mitral valve replacement 19.2%, associated tricuspid valve repair 38.4%, tricuspid valve replacement 3.8%, aortic and mitral valve repairs 3.8%, and redo surgery in 15.3%.
The pre-operative left atrial (LA) size ranged from 6.2 - 10.8 cm, mean 7.64. The mean cross clamp time was 84.6 minutes. Mean bypass time was 96.5 minutes and mean ablation time was 27.6 minutes. The mean hospital stay (8.5 days), and mean ventilation time (10.4 hours). The Operative Mortality was (0%), I year mortality (3.3%). There were no postoperative morbidities. Restoring sinus rhythm immediately after surgery was successful in 95%, before discharge from the hospital in 88.2%, at three months 82.4%, at six months 82.4%, and one year 82.4%. Atrial Restoration has got higher success rate (90.4%) at 1 year follow up. No patient (0%) has needed permanent pacemaker. Anticoagulation has successfully avoided in 82.4% after six months. Histopathology of LA appendage and ANP levels were studied as well.
Conclusion: Microwave ablation for AF was successful in restoring sinus rhythm in (82.4%) in patients with chronic AF and rheumatic mitral valve disease who underwent mitral valve surgery. Atrial restoration may provide superior results in maintaining sinus rhythm. Mid and long term follow up is needed
Cardiac Valve Selection Mechanical Versus Bioprosthetic Valves
Habib Tareif, FRCSI
Mohammed Bin Khalifa Bin Salman Al Khalifa Cardiac Centre, Bahrain
Although diagnostic techniques and more scientific selection of patients for valve surgery have increased the survival and improved the outcome of valve surgery, controversy still exists regarding valve selection.
With the introduction of the Starr-Edwards valve, replacement surgery has been available for over 40 years. Since then, valve characteristics, materials, transvalvular gradients, flow dynamics and durability of the valves have tremendously improved. However, the ideal valve is still awaited. The decision for valve replacement takes into consideration the natural history, operative risk and the expected outcome. The ideal valve should allow for excellent hemodynamics, cause minimal RBC damage, be durable, easily placed and cause minimal immune response. However, problems following valve replacement include structural deterioration, thromboembolism and valve dysfunction.
The pros and cons of mechanical and bioprosthetic valves were discussed including valve selection in pregnancy, the durability of bovine pericardial valves and recent improvements in mechanical valve hemodynamics. A short summary of the Bahrain experience in valve replacement surgery was presented.
The Surgical Management of Ischemic Mitral Regurgitation
Dr. Riyad Tarazi
Chest Disease Hospital, Kuwait
The therapy of ischemic mitral regurgitation (MR) is intriguing. The traditional management has been to repair during CABG. Surgery has been limited to those with severe mitral regurgitation Grade +3 to +4. MR Grade +1 and +2 are generally left alone. There are some general beliefs that have been shown to be largely unfounded. They are the following:
The mechanism of mitral regurgitation is as follows: Coronary artery disease results in an ischemic area of the myocardium. This area sags during systole. The sag pulls the mitral valve apparatus, tenting the leaflets and causing mitral regurgitation.
- Assessment of mitral regurgitation under general anesthesia is accurate (not true).
- Revascularization would improve left ventricular function and correct mitral regurgitation (not true).
- Residual postoperative mitral regurgitation has no impact on survival (not true).
- Adding a mitral valve procedure to CABG would significantly increase the postoperative mortality over CABG alone (not true).
Lamas in 1997 (SAVE Trial arm) showed that following myocardial infarction (MI), the presence of mitral regurgitation impacted negatively on survival. The 3-year survival post MI was 85% without the presence of mitral regurgitation and 65% if mitral regurgitation was present. Hausman noted that the mortality during follow up of patients with mitral valve repair was significantly higher in patients with residual mitral regurgitation of more than grade +1. Bolling noted that the mortality of mitral valve repair in 215 patients with ischemic cardiomyopathy and mean EF 16% was 4%.
At the Chest Diseases Hospital in Kuwait, I reviewed my personal data of ischemic mitral regurgitation patients operated on during the period September 2000 - September 2004. There were 41 patients (31 mitral valve repair and 10 mitral valve replacement). The mortality in the repair group was 3% and in the replacement group was 0%. The actual survival in the repair group was 93.5% at 1 year and 90.3% at 2 years. I believe that the optimal management of patients with ischemic mitral regurgitation is to repair patients with Grade +2 and above using a semi flexible circumferential annuloplasty ring.
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