PREVENTIVE ABLATION OF ATRIA IN PATIENTS WITH MITRAL VALVE DISEASE AND ATRIOMEGALY

To assess safety and efficacy of preventive ablation of the left atrium (LA) during correction of mitral valve disease with atriomegaly, 40 patients were included in a pilot prospective randomized study. The inclusion criteria were as follows: hemodynamically significant mitral valve disease when its surgical correction was indicated, dilated LA (LA size >60 mm according to the echocardiographic data), sinus rhythm, and no documented evidence of the history of atrial fibrillation (AF). The exclusion criteria were as follows: hemodynamically significant aortic valve disease, coronary lesions when interventions were indicated, and the subject’s refusal to take part in the study. The study subjects were distributed into two following groups: Study Group (n=20) consisted of patients who underwent the surgical prevention of AF; Control Group (n=20) consisted of patients in whom isolated interventions on the mitral valve were carried out. All baseline parameters were similar in both groups. The ablation was performed according to the earlier described technique using non-irrigated bipolar radiofrequency clamp electrode or cryoprobe. The radiofrequency ablation was performed according to the following technique: the right and left pulmonary vein isolation by separate collectors; the LA posterior wall isolation, with a line applied towards the LA appendage. In case of cryoablation, the LA posterior wall isolation, with a line applied towards the LA appendage was performed. The LA appendage was removed from circulation by double-layer continuous suture. The cardiac rhythm was assessed in the early postoperation period using 24-hour Holter monitoring and in 3 months and thereafter using 72-hour Holter monitoring. No hospital mortality was revealed. No significant difference between the groups was found in the pattern and the number of perioperative events. The early postoperative period was characterized by a higher occurrence of paroxysmal AF in Control Group than in the Study Group subjects: 9 patients (45%) and 3 patients (15%), respectively (p=0.009). The analysis of cumulative parameters of occurrence of AF, atrial flutter, or atrial tachycardias showed their predominance in Control Group (log-rank test; p<0.001). It was shown that the predictors of AF occurrence within 12 months of follow-up were as follows: baseline LA size, age, no preventive ablation, male sex, left ventricular ejection fraction, and mitral regurgitation at baseline. Thus, the procedure of surgical AF prevention in the patients with mitral valve defects is safe. The preventive ablation showed a significant benefit of freedom from AF, atrial flutter, or atrial tachycardias in 12 months. The preventive ablation explains a lower annual incidence of AF-associated hospitalizations after mitral valve interventions. Further randomized studies tailored to assess efficacy of the AF surgical prevention are needed.

mitral valve disease, left atrium, pulmonary veins, atrial fibrillation, radiofrequency ablation, echocardiography, Holter monitoring

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