Concomitant Atrial Fibrillation in Patients with Mitral Valve Defects

The current state of the problem of concomitant atrial fibrillation (AF) in patients with mitral valve defects was considered. The data on the epidemiology of mitral valve disease and the etiology and pathogenesis of atrial fibrillation were presented. The characteristics of the development of the heart rhythm disorder in patients with mitral valve disease and the possibilities of heart rhythm recovery after the valve surgery were showed. The probability of spontaneous recovery of sinus rhythm in these patients was found to be low especially in patients with persistent AF requiring concomitant interventions.

The history of the development of surgical techniques of atrial fibrillation management was reviewed. Now, a classic operation “Cox-Maze III” considered to be the “gold standard”, has commonly been displaced by alternative technologies replacing a scalpel. The data on the modern devices for surgical ablation (cryoablation, microwave, ultrasound ablation) were presented. Currently, the most common method is the radiofrequency ablation (RFA) consisting in the use of AC current of 50 kHz to 1 mHz. There were reviewed the properties of the method, its varieties, advantages and limitations. Initially used monopolar ablation was shown to have relatively low efficiency and the higher probability of complications than bipolar ablation that came into use later. “Cox-Maze IV” operation using bipolar RFA demonstrates the efficiency comparable to the classical “Maze III”. Despite certain advances in the surgical treatment of atrial fibrillation, the question of developing an optimal method able to be widely implemented with maximum efficiency and minimal complications was concluded to remain still open.

1. Atrial fibrillation ablation, 2011 Update. Natale A., Raviele A. (editors). UK: Wiley-Blackwell; 2011; 192 p.
2. Calkins H., Brugada J., Cappato R., et al. 2012 HRS/EHRA/ECAS Expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Heart Rhythm J 2012; 9(4): 632–696.
3. European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, Camm A.J., Kirchhof P., Lip G.Y., et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010 Oct; 31(19): 2369–2429.
4. Klinicheskie rekomendatsii po provedeniyu elektrofizio­logicheskikh issledovaniy, kateternoy ablyatsii i primeneniyu implantiruemykh antiaritmicheskikh ustroystv (redaktsiya 2011) [Clinical recommendations on electrophysiological researches, catheter ablation and the application of implanted anti-rhythmical devices (2011 version)]. Rabochaya gruppa po razrabotke rekomendatsiy: Revishvili A.Sh., Antonchenko I.V., Ardashev A.V., et al. [Working group on the development of recommendation: Revishvili A.Sh., Antonchenko I.V., Ardashev A.V., et al.]. Moscow; 2011; 518 p.
5. Gassanov N., Caglayan E., Duru F., Er F. Atrial fibrillation. Cardiol Res Prac 2013, 2013: 142673.
6. Stefansdottir H., Aspelund T., Gudnason V., Arnar D.O. Trends in the incidence and prevalence of atrial fibrillation in Iceland and future projections. Europace 2011; 13: 1110–1117.
7. Wilke T., Groth A., Mueller S., et al. Incidence and prevalence of atrial fibrillation: an analysis based on 8.3 million patients. Europace 2013; 15: 486–493.
8. Nguyen T.N., Hilmer S.N., Cumming R.G. Review of epidemiology and management of atrial fibrillation in developing countries. Int J Cardiol 2013 Feb 28 [Epub ahead of print].
9. Levy S. Changing epidemiology of atrial fibrillation. Europace 2013; 15: 465–466.
10. Poynter J.A., Beckman D.J., Abarbanell A.M., et al. Surgical treatment of atrial fibrillation: the time is now. Ann Thorac Surg 2010; 90: 2079–2086.
11. Ringborg A., Nieuwlaat R., Lindgren P., et al. Costs of atrial fibrillation in five European countries: results from the Euro Heart Survey on atrial fibrillation. Europace 2008; 10: 403–411.
12. Reinold T., Lindig C., Willich S.N., Brüggenjürgen B. The costs of atrial fibrillation in patients with cardiovascular comorbidities — a longitudinal analysis of German health insurance data. Europace 2011; 13: 1275–1280.
13. Ngaage D.L., Schaff H.V., Mullany C.J., et al. Influence of preoperative atrial fibrillation on late results of mitral repair: is concomitant ablation justified? Ann Thorac Surg 2007; 84: 434–443.
14. Rain D., Dark J., Bourke J.P. Effect of mitral valve repair/replacement surgery on atrial arrhythmia behavior. J Heart Valve Dis 2004 Jul; 13(4): 615–621.
15. Bokeriya L.A., Gudkova R.G. Serdechno-sosudistaya khirurgiya — 2011. Bolezni i vrozhdennye anomalii sistemy krovoobrashcheniya [Cardiovascular surgery — 2011. Diseases and congenital circulatory anomalies]. Moscow: NTsSSKh im. A.N. Bakuleva RAMN; 2012; 196 p.
16. Nkomo V.T., Gardin J.M., Skelton T.N., et al. Burden of valvular heart diseases: a population-based study. Lancet 2006 Sep; 386: 1005–1011.
17. Natsional’nye rekomendatsii po vedeniyu, diagnostike i lecheniyu klapannykh porokov serdtsa [National recommendations on management, diagnosis and treatment of valvular heart diseases]. Rabochaya gruppa po razrabotke rekomendatsiy: Bokeriya L.A., Abdulkasumova S.K., Bogachev-Prokof’ev A.V. et al. [Working group on the development of recommendation: Bokeriya L.A., Abdulkasumova S.K., Bogachev-Prokof’ev A.V., et al.]. Moscow: Izd-vo NTsSSKh im. A.N. Bakuleva RAMN; 2009; 356 p.
18. Marijon E., Mirabel M., Celermajer D.S., Jouven X. Rheumatic heart disease. Lancet 2006; 379: 953–964.
19. Boudoulas H. Etiology of valvular heart disease in the 21st century. Hellenic J Cardiol 2002; 43: 183–188.
20. Boudoulas H. Etiology of valvular heart disease. Expert Rev Cardiovasc Ther 2003; 1(4): 523–532.
21. Bhandari S., Subramanyam K., Trehan N. Valvular heart disease: diagnosis and management. JAPI 2007; 55: 575–584.
22. Braunwald’s heart disease: a textbook of cardiovascular medicine. Libby P., Bonow R.O., Mann D.L., Zipes D.P. (editors). Philadelphia: Elsevier Saunders; 2007; 616 p.
23. Jahangiri M., Weir G., Mandal K., Savelieva I., Camm J. Current strategies in the management of atrial fibrillation. Ann Thorac Surg 2005; 82: 357–364.
24. Chen M.C., Chang J.P., Chen Y.L. Surgical treatment of atrial fibrillation with concomitant mitral valve disease: an Asian review. Ann Thorac Cardiovasc Surg 2011; 17(2): 148–152.
25. Kim J.B., Ju M.H., Yun S.C., et al. Mitral valve replacement with or without a concomitant Maze procedure in patients with atrial fibrillation. Heart 2010; 96: 1126–1131.
26. Kalil A.K., Maratia C.B., D’Alvia A., Ludwig F.B. Predictive factors for persistence of atrial fibrillation after mitral valve operation. Ann Thorac Surg 1999; 67: 614–617.
27. Langerveld J., van Hemel N.M., Kelder J.C., et al. Long-term follow-up of cardiac rhythm after percutaneous mitral balloon valvotomy. Europace 2003; 5: 47–53.
28. Fragakis N., Pantos I., Younis J., et al. Surgical ablation for atrial fibrillation. Europace 2012, 14: 1545–1552.
29. Funatsu T., Kobayashi J., Nakajima H., et al. Long-term results and reliability of cryothermic ablation based maze procedure for atrial fibrillation concomitant with mitral valve surgery. Eur J Cardiothorac Surg 2009; 36: 267–271.
30. Nitta T. Surgery for atrial fibrillation. Ann Thorac Cardiovasc Surg 2005; 11(3): 148–152.
31. Banach M., Mariscalco G., Ugurlucan M., et al. The significance of preoperative atrial fibrillation in patients undergoing cardiac surgery: preoperative atrial fibrillation — still underestimated opponent. Europace 2008; 10: 1266–1270.
32. Bando K., Kobayashi J., Kosakai Y., et al. Impact of Cox maze procedure on outcome in patients with atrial fibrillation and mitral valve disease. J Thorac Cardiovasc Surg 2002 Sep; 124(3): 575–583.
33. Qian Y., Meng J., Tang H., et al. Different structural remodelling in atrial fibrillation with different types of mitral valvular diseases. Europace 2010; 12: 371–377.
34. Fukada J., Morishita K., Komatsu K., et al. Is atrial fibrillation resulting from rheumatic mitral valve disease a proper indication for the maze procedure? Ann Thorac Surg 1998; 65: 1566–1569.
35. Sueda T., Imai K. Surgical ablation of atrial fibrillation. Ann Thorac Cardiovasc Surg 2005; 11(5): 285–287.
36. Cox J.L. Surgical treatment of atrial fibrillation: a review. Europace 2004; 5: S20–S29.
37. Makhaldiani Z.B., Neftyaliev I.M. Evolyutsiya i sovremennoe sostoyanie voprosa khirurgicheskogo lecheniya fibrillyatsii predserdiy. Chast’ 1. Radiochastotnaya, mikrovolnovaya ablatsiya i krioablatsiya [Evolution and current state of the problem of surgical management of atrial fibrillation. Part 1. Radiofrequency, microwave ablation and cryoablation]. Annaly aritmologii — Arrhythmia Annals 2011; 3: 31–38.
38. Bakir I., Casselman F.P., Brugada P., et al. Current strategies in the surgical treatment of atrial fibrillation: review of the literature and Onze Lieve Vrouw Clinic’s strategy. Ann Thorac Surg 2007; 83: 331–340.
39. Weimar T., Schena S., Bailey M.S., et al. The Cox-Maze procedure for lone atrial fibrillation: a single-center experience over 2 decades. Circ Arrhythm Electrophysiol 2012; 5: 8–14.
40. Zheleznev S.I., Bogachev-Prokof’ev A.V., Pivkin A.N., et al. Sravnenie rezul’tatov konkomitantnoy protsedury Maze III i radiochastotnoy ablatsii predserdiy u patsientov s klapannymi porokami serdtsa [The comparison of the results of concomitant Maze III procedure and radiofrequency ablation in patients with valvular heart disease]. Patologiya krovoobrashcheniya i kardiokhirurgiya — Circulation pathology and Cardiac Surgery 2012; 4: 9–14.
41. Jahangiri M., Weir G., Mandal K., et al. Current strategies in the management of atrial fibrillation. Ann Thorac Surg 2006; 82: 357–364.
42. Gillinov A.M., Blackstone E.H., McCarthy P.M. Atrial fibrillation: current surgical options and their assessment. Ann Thorac Surg 2002; 74: 2210–2217.
43. Stulak J.M., Dearini J.A., Sundt T.M., et al. Ablation of atrial fibrillation: comparison of catheter-based techniques and the Cox-Maze III operation. Ann Thorac Surg 2011; 91: 1882–1889.
44. Makhaldiani Z.B., Neftyaliev I.M. Evolyutsiya i sovremennoe sostoyanie voprosa khirurgicheskogo lecheniya fibrillyatsii predserdiy. Chast’ 2. Ul’trazvukovaya i lazernaya ablatsiya, torakoskopicheskie tekhnologii [Evolution and current state of the problem of surgical management of atrial fibrillation. Part 2. Ultrasound and laser ablation, thoracoscopic technologies]. Annaly aritmologii — Arrhythmia Annals 2011; 3: 38–43.
45. Sukhanov M.S. Sravnitel’naya kharakteristika priborov, primenyaemykh pri operatsii “Cox-Maze III” v khirurgicheskom lechenii fibrillyatsii predserdiy [Comparative analysis of the devices used in “Cox-Maze III” operation in surgical management of atrial fibrillations]. Annaly aritmologii — Arrhythmia Annals 2010; 1: 26–29.
46. Kim J.B., Bang J.H., Jung S.H., et al. Left atrial ablation versus biatrial ablation in the surgical treatment of atrial fibrillation. Ann Thorac Surg 2011; 92: 1397–1405.
47. Sakamoto Y., Takakura H., Onoguchi K., et al. Cryosurgical left-sided maze procedure in patients with valvular heart disease: medium-term results. Ann Thorac Cardiovasc Surg 2011; 17(2): 148–152.
48. Gillinov A.M., Smedira N.G., Cosgrove D.M. Microwave ablation of atrial fibrillation during mitral valve operations. Ann Thorac Surg 2002; 74: 1259–1261.
49. Kim K.B., Cho K.R., Sohn D.W., et al. The Cox-Maze III procedure for atrial fibrillation associated with rheumatic mitral valve disease. Ann Thorac Surg 1999; 68: 799–803.
50. De Lima G.G., Kalil R.A.K., Leiria T.L.L., et al. Randomized study of surgery for patients with permanent atrial fibrillation as a result of mitral valve disease. Ann Thorac Surg 2004; 77: 2089–2094.
51. Gillinov A.M., Bakaeen F., McCarthy P.M., et al. Surgery for paroxysmal atrial fibrillation in the setting of mitral valve disease: a role for pulmonary vein isolation? Ann Thorac Surg 2006; 81: 19–28.
52. Kalil R.A.K., Lima G.G., Leiria T.L.L., et al. Simple surgical isolation of pulmonary veins for treating secondary atrial fibrillation in mitral valve disease. Ann Thorac Surg 2002; 73: 1169–1173.
53. Wong J.W.W., Mak K.H. Impact of maze and concomitant mitral valve surgery on clinical outcomes. Ann Thorac Surg 2006; 82: 1938–1947.
54. Tanaka H., Narisawa T., Mori T., et al. Pulmonary vein isolation for chronic atrial fibrillation associated with mitral valve disease: the midterm results. Ann Thorac Cardiovasc Surg 2002; 8(2): 88–91.
55. Chaput M., Bouchard D., Demers P., et al. Conversion to sinus rhythm does not improve long-term survival after valve surgery: insights from a 20-year follow-up study. Eur J Cardiothorac Surg 2005; 28: 206–210.
56. Fukunaga S., Hori H., Ueda T., et al. Effect of surgery for atrial fibrillation associated with mitral valve disease. Ann Thorac Surg 2008; 86: 1212–1217.
57. Halkos M.E., Craver J.M., Thourani V.H., et al. Intraoperative radiofrequency ablation for the treatment of atrial fibrillation during concomitant cardiac surgery. Ann Thorac Surg 2005; 80: 210–216.
58. Chiappini B., Di Bartolomeo R., Marinelli G. Radiofrequency ablation for atrial fibrillation: different approaches. Asian Cardiovascular & Thoracic Annals 2004; 12(3): 272–277.
59. Saint L.L., Bailey M.S., Prasad S., et al. Cox-Maze IV results for patients with lone atrial fibrillation versus concomitant mitral disease. Ann Thorac Surg 2012; 93: 789–795.
60. Zheleznev S.I., Bogachev-Prokof’ev A.V., Pivkin A.N., et al. Vliyanie razlichnykh modifikatsiy protsedury Maze na gormonal’nuyu funktsiyu predserdiy i uroven’ kardiospetsificheskikh markerov povrezhdeniya [The effect of different modifications of Maze procedure on atrial hormonal function and the level of cardiospecific damage markers]. Patologiya krovoobrashcheniya i kardiokhirurgiya — Circulation Pathology and Cardiac Surgery 2012; 1: 27–31.
61. Jessurun E.R., de Bakker J.M.T., van Hemel N.M., et al. Right atrial modification of maze surgery does not affect refractoriness and conduction patterns of human lone atrial fibrillation. Europace 2003; 5: 39–46.
62. Sueda T., Imai K., Orihashi K., et al. Late occurrence of atrial arrhythmias after the simple left atrial procedure for chronic atrial fibrillation in mitral valve surgery. Ann Thorac Surg 2010; 90: 1959–1966.
63. Sueda T. What is essential for the elimination of persistent or chronic atrial fibrillation? Surg Today 2013 Mar; 24 [Epub ahead of print].
64. Sankar N.M., Farnsworth A.E. Left atrial reduction for chronic atrial fibrillation associated with mitral valve disease. Ann Thorac Surg 1998; 66: 254–256.

Yambatrov А.G., Medvedev А.P. Concomitant Atrial Fibrillation in Patients with Mitral Valve Defects. Sovremennye tehnologii v medicine 2013; 5(3): 100