Patwardhan AM
Funding or
conflict of interest disclosure: none
Address for
correspondence: Dr.
Patwardhan AM, Professor and Head, Dept. of Cardio-Vascular and
Thoracic Surgery, Seth G.S. Medical College and K.E.M. Hospital, Parel,
Mumbai - 400 012, India. Email: anil.patwardhan@gmail.com
Abstract
Patients in
normal sinus rhythm have lesser stroke rate, better functional class
and quality of life than those in atrial fibrillation. Adding a
surgical procedure to cure atrial fibrillation in patients needing
correction of structural heart disease has been shown to be a safe
option, which benefits the majority in restoration of sinus rhythm. Age
is no bar to implement this option. The same does not hold true for
lone atrial fibrillation. The affirm trial has shown that there is need
for improved treatment strategies for patients in atrial fibrillation,
although young patients were not represented in sizable proportion.
There is need to develop curative treatment for patients with lone
atrial fibrillation. And there are technological advances in the form
of ablative energy sources and hardware for applying these with
minimal invasion. “Between tomorrow’s dream and yesterday’s regret is
today’s opportunity”. Let’s make the best of it!
Key words: Atrial fibrillation; surgical ablation
Why
should one consider the surgical option to treat atrial fibrillation
(AF)? The answer lies in the influence of this arrhythmia on the stroke
rate, NYHA class and quality of life. In the United States, 2.2million
people have AF and 75000 strokes occur in these patients each year
1. The stroke rate varies between 2.5% to
5% per year under influence of associated risk factors, such as
hypertension, diabetes mellitus, congestive heart failure and ischemic
heart disease. James Cox
2
showed beyond any doubt that restoration of normal sinus rhythm (NSR)
and obliteration of left atrial appendage, remarkably reduced the
stroke rate. Vaturi et al
3
compared patients who had their mitral valve replaced, for their
functional status with respect to rhythm. The patients were matched for
age sex and time from valve replacement. The NYHA class for AF patients
was 2.8 +/- 0.8 while that for NSR was 1.1+/- 0.7. The trans-mitral
gradients were greater and the size of the atria was greater in
patients in AF. Lonnerholm S. et al
4
showed that following the maze procedure the quality of life indices
significantly improved as compared to pre-operative indices. All this
data should make the physicians look for treatment options suitable for
their patients in restoring sinus rhythm. And there can be no better
opportunity for a surgeon for treating AF when the patient needs
surgical correction of structural heart defect.
In this issue,
Geidel S. et al
5 have shown
that an intraoperative radiofrequency approach is successful in
73% of patients with permanent AF who were above the age of 70 years.
This was achieved with a low mortality and morbidity. The procedure
time for performing the ablations is less than 15 minutes. This is
enough evidence for the surgeons to treat permanent AF even in the
elderly needing cardiac surgery.
The data from
western countries shows that the incidence of atrial fibrillation rises
with age and approximately 10 % of patients above the age of 80
have AF. The Framingham study shows that AF is associated with a 1.5
fold greater risk of death for men and a 1.9 fold greater risk of death
for women shortening men’s life by 18 years and women’s by 21 years
6.
The risk of stroke in patients over 70 years is increased 3 to 5 fold
by AF. The AFFIRM trial
7
has shown that there is no diference in survival or stroke rate in the
rhythm control or rate control arms. The clinical outcomes in this
trial have demonstrated the need for improved treatment
strategies. It follows that truly curative therapies for
treating atrial fibrillation need to be explored. As of now catheter
based ablation therapy or surgical therapy holds promise in the
patients who do not have structural heart disease but have permanent
AF. Catheter ablation for paroxysmal AF has shown promise
8. But Cox’s maze III procedure
which has been highly successful one has a reported 2% mortality
9. Scahff et al
10
have reported an early mortality of 1.4% for the same procedure. The
morbidity of any surgical procedure with the use of cardiopulmonary
bypass is well known. It makes no sense to use a procedure even with
any mortality to ablate lone AF. Therefore there was the need to
develop a minimally invasive surgical procedure which would have no
mortality and minimal morbidity and a high degree of
success. Thoracoscopic pulmonary vein isolation using
microwave catheter has been done successfully
11.
The LA appendage can be
stapled off with an endo GI stapler. Cryo catheters have been developed
to ablate atrial myocardium in the cath lab and these can also be
used for minimally invasive surgical approaches. Thus the future
holds great promise for cure for permanent AF without structural heart
disease with minimal invasion. It is only through efforts of the
medical community and with the support of the innovative industry that
the promise can translate into reality.
References
1.
FeinburgWM, Blackshear JL, Laupasias A. et al. Prevalence,
gender and age distribution of patients with atrial fibrillation .
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2. Cox JL, Ad N, Palazzo T.
Impact of the maze procedure on the stroke rate in patients with atrial
fibrillation. J Thorac Cardiovasc Surg 1999; 118:833-840
3.
Vaturi M, Sajie A, Shapira Y. et al. Impact of atrial fibrillation on
clinical status, atrial size and hemodynamics in patients after mitral
valve replacement. J Heart Valve Dis. 2001; 10:763-6
4. Lonnerholm S, Blomstrom
P, Nilsson L. et al. Effects of the maze operation on health-related
quality of life in patients with atrial fibrillation. Circulation.
2000;101:2607-11.
5. Geidel
S, Lass M,
Ostermeyer J. Permanent
Atrial
Fibrillation Ablation Surgery in Patients with Advanced Age. Indian
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6. Benjamin
EJ, Wolf PA, D’Agostino RB et al. Impact of atrial fibrillation on the
risk of death. The Framingham heart study. Circulation 1998; 98:946-52
7.
Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron
EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD; Atrial
Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM)
Investigators. A comparison of rate control and rhythm control in
patients with atrial fibrillation. N Engl J Med. 2002 Dec
5;347(23):1825-33.
8.
Marrouchhe NF, Dressing T, Cole C et al.Circular
mapping and ablation of the pulmonary vein for treatment of atrial
fibrillation : impact of different catheter technologies. J Am Coll
Cardiol. 2002;40:464-474
9. Cox JL, AD N, Palazzo T et al
Current status of the Maze procedure for the treatment of atrial
fibrillation. Semin Thorac Cardiovasc Surg 2000;12:15-9
10. Schaff
HV, Dearani JA, Daly RC et al. Cox Maze procedure for atrial
fibrillation : Mayo clinic experience. . Semin Thorac Cardiovasc Surg
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11. Saltman
AE, Rosenthal AS,Francalansia NA et al. A complete endoscopic approach
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