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Left atrial radiofrequency ablation during mitral valve surgery for continuous atrial fibrillation: A randomized controlled trial
Scopus
Toplam 162 atıf DOI
Context: Although left atrial radiofrequency ablation (RFA) is increasingly used for the treatment of chronic atrial fibrillation during mitral valve surgery, its efficacy to restore sinus rhythm and any resulting benefits have not been examined in the context of an adequately powered randomized trial. Objective: To determine whether intraoperative RFA of the left atrium increases the long-term restoration of sinus rhythm and improves exercise capacity. Design, Setting, and Patients: Randomized, double-blind trial performed in a single UK tertiary referral center with enrollment between December 2001 and November 2003. A total of 101 patients referred for mitral valve surgery with at least 6 months' history of uninterrupted atrial fibrillation were assessed for eligibility; 97 were enrolled. Patients were followed up for 12 months. Intervention: Patients were randomly assigned to undergo mitral valve surgery and RFA of the left atrium (n=49) or mitral valve surgery alone (controls; n=48). Main Outcome Measures: The primary outcome measure was presence of sinus rhythm at 12 months; secondary measures were patient functional status and exercise capacity (assessed by shuttle-walk test), left atrial contractility, and left atrial and left ventricular dimension and function and plasma levels of B-type natriuretic peptide. Results: At 12 months, sinus rhythm was present in 20 (44.4%) of 45 RFA patients and in 2 (4.5%) of 44 controls (rate ratio, 9.8; 95% CI, 2.4-86.3; P<.001). Restoration of sinus rhythm in the RFA group was accompanied by a greater improvement in mean (SD) shuttle-walk distance compared with controls (+94 [102] m vs +48 [82] m; P=.003) and a greater reduction in the plasma level of B-type natriuretic peptide (-104 [87] fmol/mL vs -51 [82] fmol/mL; P=.03). Patients randomized to receive RFA had similar rates of postoperative complications and deaths as control patients. Conclusions: Radiofrequency ablation of the left atrium during mitral valve surgery for continuous atrial fibrillation significantly increases the rate of sinus rhythm restoration 1 year postoperatively, improving patient exercise capacity. On the basis of its efficacy and safety, routine use of RFA of the left atrium during mitral valve surgery may be justified. Trial Registration: ClinicalTrials.gov Identifier: NCT00238706. ©2005 American Medical Association. All rights reserved.
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The effect of preoperative atrial fibrillation on survival following mitral valve repair for degenerative mitral regurgitation
Scopus
Havuzumuzda 51 atıf almış
Objective: There is conflicting evidence with regard to the impact of preoperative atrial fibrillation (AF) on the post mitral valve (MV) repair on the early and late outcome. Methods: A total of 349 patients undergoing various MV repair procedures for degenerative mitral regurgitation (MR) between 1997 and 2003 were studied. Preoperatively, 152 (44%) of these patients were in AF and 197 (56%) patients were in sinus rhythm (SR). The clinical features and the outcome in these two cohorts of patients were compared. Results: The patients in the AF group were older than their counterparts in the SR group (66 ± 7 vs 62 ± 9 years) (p = 0.01), had a higher mean NYHA class score (2.4 ± 0.6 vs 2.2 ± 0.7) (p = 0.04) and were more likely to have impaired left ventricular function (60% vs 36%) (p < 0.0001). A similar proportion of patients in the AF (38%) and SR (30%) groups had additional cardiac surgical procedures (p = 0.12). Operative mortality was 3.9% in AF group versus 0.5% in SR group (p = 0.04), and operative morbidity was 27% versus 17%, respectively (p = 0.03). At latest follow up, 4% of patients that were in SR preoperatively developed AF; conversely, 2% of the patients in the AF group converted to SR. The rates of recurrent grade II or III MR (4% vs 5%) (p = 0.8) and MV re-operation (2.6% vs 2.5%) (p = 1.0) were similar in the AF and SR groups. Kaplan-Meier survival at 7 years was 75 ± 6% versus 90 ± 3% (p = 0.005). On Cox proportional hazards regression model, impaired LV function [(p = 0.02), hazard ratio 0.25 (95% confidence intervals (C.I.) 0.078-0.84)] and AF [(p = 0.03), hazard ratio 2.70 (95% C.I. 1.09-6.68)] were significant adverse predictors of survival. Conclusions: This study shows that in patients undergoing MV repair for degenerative MR, preoperative AF has a major negative impact on the early and late survival. © 2007 European Association for Cardio-Thoracic Surgery.