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Eur J Cardiothorac Surg 2007;32:399. doi:10.1016/j.ejcts.2007.04.020
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Letters to the Editor

Reply to Villa et al.

Ki-Bong Kim*

Department of Thoracic & Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea

Received 13 April 2007; accepted 17 April 2007.

* Tel.: +82 2 2072 3482; fax: +82 2 747 5245. (Email: kimkb{at}snu.ac.kr).

Key Words: Arrhythmia • Maze procedure • Atrial fibrillation • Rheumatic valvular disease

We would like to thank Dr Emmanuel Villa [1] for his comment and insight on our manuscript [2]. As we indicated, one of the main findings in our study was that the Cox-Maze III procedure (CM-III) for persistent atrial fibrillation (AF) associated with rheumatic mitral valve (MV) disease demonstrated a progressively decreased rate of freedom from AF during the follow-up period. As previous studies [3–5] have demonstrated that large left atrial (LA) diameter is one of the major predictors for AF recurrence or AF treatment failure, causing a progressively decreased rate of freedom from AF, most surgeons try to reduce the LA size during the maze procedure. In a previous study [6], however, we did not demonstrate the preoperative LA size as a predisposing factor for AF treatment failure. We have reduced the LA size by plication of LA cuff during closure, plication to reduce the posterior LA wall in case of giant LA, and closure of the LA appendage, which might significantly reduce the LA size in patients with large LA. To find factors affecting AF recurrence or AF treatment failure, we studied the postoperative LA size instead of the preoperative LA size [2].

As Dr Emmanuel Villa indicated, there seemed to be a vicious cycle that links tricuspid regurgitation (TR) and AF. Although none of our patients developed more than a mild degree of TR early after surgery, patients with AF treatment failure or late AF recurrence showed a higher incidence of late TR, suggesting that permanent AF may affect the worsening of TR over time or that progression of TR after rheumatic MV surgery predisposed late AF recurrence. Prospective, randomized clinical trials are warranted to further clarify the mechanism of late TR and AF. As indicated in the manuscript, early surgical therapy, LA reduction and correction of TR at time of surgery may increase the long-term success rate after the CM-III for persistent AF associated with rheumatic MV disease.

References

  1. Villa E, Messina A, Cirillo M, Giovanni T. Size matters in atrial fibrillation surgery. Eur J Cardiothorac Surg 2007;32:398-399.[Free Full Text]
  2. Kim KC, Cho KR, Kim Y-J, Sohn D-W, Kim K-B. Long-term results of the Cox-Maze III procedure for persistent atrial fibrillation associated with rheumatic mitral valve disease: 10-year experience. Eur J Cardiothorac Surg 2007;31:261-266.[Abstract/Free Full Text]
  3. Itoh A, Kobayashi J, Bando K, Niwaya K, Tagusari O, Nakajima H, Komori S, Kitamura S. The impact of mitral valve surgery combined with maze procedure. Eur J Cardio-thorac Surg 2006;29:1030-1035.[Abstract/Free Full Text]
  4. Ad N, Barnett S, Lefrak EA, Korach A, Pollak A, Gilon D, Elami A. Impact of follow-up on the success rate of the cryosurgical maze procedure in patients with rheumatic heart disease and enlarge atria. J Thorac Cardiovasc Surg 2006;131:1073-1079.[Abstract/Free Full Text]
  5. Gillinov AM, Sirak J, Blackstone EH, McCarthy PM, Rajeswaran J, Pettersson G, Sabik III JF, Svensson LG, Navia JL, Cosgrove DM, Marrouche N, Natale A. The Cox maze procedure in MV disease: Predictors of recurrent atrial fibrillation. J Thorac Cardiovasc Surg 2005;130:1653-1660.[Abstract/Free Full Text]
  6. Kim K-B, Cho KR, Sohn D-W, Ahn H, Rho JR. The Cox-Maze III procedure for atrial fibrillation associated with rheumatic mitral valve disease. Ann Thorac Surg 1999;68:799-804.[Abstract/Free Full Text]




This Article
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Ki-Bong Kim
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Right arrow Valve disease

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