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THE RHYTHM IN LIFE THE  SEASONS DO NOT PUSH ONE ANOTHER; NEITHER DO CLOUDS RACE THE WIND ACROSS THE SKY .  ALL THINGS H - PowerPoint PPT Presentation


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THE RHYTHM IN LIFE THE  SEASONS DO NOT PUSH ONE ANOTHER; NEITHER DO CLOUDS RACE THE WIND ACROSS THE SKY .  ALL THINGS HAPPEN IN THEIR OWN GOOD TIME. Surgical ablation of chronic AF using radiofrequency energy in patients undergoing mitral valve surgery.

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THE RHYTHM IN LIFE

THE  SEASONS DO NOT PUSH ONE ANOTHER; NEITHER DO CLOUDS RACE THE WIND ACROSS THE SKY .

 ALL THINGS HAPPEN IN THEIR OWN GOOD TIME.


Surgical ablation of chronic AF

using radiofrequency energy in patients

undergoing mitral valve surgery


Chronic af in patients with mitral valve disease
Chronic AF in patients with Mitral Valve Disease

  • Its prevalence might reach up to 75%.

  • An important marker of more advanced cardiovascular disease.

  • The onset of AF is now considered a relative indication for mitral valve surgery.

  • Persistence of postoperative AF is linked to increased mortality & morbidity

  • Surgical correction of the valve rarely eliminates the arrhythmia.


Surgical treatment of atrial fibrillation
Surgical treatment of atrial fibrillation

  • Left atrial isolation procedure

  • Corridor procedure

  • Cox- Maze procedure

  • The radial approach

  • Mini- Maze procedures


  • Since the Cox- maze III procedure showed that AF can be definitely eradicated, efforts were made to achieve alternative & particularly less complex methods using surgical catheter ablation techniques during cardiac surgery.


Rationale for rf ablation
Rationale for RF ablation

  • Based on the hypothesis that the pulmonary veins and surrounding areas frequently house focal triggers and re-entrant circuits critical to the genesis and perpetuation of AF, it was postulated that circumferential isolation of pulmonary veins eliminates or isolates the arrhythmogenic activity that perpetuates chronic AF within the pulmonary veins


An ideal lesion pattern should combine
An ideal lesion pattern should combine:

  • Slight invasiveness

  • Simplicity

  • High reproducibility

  • Saving of time

  • With excellent success rate.

  • Radiofrequency ablation techniques must guarantee lesion transmularity & continuity without cardiac tissue injury.



  • The purpose of this study is to assess the feasibility, safety , &efficacy of circumferential isolation of each pulmonary vein using endocardial radiofrequency pulses to restore stable sinus rhythm during mitral valve surgery.

  • Also, to identify the clinical predictors to sinus rhythm restoration and left atrial mechanical contraction in this group of patients.


Patients & methods feasibility, safety , &efficacy of circumferential isolation of each pulmonary vein using endocardial radiofrequency pulses to restore stable sinus rhythm during mitral valve surgery.


  • This is a prospective randomized controlled study. It had been conducted on sixty patients known to have rheumatic mitral valve disease and chronic atrial fibrillation, referred to the National Heart Institute, for mitral valve surgery between November 2001 and November 2004.

  • They were divided into two groups according to being subjected to surgical ablation of chronic atrial fibrillation using radiofrequency energy in addition to the mitral valve surgery.


  • Exclusion criteria: been conducted on sixty patients known to have rheumatic mitral valve disease and chronic atrial fibrillation, referred to the National Heart Institute, for mitral valve surgery between November 2001 and November 2004.

  • Patients with associated aortic valve disease are excluded from the study due to expected elongation of cross clamp time needed for double valve replacement.


  • All patients were subjected to the following: been conducted on sixty patients known to have rheumatic mitral valve disease and chronic atrial fibrillation, referred to the National Heart Institute, for mitral valve surgery between November 2001 and November 2004.

  • Clinical assessment

  • Electrocardiography

  • Echocardiography

  • Surgical procedure


  • Surgical procedure : been conducted on sixty patients known to have rheumatic mitral valve disease and chronic atrial fibrillation, referred to the National Heart Institute, for mitral valve surgery between November 2001 and November 2004.

  • Tricuspid valve repair on a beating heart .

  • Warm cardioplegia .

  • Normothermia ( core temperature 36°C ) .

  • Mitral valve surgery .

  • Lastly, RF endocardial ablation was performed under temperature control.


  • RF pulses were delivered under temperature control not exceeding 70 °C for a period of 2 min. aiming to produce continuous lesion lines to encircle each pulmonary vein without any interconnecting lines. The duration of ablation for each point was not less than 8-10 seconds.



Postoperative management
Postoperative management pulmonary vein

  • Antiarrhythmic medications :all patients were started on a loading dose of amiodarone in the early post-operative period, followed by a maintenance dose of 200 mg/day for 3 months.

  • In case of postoperative AF prior to hospital discharge, electric cardioversion was attempted either alone or in combination with the administration of amiodarone.


Follow up
Follow-up pulmonary vein

  • Follow - up was performed on post-operative days 1, 7, & 14 and after 1, 3 & 6 months.

  • At each follow- up visit, clinical history, ECG, and echocardiogram were obtained.


Anticoagulation regimen
Anticoagulation regimen pulmonary vein

  • The anticoagulation regimen was started on the second postoperative day by IV heparin administered to each patient in the two groups, with the activated partial thromboplastin time kept between 1.5 & 2 times that of the control time for 7-14 days until the targeted INR was reached.


Results pulmonary vein



  • Patients were subdivided into two groups : valve surgery +/- tricuspid valve repair.

  • Group (A): thirty patients who were subjected to circumferential pulmonary vein isolation using RF ablation in addition to the mitral valve surgery (RF group).

  • Group (B): another thirty patients were subjected to mitral valve surgery alone without any ablative procedures for the atrial fibrillation and served as the control group.


Clinical characteristics of the patients
Clinical characteristics of the patients valve surgery +/- tricuspid valve repair.


Clinical characteristics of the patients1
Clinical characteristics of the patients valve surgery +/- tricuspid valve repair.


Echocardiographic data
Echocardiographic data valve surgery +/- tricuspid valve repair.


Echocardiographic data1
Echocardiographic data valve surgery +/- tricuspid valve repair.


Postoperative cardiac rhythm
Postoperative Cardiac Rhythm valve surgery +/- tricuspid valve repair.


Postoperative cardiac rhythm1
Postoperative Cardiac Rhythm valve surgery +/- tricuspid valve repair.

  • Immediately postoperative


Postoperative cardiac rhythm2
Postoperative Cardiac Rhythm valve surgery +/- tricuspid valve repair.

  • 6 month postoperative


Percentage of sr restoration in both rf and control groups
Percentage valve surgery +/- tricuspid valve repair. of SR restoration in both RF and control groups


Surgical procedure
Surgical procedure valve surgery +/- tricuspid valve repair.


Echocardiographic data of the patients in RF group: preoperatively, immediately postoperative, & after 6 months



Echocardiographic data of patients in control group: preoperatively, immediately postoperative, & after 6 months


Factors that might be influencing recurrence of atrial fibrillation

Preoperative variables preoperatively, immediately postoperative, & after 6 months

Age

Duration of AF

Type of MV disease

Left atrial diameters

Left ventricular EF

Intraoperative variables

Duration of CPB

Duration ACC

Diameter of dilated of pulmonary vein orifices.

Factors that might be influencing recurrence of atrial fibrillation






Echocardiographic findings pre postoperative in the rf subgroups with and without af
Echocardiographic Findings (pre & postoperative) in the RF subgroups (with and without AF )


Percentage of SR restoration of patients in RF group according to their left atrial antero-posterior diameters


Percentage of SR restoration of patients in control group according to their left atrial antero-posterior diameters



CONCLUSION left atrial diameters


  • Data in this study are encouraging for using this new approach in eliminating AF associated with mitral valve disease.

  • Simple "circumferential isolation of each pulmonary vein" ablation lines met the essential requirements to eliminate AF; is simple, easy, and quick to perform; effectively eliminated AF




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