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Eur J Cardiothorac Surg 2005;28:660-661
© 2005 Elsevier Science NL

Letter to the Editor

Reply to Aazami and Salehi

Siyami Ersek Thoracic and Cardiovascular Surgery Center, Baglarbas mah, Fetih sok, No. 9, 41700 Darca/Gebze, Istanbul, Turkey

Received 23 June 2005; accepted 27 June 2005.

^* Corresponding author. Tel.: +90 262 7451416; fax: +90 216 3486237. (Email: erenenc{at}superonline.com).

Key Words: Atrial fibrillation • Myocardial revascularization • On-pump • Off-pump

We thank you for your contributions to our study. As excepted, many factors influence the occurance of atrial fibrillation (AF) after myocardial revascularization. However, when you compare the incidence of atrial fibrillation after on-pump and off-pump myocardial revascularization, the main factor affecting the incidence of AF is the use of cardiopulmonary bypass. The others are secondary factors. The studies comparing the incidence of AF after on- and off-pump myocardial revascularization should be well designed to minimize the effect of secondary factors. The aortocoronary perfusion that can result functional atrial mal-perfusion should be deemed as secondary factor. Since, it always occurs after both on-pump and off-pump surgery, we have not chosen to study the effect of aortocoronary perfusion resulting functional atrial ischemia. Besides, we compare the incidence of AF in patients with single vessel disease in which the indication of surgical revascularization was definite. In our study, almost all patients undergoing complete myocardial revascularization for single vessel disease have had proximal severe long lessions not suitable for angioplasty. So, risk of functional atrial ischemia due to aortocoronary perfusion was not probable in these patients. Accordingly, the effect of graft type that influence the systolic leakage of coronary perfusion was not studied in patients with single vessel disease. The arterial graft (LITA) was used in all patients for revascularization. The overall incidence of postoparetive AF in patients with single vessel disease without regarding the method of revascularization was 15.3%.

On the other hand, it was reported in literature that structural and functional changes in the atria commonly seen in elderly population with chronic AF are also prevalent in surgical patients who develope AF after myocardial revascularization. So, Leung et al. suggested that postoperative and chronic AF may have similar pathophysiology [1]. However, postoperative AF generally is not chronic, but aortocoronary perfusion is continuous. Besides, Ak et al. recently reported that preoperative metabolic status of myocardial cells affect the incidence of postoperative AF. They applied histologic examination of atrial tissue sampled before operation and the examination showed that larger sized myolytic vacuoles and apoptotic myocytes were significantly higher in patients with postoperative AF [2]. Therefore, it is still not clear whether preoperative metabolic status of atrial tissue or aortocoronary perfusion occuring after revascularization more significantly affect the incidence of AF.

In conclusion, we agree with you that without well-designed study regarding all possible involving pathophysiological pathways, we cannot answer the question whether or not off-pump myocardial revascularization decrease the incidence of postoperative AF. We believe that our retrospective study was helpful to disclose the correct answer of the question.

References

1. Leung JM, Bellows WH, Schiller NB. Impairment of left atrial function predicts post-operative atrial fibrillation after coronary artery bypass graft surgery. Eur Heart J 2004;25(20):1836-1844.[Abstract/Free Full Text]
2. Ak K, Akgun S, Tecimer T, Isbir CS, Civelek A, Tekeli A. Determination of histopathologic risk factors for postoperative atrial fibrillation in cardiac surgery. Ann Thorac Surg 2005;79(6):1970-1975.[Abstract/Free Full Text]

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