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Eur J Cardiothorac Surg 2000;17:530-537
© 2000 Elsevier Science NL

Mitral valve surgery and atrial fibrillation: is atrial fibrillation surgery also needed?

Emile R. Jessurun, Norbert M. van Hemel, Johannes C. Kelder, Suzanne Elbers, Aart Brutel de la Rivière, Jo J.A.M. Defauw, Jef M.P.G. Ernst

Departments of Cardiology and Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands

Corresponding author. Tel.: +31-30-609-9111; fax: +31-30-603-4420


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions and perspectives
 References
 
Objective: Atrial fibrillation (AF) persisting after mitral valve surgery reduces survival due to heart failure and thrombo-embolisms, and impairs quality of life. Arrhythmia surgery for AF shows today very satisfying results and therefore mitral valve surgery with AF surgery appears appealing. This study explores whether combined surgery in view of today's results of mitral valve surgery is indicated. Methods and results: An outcome analysis of the arrhythmia outcome of patients undergoing exclusive mitral valve surgery with or without tricuspid repair was done. Preoperative baseline characteristics including arrhythmia pattern, surgical methods and follow-up findings were reviewed. Postoperative management of AF was not protocolized. Between 1990 and 1993, 162 consecutive patients underwent mitral valve surgery; follow-up was a mean of 3.3±1.9 years. In-hospital and late mortality were 1 and 9%, respectively. Sinus rhythm was preserved in 40 of 57 (70%) patients with preoperative sinus rhythm whereas AF persisted in 58 of 68 (85%) of patients with preoperative chronic AF (>1 year present). Sinus rhythm without AF was observed in 10 of 29 (34%) patients with preoperative paroxysmal AF. The 4-year Kaplan–Meier survival did not differ between patients with preoperative sinus rhythm (95.2%), paroxysmal AF (89.2%) and chronic AF (82.9%) but AF persisting after surgery tended to determine survival (P=0.05). Gender, age and right ventricular pressure and tricuspid valve repair were risk factors for postoperative recurrence of AF in patients with sinus rhythm at discharge, relative risk 0.35, 1.06, 1.04 and 2.9, respectively. Conclusion: Current mitral valve surgery with or without tricuspid valve repair does not eliminate preoperative paroxysmal or chronic AF. Secondly, because preoperative AF did not determine survival after mitral valve surgery, whereas postoperatively persisting AF was weakly associated with survival, atrial arrhythmia surgery primarily aims to reduce morbidity due to AF. Some characteristics can identify patients with increased propensity for persisting AF after surgery. Randomized studies of AF surgery are needed to identify suitable candidates for combined surgery.

Key Words: Atrial fibrillation • Mitral valve surgery


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions and perspectives
 References
 
Surgical treatment of serious mitral valve abnormalities has become a standard therapy. Mitral valvuloplasty is today preferred to valve replacement because lifelong anticoagulant therapy is avoided as well as the risks of prosthetic valve failure [1,2].

In the last decade, several surgical methods for correction or prevention of AF have been devised. Successively, the long-term results of the corridor operation [3,4], isolation of the left atrium [5], the maze operation [6,9], the compartment operation [10,11] and the pulmonary veins isolation [12] have been reported. These methods consist of either isolation of atrial areas for excluding AF and/or channeling of particular zones for preserving unimpaired sinus rhythm. In view of the promising results of surgical correction of AF, patients may benefit from combining mitral valve surgery with arrhythmia surgery [7–9,12,13]. Although previous studies on mitral valve surgery demonstrated a high prevalence of persisting postoperative AF, it can be questioned whether this finding is still viable. Differences in patient selection and surgical techniques of mitral valve repair [14–16], sometimes combined with other surgery [17], strongly determine the arrhythmic events afterwards. Additionally, a diminished prevalence of rheumatic heart disease and an increase in degenerative mitral valve disease influence today's results of mitral surgery as well. The aim of this study was to examine the long-term arrhythmia outcome employing current patient profile and surgical selection and techniques for mitral valve surgery, to determine whether mitral valve surgery should be combined with surgical correction of AF.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 5. Conclusions and perspectives
 References
 
The charts of all patients undergoing isolated mitral valve surgery with or without concomitant tricuspid surgery between January 1, 1990 and December 31, 1993, were reviewed. Preoperative clinical baseline characteristics, history and drug management of arrhythmias were studied and stored in a data base. Patients with significant coronary artery disease confirmed by angiography, or other valvular abnormalities except tricuspid valve disease, were excluded. Patients with preoperatively implanted pacemaker were excluded as well. Time and surgical methods for correcting mitral valve disease, in-hospital complications and death were examined. After chest closure and discharge, preservation of sinus rhythm, incidence of new attacks or persistence of AF, and the number of electrical cardioversions were traced. Antiarrhythmic drug therapy was categorized into drugs for rate control (digoxin, beta-adrenergic blocking agents and calcium channel blockers), and for prevention of AF (sotalol, flecainide, disopyramide and amiodarone). In-hospital and follow-up selection and dosages of antiarrhythmic drugs, and indication and timing of electrical cardioversion of AF were not protocolized but left to the cardiologist's opinion. Rhythmic events were determined and categorized into preserved sinus rhythm, paroxysmal or chronic AF. Chronic AF was defined as arrhythmia persisting for more than 1 year. Time and cause of death, and clinical events such as stroke, admission for heart failure and new valvular complications requiring repeat surgery, were gathered.

2.1. Statistical analysis
All values were expressed as mean±SD or percentages. Student's unpaired t-test, Mann–Whitney and Fisher's exact test were used for comparison. For more than two groups the ANOVA, Kruskal–Wallis or exact test were applied. A P-value of less than 0.05 was considered statistically significant. All P-values of less than 0.1 are reported. The P-values greater than 0.1 are reported as NS (not significant). Freedom of events during follow-up were visualized using the Kaplan–Meier method and compared with the log-rank test. Multivariate analysis was performed by means of the Cox proportional hazard method. The statistical computer package was SAS version 6.12 for Windows.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 5. Conclusions and perspectives
 References
 
3.1. Patients
From 1990 up to and including 1993, 162 consecutive patients underwent mitral valve surgery. According to the preoperative rhythm, 59 (36%) patients constituted the sinus rhythm group, 29 (18%) the paroxysmal AF group and 74 (46%) the chronic AF group (Table 1). The causes and type of mitral valve disease were unequally distributed over the three groups: degeneration and incompetence of the valve was more often seen in patients with preoperative sinus rhythm whereas rheumatic mitral valve disease and mitral stenosis or combined valve pathology were more frequently observed in patients with preoperative chronic AF (Table 1). Patients with chronic AF were older, and echocardiography showed larger left atrial dimension than in other patients. The end-diastolic left ventricular diameter was smaller in patients with chronic AF, probably resulting from a higher frequency of mitral stenosis. Although an estimation, the quality of the left ventricular function was visually categorized at surgery into normal, slightly, moderately or severely reduced. The left ventricular function was normal in 60% of the patients, 20% had a slightly reduced, and 20% a moderately or severely reduced function; this finding was equally distributed over the three groups (Table 1).


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  		Table 1. Baseline characteristics of mitral valve operated patientsa

 
3.2. Surgery
Mitral valve replacement was carried out more frequently than mitral valve plasty: in 113 (70%) and 49 (30%) patients, respectively (Table 2). Mechanical valves were more often implanted than bioprostheses: in 99 (88%) and 14 (12%) patients, respectively. In only three of 49 (6%) valve repairs a supportive ring was not used. The surgical methods were unequally distributed over the three groups: mitral valve plasty was done more often in patients with preoperative sinus rhythm (36%) and paroxysmal AF (52%) than in those with preoperative chronic AF (16%). On the other hand, valves were more frequently replaced in patients with preoperative chronic AF than in other patients. Nine patients (5%) underwent rethoracotomy for various reasons. Bypass time was 113±32.5 (58–291) and cross-clamp time 78±23 (39–187) min; both periods did not differ significantly between the three groups. Before discharge, pharmacologic or electrical cardioversion of AF was significantly more performed in patients with preoperative sinus rhythm (39%) or paroxysmal AF (41%) than in those with preoperative chronic AF (4%) (Table 2). Two (1.2%) patients died in hospital due to, respectively, sepsis and multi-organ failure.


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  		Table 2. Surgical procedures and in-hospital arrhythmia treatmenta

 
3.3. Rhythm at discharge
Sinus rhythm persisted in 86% of the patients with preoperative sinus rhythm whereas AF continued in 94% of the cases with preoperative chronic AF (Table 3). Paroxysmal AF persisted after surgery in 95% of the patients with preoperative AF, despite antiarrhythmic drugs. In 42% of patients with preoperative sinus rhythm, antiarrhythmic drugs were administered at time of discharge, mostly digoxin (Table 3). This was the case in 58% of the patients with preoperative paroxysmal AF and 58% with preoperative chronic AF. The distribution of patients with or without antiarrhythmic drugs at discharge did not differ between the three groups (NS).


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  		Table 3. Rhythm at dischargea

 
3.4. Long-term rhythm results
After a mean follow-up interval of 3.3±1.9 years permanent sinus rhythm was recorded in 70% of patients with preoperative sinus rhythm, in 34% of patients with preoperative paroxysmal AF, and in only 4% of patients with preoperative chronic AF (Table 4). In contrast to discharge, the distribution of patients using or not using antiarrhythmic drugs at end of follow-up differed markedly between the three groups (P<0.001). In patients with preoperative paroxysmal or chronic AF, antiarrhythmic drugs were more often prescribed than in patients with preoperative sinus rhythm (Table 4). Analysis of patients with preoperative sinus rhythm, or paroxysmal AF, showing postoperatively recurrence of paroxysmal or chronic AF (n=16 and n=16, respectively) (Table 4), identified in the sinus group three patients with late left ventricular dysfunction and one patient with severe mitral valve incompetence after valve plasty. In the preoperative paroxysmal AF group one patient had severe tricuspid incompetence, one had severe mitral incompetence after valve plasty, and one showed serious left ventricular dysfunction. The Kaplan–Meier proportion of patients without AF after surgery showed a gradual decline that was comparable in the three patient categories (Fig. 1).


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  		Table 4. Follow-up resultsa

 


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  		Fig. 1. Preoperative rhythm and sinus rhythm after mitral valve surgery. Kaplan–Meier curves of patients with sinus rhythm after mitral valve surgery. The 4-year proportion of patients showing only sinus rhythm was 63.3, 29.7 and 2.0%, respectively, in patients with preoperative sinus rhythm (n=59), paroxysmal (n=29) or chronic atrial fibrillation (n=74). The curves show a significant difference: P<0.001. The figures at the bottom represent the number of patients at risk.

 
To define risk factors for recurrence of postoperative AF, multivariate analysis was done in the 88 patients with preoperative sinus rhythm or paroxysmal AF at discharge (Table 3). The number of patients with sinus rhythm at discharge in the preoperative chronic AF group was too small (6%) for including in the analysis. Preoperative rhythm, etiology and type of mitral valve disease, mean right atrium pressure, type, time and duration of surgery, left ventricular echocardiographic dimension, left atrial dimension and wedge pressure did not determine arrhythmia outcome. However, sex (relative risk 0.355 (95% confidence limit (CL) 0.126–0.996), age (relative risk 1.058 (95% CL 1.004–1.115)), right ventricular pressure (relative risk 1.039 (95% CL 1.002–1.077)) and tricuspid valve repair (relative risk 2.903 (95% CL 1.250–7.489)) (Fig. 2a,b) could be considered risk factors for recurrence of paroxysmal or chronic AF. Age accounted for a relative risk, increasing 1.32 per 5 years, whereas right ventricular pressure showed an increase in relative risk of 1.10 per 2.5 mmHg.



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  		Fig. 2. (a) Postoperative sinus rhythm and additional tricuspid repair. Kaplan–Meier curves of patients with mitral valve surgery and additional tricuspid repair, with postoperative sinus rhythm. The 4-year atrial fibrillation-free percentage was 37.3% in patients without tricuspid repair and 0% in patients with tricuspid repair. The curves show a clear difference: P<0.001. The figures at the bottom represent the number of patients at risk. (b) Postoperative sinus rhythm in patients discharged with sinus rhythm and additional tricuspid repair. Kaplan–Meier curves of patients with mitral valve surgery and additional tricuspid repair, discharged with sinus rhythm. The 4-year atrial fibrillation-free percentage was 66% in patients without tricuspid repair and 0% in patients with tricuspid repair. The curves show a clear difference: P<0.003. The figures at the bottom represent the number of patients at risk.

 
3.5. Survival
At the end of follow-up, more patients with preoperative chronic AF had died than those with preoperative sinus rhythm or paroxysmal AF (13.5, 4 and 10%, respectively) (Table 4). The distribution of causes of death did not differ between the three groups. The Kaplan–Meier survival was comparable for patients with preoperative sinus rhythm, paroxysmal and chronic AF (Fig. 3a). AF persisting after surgery tended to determine survival (P=0.05) (Fig. 3b).



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  		Fig. 3. (a) Preoperative rhythm and survival after mitral valve surgery. Kaplan–Meier survival curves of patients after mitral valve surgery, with preparative sinus rhythm, paroxysmal or chronic atrial fibrillation. The 4-year survival was 95.2, 89.2 and 82.9%, respectively. The curves did not show difference: P=0.13. The figures at the bottom represent the number of patients at risk. (b) Postoperative sinus rhythm and survival after mitral valve surgery. Kaplan–Meier survival curves of patients after mitral valve surgery, with postoperative sinus rhythm or paroxysmal or chronic atrial fibrillation. The 4-year survival was 94.8 and 88%, respectively. The curves tend to show difference: P=0.05. The figures at the bottom represent the number of patients at risk.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
5. Conclusions and perspectives
 References
 
This retrospective long-term analysis of a large series of consecutive patients specifically operated for mitral valve disease showed that sinus rhythm was preserved in the majority of patients (70%) with preoperative sinus rhythm in contrast to those with preoperative chronic AF (4%). In the latter category, chronic AF persisted in 85% despite the surgical correction. In half of the patients with preoperative paroxysmal AF, sinus rhythm dominated at the end of follow-up. These findings suggest that many patients showing preoperatively paroxysmal or chronic AF would be candidates for combining mitral valve surgery with AF surgery. Whether this strategy is justified depends on a favorable benefit/risk outcome.

4.1. Prevalence of preoperative AF in mitral valve disease
The few reports on the prevalence of AF in patients undergoing mitral valve surgery showed that the prevalence varies from 30 to 50% [13–17]. An increased left atrial size and rheumatic heart disease causing mitral valve pathology are frequently associated with preoperative chronic AF [13–17]. We also observed chronic AF more frequently in patients with rheumatic heart disease than in other aetiology categories (Table 1). Because these patients were older, and had larger left atrial dimension than those with preoperative sinus rhythm or paroxysmal AF, age and left atrial dimension are considered risk factors for the onset of AF in the natural course of mitral valve disease. Whether patients profit from an aggressive strategy for eliminating AF prior to surgery with antiarrhythmic drugs and repeat DC cardioversion [17–21] is today unknown.

4.2. Prevalence and risk factors of AF after mitral valve surgery
Four studies addressed the contribution of repeat DC cardioversion in conjunction with drug therapy for eliminating AF after mitral valve surgery [16–19]. This management failed in about 50% of the patients with persisting AF after mitral valve surgery. Despite hemodynamic improvement following valve surgery, the propensity for AF continued, particularly in older patients, with AF present more than 1 year prior to surgery, enlarged left atrial dimensions, rheumatic heart disease and cardiomegaly [17–19]. The type of mitral valve operation was not associated with the arrhythmic outcome [14]. There is a general agreement that patients with preoperative sinus rhythm have the best chance to maintain sinus rhythm [13,17]. Our data of recent mitral valve surgery confirm this opinion. Additionally, we showed that age, sex, and right ventricular pressure and tricuspid valve repair (Fig. 2a,b) were risk factors for recurrence of AF after mitral valve surgery in patients with preoperative sinus rhythm with or without paroxysmal AF, while etiology and type of valve disease were not. These characteristics can support the identification of candidates for combined surgery.

4.3. Atrial fibrillation after mitral valve surgery and survival
Maintenance of sinus rhythm after successful cardioversion promotes both atrioventricular synchrony and active diastolic ventricular filling [20]. Preserved sinus rhythm after mitral valve surgery probably will promote survival because of prevention from tachycardia-related cardiomyopathy due to uncontrolled AF and stroke. In a selected, retrospectively studied group of patients undergoing serial electrical cardioversion after mitral valve surgery, persisting AF was associated with a higher incidence of congestive heart failure and cardiovascular death [20]. However, two studies showed that persistence of AF did not affect survival of patients who underwent mitral valve repair [13,17], in contrast to preoperative ejection fraction, concomitant coronary bypass surgery and age [13]. In our study, preoperative AF did not determine survival (Fig. 3a) whereas AF persisting after surgery tended to determine survival (Fig. 3b). Today, it can be concluded that attempts to restore postoperative sinus rhythm are sensible but it is uncertain whether survival after mitral valve surgery improves.

4.4. Results of arrhythmia surgery for AF
Patient selection based on severity of symptoms, type and duration of AF, and concomitant cardiac and noncardiac abnormalities and surgical technique determine the long-term outcome of arrhythmia surgery. Long-term results of the ‘corridor’ operation [3] showed a Kaplan–Meier recurrence rate of AF arising in the corridor in 8% of the patients, and a Kaplan–Meier incidence of new and different atrial arrhythmias in the corridor in 27% of the patients at 5 years after surgery [4,22]. Incompetent sinus node function requiring pacing was observed with a Kaplan–Meier rate of 13% at 5 years after surgery. Graffina et al. reported 100 patients who underwent mitral valve surgery combined with left atrial isolation [5]. After a mean follow-up of 14 months, 72% of patients showed sinus rhythm. Recent reports of the Cox ‘maze’ operation [6] demonstrated a long-term elimination of AF in 84–98% of the cases. The initially high incidence of incompetent sinus node function can be ascribed to improperly selected cases, including pre-existing sick-sinus syndrome and the early ‘maze’ design impairing the sinus node vascular supply [7]. All available information shows a limited in-hospital morbidity and mortality related to these different surgical methods, despite additional cross clamp time.

If, based on these studies, a long-term success rate of 80% of arrhythmia surgery for AF is assumed, and the results of this study are compared with former findings, the following relative risks for recurrence could be calculated. Preoperative sinus rhythm without additional arrhythmia surgery would be related to a relative risk of 1.18 (95% CL 54–79), preoperative paroxysmal AF with a relative risk of 2.35 (95% CL 18–54), and preoperative chronic AF with a relative risk of 19.2 (95% CL 0.8–12). These data disclose the potential usefulness of additional arrhythmia surgery for AF in view of current methods.

4.5. Postoperative sinus node function
After surgical elimination of chronic AF, resumption of sinus node function remains unpredictable. In addition, atrial surgery may intrinsically account for adverse effects on the behavior of the sinus node as evidenced by results of the ‘maze’ prototypes [6,7]. Depressed sinus node automaticity and/or prolonged sino-atrial conduction, of which the mechanism is unknown [23], was also observed in experimentally induced chronic AF. It has been suggested that the atrial tissue substrate of lone AF, despite successful surgical elimination of AF, shows progression of the disease [22]. Therefore, involvement of the sinus node function can reflect this ongoing process, but in our study the frequency of pacemaker implants for bradycardia was limited (Tables 3 and 4). Also, the incidence of impaired sinus node function due to mitral valve disease or valve surgery as such remains unclear.

4.6. Study limitations
Drug treatment and DC cardioversion of AF were not protocolized but left to the cardiologist's opinion and referring centers, and reflect therefore current daily practice after mitral valve surgery. It remains questionable whether a standardized management of AF would have brought out a different incidence of postoperative AF [17]. Secondly, this retrospective follow-up study was focused on postoperative rhythmic events rather than mitral valvular function and ventricular performance, or thromboembolic complications. Quality of life after surgery was not studied at all. These conditions also account for the decision for combining valvular and AF surgery.


   5. Conclusions and perspectives
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions and perspectives
References
 
This study showed that the preoperative rhythm strongly determines the postoperative rhythm. Despite current selection criteria and surgical methods, chronic AF was associated with persisting AF after mitral valve surgery. Because etiology and type of mitral valve disease were not risk factors for postoperative AF, atrial electrical remodeling strongly contributes to persistence of AF [21]. In view of the promising results of AF surgery, combining mitral valvular surgery with AF surgery primarily aims to improve morbidity after mitral valve surgery because it is doubtful today whether persisting AF impairs survival as was suggested earlier [18]. Older and female patients with preoperative AF, and particularly those who need tricuspid valve repair or have elevated right ventricular pressure, are potential candidates for combined surgery, provided sinus node function prior to surgery is normal and the surgical risk limited. Because other preoperative characteristics were not associated with arrhythmia outcome, randomized studies with or without AF surgery together with mitral valve surgery are needed. Detailed preoperative arrhythmic characteristics [17], surgical techniques and endpoints of these studies have to be defined [24].


   Acknowledgments
 
We gratefully thank Gérard M. Guiraudon, M.D., Buffalo, NY, for valuable comments, Mrs Gerda van der Kuijl for manuscript preparation, and Mrs Elly Hoogteijling-van Dusseldorp for final data collection.


   Footnotes
 
Presented in part at the Scientific Session of the Dutch Society of Cardiology, April, 1998.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions and perspectives
 References
 

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Received November 9, 1999; received in revised form February 11, 2000; accepted February 15, 2000.




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