Asian Cardiovasc Thorac Ann 2001;9:171-175
© 2001 Asia Publishing EXchange Pte Ltd
Volume Reduction Procedures in Giant Left Atrium
Hasan Basri Erdo
an, MD,
Gökhan Ipek, MD,
Kaan Kirali, MD,
Suat Nail Ömerolu, MD,
Mustafa Güler, MD,
Ömer I
ik, MD,
Cevat Yakut, MD
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Department of Cardiovascular Surgery Kouyolu Heart and Research Hospital Istanbul, Turkey
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For reprint information contact: Hasan Basri Erdoan, MD Tel: 90 216 325 5457 Fax: 90 216 339 0441 email: kosuyolu{at}superonline.com Department of Cardiovascular Surgery, Kouyolu Heart and Research Hospital, Kadiköy, Istanbul 81020, Turkey.
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Abstract
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Partial left atrial resection was performed in 8 males and 12 females, aged 19 to 63 years, with giant left atrium and mitral valve disease. Preoperatively, 18 patients had atrial fibrillation, and 2 had normal sinus rhythm. Echocardiography revealed left atrial thrombosis in 3 patients and spontaneous echo contrast in 5. The lateral wall of the left atrium, the region between the pulmonary veins, the roof of the atrium, and the tissue parallel to the mitral annulus were resected. Resection was performed using the cardiac autotransplantation technique in 6 patients. The mitral valve was replaced in 9 patients and reconstructed in 11. Mean aortic crossclamp time was 101 ± 35 minutes and total perfusion time was 135 ± 26 minutes. Mean follow-up was 20.4 ± 1.1 months. There was no operative mortality. One patient (5%) died suddenly in the late postoperative period. Left atrial volume was reduced from 265.3 ± 125 mL to 83 ± 43 mL (p < 0.01). Left atrial diameter decreased from 8.02 ± 1.31 cm to 4.4 ± 1.23 cm (p < 0.01). Sinus rhythm was detected in 13 patients (65%) postoperatively. No left atrial thrombosis or spontaneous echo contrast were found during follow-up. Statistically significant reductions in cardiac size and improvements in functional capacity were observed.
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Introduction
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In spite of surgical correction of mitral valve disease, factors such as atrial fibrillation (AF), giant left atrium (LA), and low cardiac output cause stagnation of blood in the LA and consequent thrombosis formation.1,2 A giant LA may exert pressure on the left ventricle, pulmonary vessels, and bronchial tree. Various techniques such as para-annular or posterior wall plication can be performed to reduce LA size.3,4 Cardiac autotrans-plantation has been suggested for effective volume reduction in giant LA.5,6 Atrial volume reduction procedures can be applied together with the maze procedure for treatment of AF.7 In this prospective study, 20 patients with giant LA were chosen randomly to study the clinical results of left atrial resection.
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Patients and Methods
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Between 1997 and 1999, 20 patients underwent a left atrial resection concomitant with mitral valve operations at Kosüuyolu Heart and Research Hospital. There were 8 males and 12 females aged 19 to 63 years (mean, 36.4 ± 11.1 years). The etiology of the mitral disorders was rheumatic in all patients and comprised mitral regurgitation in 12, mitral stenosis in 4, and mixed mitral disease in 4; 7 patients had moderate to severe aortic insufficiency, and 4 had mild to severe tricuspid insufficiency. There were 4 cases of moderate to severe pulmonary hyper-tension. AF was observed in 18 patients, and normal sinus rhythm in 2. Three patients had undergone a prior valve operation (closed mitral valvotomy). Preoperatively, 13 patients (65%) were in New York Heart Association functional class III, and 7 (35%) were in class II. Preoperative echocardiography (Table 1
) revealed throm-bosis of the LA in 3 patients, and a spontaneous echo contrast in 5. A marked indentation of the esophagus by the LA was detected on barium study in 3 patients.
All patients underwent surgery with cardiopulmonary bypass (CPB) and moderate hypothermia (28°C). CPB was instituted with aortic and bicaval venous cannulation with snares. Myocardial protection was obtained by continuous retrograde infusion of isothermic blood cardioplegia through the coronary sinus. Direct superior vena caval cannulation was performed in 6 patients in whom cardiac autotransplantation was planned. The superior vena cava was cannulated directly with a 24F cannula to avoid the sinoatrial node. Surgical exposure of the LA was achieved by a vertical left atriotomy posterior to the interatrial groove and anterior to the right pulmonary vein. Limited resection of the LA was undertaken in 9 patients (Figure 1) and they were considered to have gained sufficient benefit from this degree of resection. The area between the right and left pulmonary veins and the lateral wall of the LA (24 x 7–9 cm) were resected as well as the atrial wall between the pulmonary veins and the mitral annulus (2 x 3–4 cm). The appendix of the LA was excised and the incisions were extended to surround the right and left pulmonary veins without undertaking additional resection (Figure 1).
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Figure 1. Limited left atrial resection. (A) The left atrial appendage, the lateral wall, the area between the pulmonary veins, and the para-annular area were resected. (B) The incisions were extended to surround the right and left pulmonary veins without additional excision. IVC = inferior vena cava, LAA = left atrial appendage, MV = mitral valve, PV = pulmonary vein, RAA = right atrial appendage, SN = sinus node, SVC = superior vena cava, TV = tricuspid valve.
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Extended resection of the LA was performed in 11 patients (Figure 2). The right and left pulmonary vein orifices were separated and preserved together. The atrial roof, appendix of the LA, the tissue between the right and left pulmonary veins, and the area between the pulmonary veins and the mitral annulus were widely resected (Figure 2). The LA was resected using the cardiac autotransplantation technique in 6 of these 11 patients (Figure 3). Resection was performed more easily and closure of the LA was safer from the posterior of the heart. Incisions in the LA were closed with continuous 4/0 polypropylene sutures. Atrial septum aneurysms were resected in 2 patients. Concomitant mitral valve procedures were completed before closure of the LA. Depending on the condition of the mitral apparatus, the mitral valve was preserved, repaired, or replaced with a mechanical prosthesis. Limiting the incision in the right atrium simplified the operation for patients who had tricuspid valve disease primarily. Combined valvular procedures were required in all patients, comprising mitral valve replacement in 9, mitral valve reconstruction in 11, aortic valve replacement in 3, aortic valve reconstruction in 4, and tricuspid annuloplasty in 4. Atrioventricular pacing wires were routinely left in all patients. Mean aortic crossclamp time was 101 ± 35 minutes (range, 68 to 160 minutes) and mean CPB time was 135 ± 26 minutes (range, 96 to 183 minutes). In 6 patients, inotropic support was required during weaning from CPB, and an intraaortic balloon pump was used in 4. The others were easily weaned from CPB.
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Figure 3. Operative view of left atrium and mitral valve resections in the autotransplantation technique.
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Warfarin sodium and acetyl salicylic acid therapy were started orally on the first postoperative day in all patients except those who had undergone mitral valve reconstruction and were in sinus rhythm. The dosage of warfarin was regulated so that the prothrombin time was twice the normal value or the international normalized ratio was between 2 and 3.5. Nine patients who underwent mitral valve replacement received intravenous heparin for early anticoagulation so that the activated clotting time was approximately 200 seconds in the first 48 hours. The mean follow-up period was 20.4 ± 3.5 months (range, 14 to 32 months). All patients were studied by echocardiography and 24-hour Holter monitoring between the 10th and 15th day and in the 3rd, 6th, and 12th month postoperatively. Doppler echocardiography was used to investigate contraction of the LA and the presence of A waves.
Data are presented as mean ± standard deviation. The Mann-Whitney U test and chi-squared test were used in data analysis. Values of p < 0.05 were accepted as statistically significant.
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Results
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There was no early mortality. One patient (5%) died suddenly in the 4th postoperative month. Three patients (15%) required reexploration for excessive bleeding. Sinus rhythm was restored in 13 patients (65%) and junctional rhythm in 2; transient pacing was used in these 2 patients and both returned to AF in the early postoperative period (3rd to 5th day). Permanent pacing was not required in any patient. Atrial A waves were detected by Doppler studies of transmitral flow in all 13 patients who were in sinus rhythm.
Mean LA diameter decreased by 45% (p = 0.023) and mean LA volume was reduced by 69% (p = 0.012) after the operation (Table 1
, Figure 4). No thrombosis of the LA or spontaneous echo contrast was detected in the follow-up period. The decrease in cardiothoracic index (Table 1) was statistically significant (p < 0.01). The mean New York Heart Association functional class improved from 2.7 ± 1.2 to 1.2 ± 1.1 (p < 0.05) 6 months postoperatively in the 19 patients who survived.
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Figure 4. Echocardiograms of (A) preoperative and (B) postoperative left atrial volumes in the same patient.
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Discussion
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The possibility of spontaneous echo contrast or thrombosis is still high after mitral valve surgery in patients with giant LA and AF. The size of the LA is one of the strongest independent predictors of thromboembolism.8 Para-annular plication, posterior wall plication, ligation of the appendix of the LA, and partial resection using autotransplantation have been suggested as modes of diminishing size and preventing stagnation.4,5 Plication techniques decrease the incidence of postoperative low cardiac output syndrome and respiratory dysfunction, but they do not decrease the volume of the LA sufficiently nor restore sinus rhythm in cases of AF.4,9 In patients with dilated LA, the maze procedure concomitant with mitral valve operations makes contractions of the LA detectable but incomplete, especially in the elderly. In addition to the maze procedure, resection of redundant atrial wall along the incision line may be beneficial in reducing the size of the LA and decreasing blood stagnation, as well as the risk of thromboembolism.8
While limited resection was sufficient in patients with LA diameters below 8 cm, extended resection was required in those with LA diameters over 8 cm. When performing extended resection, closure of the LA must be carried out carefully, especially in redo operations and in cases where the wall of the LA is fragile. Some patients underwent autotransplantation for extended atrial resection; although the mean aortic crossclamp period was prolonged (11 ± 3.4 minutes) by this technique, resection was easily performed, the LA could be closed more securely, postoperative bleeding was decreased, and the surgeon had better exposure.
In combined mitral valve operations and Cox-maze III procedures performed by Kosakai,10 the correlation between postoperative restoration of sinus rhythm and atrial diameter was investigated. Restoration of sinus rhythm was not detected in patients whose LA diameter was over 8.7 cm, whereas in those with an atrial diameter of less than 4.5 cm, the restoration of sinus rhythm was 100%. In this study, the mean preoperative LA diameter was 7.5 ± 1.2 cm in patients who reverted to sinus rhythm postoperatively, and 8.6 ± 1.1 cm in those who persisted in AF (p = 0.026). No statistically significant difference was found between the postoperative LA diameters in these two subgroups (p > 0.05).
In addition to the 69% decrease in mean left atrial volume after resection, sinus rhythm was restored in 61% (11/18) of patients with preoperative AF. Resection of the LA together with cryoablation or the "cut and sew" technique, and finishing with the maze procedure might enhance the restoration of sinus rhythm in patients with giant LA. Cardiac performance might also be improved by the same techniques.
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References
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Abstract
Introduction
