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Eur J Cardiothorac Surg 2001;19:233-234
© 2001 Elsevier Science NL

Letter to the Editor

Reply to Veloso

Division of Cardiac Surgery, IRCCS S. Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy

Received 12 December 2000; accepted 13 December 2000.

Corresponding author. Tel.: +39-02-2643-7109/02; fax: +39-02-2643-7125
e-mail: benussi.stefano{at}hsr.it

The rationale for the use of antiarrhythmic medications after atrial fibrillation surgery has been outlined for the first time by Cox in 1993 [1]. Exposing the results of his pioneering experience with the maze operation, the author documented early recurrences of supraventricular tachyarrhythmias as the most frequent postoperative complication, occurring in about one half of the patients.

Like in all other common cardiac operations, these arrhythmias are likely to occur because of the inflammatory effects of atrial trauma (atriotomies, myocardial ischaemia, postoperative pericarditis) and of the postoperative increase of the adrenergic tone. These alterations lead to a temporary shortening of the refractory period of the atrial myocites and to a dispersion of refractoriness, both favoring the formation of reentrant circuits.

Cox found this early (<3 months) rhythm instability effectively dealt with by a combined treatment with digoxin and procainamide.

Since then, all authors reporting results of any surgical procedure for atrial fibrillation, described the use of some combination of antiarrhythmic medications either for primary [2] or for secondary prevention [3] of postoperative recurrences, up to 6 or more months after operation [2,3].

In this kind of surgery, a great caution must be paid to the prevention of thromboembolic complications of atrial fibrillation recurrence after discharge that can frequently go undiagnosed for variable amounts of time.

This is the reason why, like other authors, in our early experience we protocolled administration of antiarrhythmic and of anticoagulant medications to last as much as 6 months postoperatively.

The choice of amiodarone in this setting seems particularly reasonable because of its effectiveness in the surgical patient and of its interaction with adrenergic receptors.

With a 76.9% 1-year success rate in a group of patients with chronic atrial fibrillation and relevant atriomegaly due to longstanding mitral valve disease, half of which rheumatic, intraoperative epicardial radiofrequency ablation out-performs whatever non-surgical strategy ever tested in comparable series. When dealing with such patients, with antiarrhythmic treatment and serial cardioversions, success rate can be as high as 36% for patients with non rheumatic mitral valve disease (reference no. 2 in the original paper), but is in the range of 10 to 26% [4,5] for patients undergoing mitral valve operations in general, also considering the studies in which amiodarone is used [5].

Interestingly, the sinus rhythm recovery rate of the largest reported experiences with different surgical treatment of chronic atrial fibrillation during mitral valve surgery is around 80% [2,3], like that emerging in our reported early experience.

Of course, to determine the precise extent to which medical treatment can possibly improve the results of surgery for atrial fibrillation in patients affected by an organic heart disease, prospective randomized trials would be needed. But since to the best of our knowledge no such study has been reported so far, the only way to assess the effectiveness of a surgical procedure is comparison with the available evidence on medical treatment alone. Still, should randomized studies or longer observation substantiate an effective contribution of antiarrhythmic medications to the effects of atrial fibrillation surgery, we do not think that would justify defining ‘palliation’ (attenuation/lessening of the disease) any of the two treatment strategies.

References

1. Cox J.L., Boineau J.P., Schuessler R.B., Kater K.M., Lappas D.G. Five-year experience with the maze procedure for atrial fibrillation. Ann Thorac Surg 1993;56:814-824.[Abstract]
2. Sueda T., Nagata H., Oriashi K., Morita S., Okada K., Sueshiro M., Hirai S., Matsuura Y. Efficacy of a simple left atrial procedure for chronic atrial fibrillation in mitral valve operations. Ann Thorac Surg 1997;63:1070-1075.[Abstract/Free Full Text]
3. Kosakai Y., Kawaguchi A.T., Isobe F., Sasako Y., Nakano K., Eishi K., Kito Y., Kawashima Y. Modified maze procedure for patients with atrial fibrillation undergoing simultaneous open heart surgery. Circulation 1995;92(suppl II):II359-II364.
4. Jessurun E.R., van Hemel N.M., Kelder J.C., Elbers S., de la Riviere B., Defaw J.J.A.M., Ernst J.M.P.G. Mitral valve surgery and atrial fibrillation: is atrial fibrillation surgery also needed?. Eur J Cardio-thorac Surg 2000;17:530-537.[Abstract/Free Full Text]
5. Kalil R.A.K., Maratia C.B., D'Avila A., Ludwig F.B. Predictive factors for persistence of atrial fibrillation after mitral valve operation. Ann Thorac Surg 1999;67:614-617.[Abstract/Free Full Text]

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				S. Benussi, S. Nascimbene, and O. Alfieri Reply to the Editor J. Thorac. Cardiovasc. Surg., June 1, 2007; 133(6): 1683 - 1684. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Benussi, S. Articles by Alfieri, O. Search for Related Content PubMed Articles by Benussi, S. Articles by Alfieri, O. Related Collections Electrophysiology - arrhythmias