Atrial Fibrillation, Valvular Heart Disease
Conditions
Keywords
Double Valve Replacement, Atrial Fibrillation Ablation
Brief summary
Current European Society of Cardiology Guidelines recommend concomitant atrial fibrillation (AF) ablation for all symptomatic patients undergoing other cardiac surgeries, but the safety and potential benefits of concomitant atrial fibrillation (AF) ablation at the time of double valve replacement remains unexamined. A retrospective review of patients with AF who underwent double valve replacement with or without concomitant surgical ablation in our institute starting from April 2006.
Detailed description
Persistent AF was defined as AF lasting more than 7 days and long-standing persistent AF as continuous AF for more than 12 months. Concomitant surgical AF ablation was offered to suitable patients as determined by the surgeon, and patients then decided whether to undergo the additional procedure. The operations were performed through median sternotomy and under cardiopulmonary bypass. The bipolar ablation clamp was positioned precisely around the pulmonary veins (PV) for bilateral circular ablation. After Marsh ligament cutting and cross-clamping the ascending aorta, the left atrial appendage was resected and left atrial cavity exposed through an incision behind the interatrial groove. Then, linear ablations were performed between the left and right inferior PVs, between the left and right superior PVs, between the left superior PV and the opening of the left atrial appendage, and between the line connecting bilateral inferior PVs and the mitral valve isthmus. Ablation at the right atrium was then performed. Briefly, the bipolar ablation clamp was positioned around the inferior vena cava (IVC) and right atrial appendage for circular ablation. An L-shaped incision was then made on the anterior wall of the right atrium and linear ablations were performed vertically from the incision to the interatrial groove and tricuspid annulus, to the ablation ring around the right atrial appendage, and from the superior vena cava to the ablation ring around the inferior vena cava. The left atrial appendage was always excluded by resection and the incision was closed with continuous running stitches. Temporary pacemakers were placed in all patients and activated when heart rate was less than 70 beats per minute.
Interventions
PROCEDUREdouble valve replacement
After median sternotomy, cardiopulmonary bypass was established via bicaval and aortic cannulation. After cross-clamping of the aorta and cardioplegia, mitral and aortic replacement were performed. Supplementary procedures such tricuspid annuloplasty, ascending aorta replacement and coronary artery bypass grafting were performed as required. The left atrial appendage was excised to avoid thrombus formation.
PROCEDUREsurgical ablation
Both left and right atrial ablation were performed using a bi-polar radiofrequency ablation clamp.
Sponsors
Guangzhou General Hospital of Guangzhou Military Command
Study design
Observational model
COHORT
Time perspective
RETROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to 70 Years
Healthy volunteers
No
Inclusion criteria
* Patients presented to our institute with valvular heart disease requiring double valve replacement and also present with persistent or long-standing persistent atrial fibrillation. * Persistent AF was defined as AF lasting more than 7 days and long-standing persistent AF as continuous AF for more than 12 months. First cardiac surgery, age\<70 years. left atrium diameter measured by transthoracic echocardiography\<7cm. Left ventricular ejection fraction \> 40%
Exclusion criteria
* \>70 years old, with LA diameter \>7 cm, or with LV ejection fraction \< 40% , repeated cardiac surgery, concomitant tricuspid valve replacement
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| mortality | from the date of the surgery until the date of death, assess up to 120 months | mortality from any cause |
| sinus rhythm rate | from 6 months after surgery until the date of first documented progression or date of death from any cause, assess up to 120 months | sinus rhythm rate examined by 24h holter monitoring |
| stroke | from the date of surgery until the date of first documented progression or date of death from any cause, assess up to 120 months | perioperative stroke |
| third degree heart block requiring permanent pacemaker implantation | from the date of surgery until the date of first documented progression or date of death from any cause, assess up to 120 months | third degree heart block diagnosed via ECG |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| warfarin requirement | from 6 months after surgery until the date of first documented progression or date of death from any cause, assess up to 120 months | oral warfarin requirement over 6 moths after the surgery |
| perioperative morbidities | from the date of surgery until the date of first documented progression or date of death from any cause, assess up to 30 days | Redo for bleeding; Low cardiac output syndrome; Renal failure requiring dialysis; Pneumonia; |
| left atrium diameter | from 6 months after surgery until the date of first documented progression or date of death from any cause, assess up to 120 months | left atrium diameter measured by transthoracic echocardiography |
| left ventricular ejection fraction | from 6 months after surgery until the date of first documented progression or date of death from any cause, assess up to 120 months | left ventricular ejection fraction measured by transthoracic echocardiography |
| Warfarin-related bleeding | from 6 months after surgery until the date of first documented progression or date of death from any cause, assess up to 120 months | bleeding events occurred during the period when warfarin was used |
| Thromboembolic events | from 6 months after surgery until the date of first documented progression or date of death from any cause, assess up to 120 months | thromboembolic events |
| New York Heart Function classification | from 6 months after surgery until the date of first documented progression or date of death from any cause, assess up to 120 months | New York Heart Function classification |
Countries
China
Contacts
Primary ContactWeida Zhang, MD
Backup ContactGuang Tong, MD,PhD
Outcome results
None listed