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Eur J Cardiothorac Surg 2001;19:231-232
© 2001 Elsevier Science NL

Letter to the Editor

Long-term efficacy of epicardial radiofrequency ablation of chronic atrial fibrillation during mitral valve surgery

Henrique Horta Veloso

Department of Cardiology, Santa Casa de Misericórdia, Belo Horizonte, Brazil

Received 1 November 2000; accepted 13 December 2000.

Corresponding author. Tel./fax: +55-31-3281-1778
e-mail: hhorta{at}cardiol.br

Key Words: Atrial fibrillation • Radiofrequency ablation • Atrial fibrillation surgery • Arrhythmia surgery • Mitral valve surgery

Atrial fibrillation is the most common sustained arrhythmia in clinical practice. Patients with mitral valve disease are particularly prone to the development of this arrhythmia because of the atrial enlargement. Its occurrence is associated with a significant increase in the morbidity and mortality, mainly due to thromboembolic events.

In a recent issue of the European Journal of Cardio-thoracic Surgery, Benussi et al. [1] described an original radiofrequency ablation technique to treat atrial fibrillation in patients undergoing mitral valve surgery, performing epicardially two encircling lesions around the ostia of the right and of the left pulmonary veins, completed with endocardial lesions connecting the encirclings between them and to the mitral valve annulus. Forty patients with chronic atrial fibrillation (mean duration of 43.1±51.9 months) underwent this therapy. One death occurred in the early postoperative period due to pulmonary infection, with no other complications. At a mean follow-up of 11.6±4.7 months, 76.9% of the patients were in stable sinus rhythm and all these cases recovered atrial contractility at echocardiographic control. Thus, the authors concluded ‘epicardial radiofrequency ablation is a safe means to achieve surgical ablation of atrial fibrillation with a high success rate’ and ‘the simplicity of the technique and the low procedure-related risk should dictate combined treatment virtually in all patients with atrial fibrillation undergoing open heart operations’.

Their technique seems to be a very interesting alternative for surgical ablation during mitral valve surgery and also highly safe. However, the efficacy of the procedure deserves further analysis.

The protocol of the study included the administration of antiarrhythmic drugs, with amiodarone as the first choice, until 6 months after operation, when it was discontinued. All but two patients received antiarrhythmic drug therapy (95%), mostly amiodarone (84%). It is largely known that amiodarone has a high efficacy in the maintenance of sinus rhythm after cardioversion of atrial fibrillation [2], even in cases with enlarged atria [3]. Furthermore, its elimination from plasma is extremely slow, with half-lives of until 103 days at steady state [4]. Thus, of the 11.6 months of the follow-up, the antiarrhythmic action of amiodarone was present until 8 or 9 months after the surgery, resulting in a very short follow-up after drug elimination to assess the reported ‘high efficacy’ of the procedure.

In addition, during the first month of follow-up, atrial fibrillation recurred in 22 patients (56.4%), even on antiarrhythmic therapy, requiring pharmacological or electrical cardioversion. So, in the majority of the patients, at least one recurrence of atrial fibrillation occurred. It can mean that triggers from the pulmonary veins or others sites of the atria and the critical mass of atrial tissue necessary for the maintenance of the multiple wavelets [5] were still present after the combined procedure and possibly will lead to future relapses.

In conclusion, this new, simple, safe and promissory technique needs a longer follow-up time after antiarrhythmic discontinuation to define if it is a curative treatment or just an palliative procedure increasing the efficacy of antiarrhythmic drug therapy.

References

  1. Benussi S., Pappone C., Nascimbene S., Oreto G., Caldarola A., Stefano P.L., Casati V., Alfieri O. A simple way to treat chronic atrial fibrillation during mitral valve surgery: the epicardial radiofrequency approach. Eur J Cardio-thorac Surg 2000;17:524-529.[Abstract/Free Full Text]
  2. Roy D., Talajic M., Dorian P., Connolly S., Eisenberg M.J., Green M., Kus T., Lambert J., Dubuc M., Gagné P., Nattel S., Thibault B., The Canadian trial of atrial fibrillation investigators. Amiodarone to prevent recurrence of atrial fibrillation. N Engl J Med 2000;342:913-920.[Abstract/Free Full Text]
  3. Brodsky M.A., Allen B.J., Walker C.J., Casey T.P., Luchet C.R., Henry W.L. Amiodarone for the maintenance of sinus rhythm after conversion of atrial fibrillation in the setting of a dilated atrium. Am J Cardiol 1987;60:572-575.[Medline]
  4. Holt D.W., Tucker G.T., Jackson P.R., McKenna W.J. Amiodarone pharmacokinetics. Br J Clin Pract 1986;44:109-114.
  5. Lévy S., Breithardt G., Campbell R.W.F., Camm A.J., Daubert J.C., Allessie M., Aliot E., Capucci A., Cosio F., Crijns H., Jordaens L., Hauer R.N.W., Lombardi F., Lüderitz B., The Working Group on Arrhythmias of the European Society of Cardiology. Atrial fibrillation: current knowledge and recommendations for management. Eur Heart J 1998;19:1294-1320.[Abstract/Free Full Text]



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K. Khargi, T. Deneke, B. Lemke, and A. Laczkovics
Irrigated radiofrequency ablation is a safe and effective technique to treat chronic atrial fibrillation
Interactive CardioVascular and Thoracic Surgery, September 1, 2003; 2(3): 241 - 245.
[Abstract] [Full Text] [PDF]

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