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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. - 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.

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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

  • 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

  • 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

  • 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:

  • Slight invasiveness

  • Simplicity

  • High reproducibility

  • Saving of time

  • With excellent success rate.

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


Aim of the work


  • 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


  • 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:

  • 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:

  • Clinical assessment

  • Electrocardiography

  • Echocardiography

  • Surgical procedure


  • Surgical procedure :

  • 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.


Scheme of the procedure : circumferential isolation of each pulmonary vein


Postoperative management

  • 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 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

  • 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


  • This study included 60 patients referred for elective mitral valve surgery +/- tricuspid valve repair.

  • The patients included 19 men & 41 women, ranging in age from 18 to 65 years (average 35.5 ± 11.9 y).


  • Patients were subdivided into two groups :

  • 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


Echocardiographic data


Echocardiographic data


Postoperative Cardiac Rhythm


Postoperative Cardiac Rhythm

  • Immediately postoperative


Postoperative Cardiac Rhythm

  • 6 month postoperative


Percentageof SR restoration in both RF and control groups


Surgical procedure


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


  • Biatrial contraction was documented by the presence of A wave transmitral and tricuspid flow using transthoracic Doppler echocardiography in 83.6% of patients in SR in the RF group within six months of the operation.


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


Preoperative variables

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


Comparison of patients' clinical characteristics with and without AFin the RF group


Patients' Intraoperative Findings in RF subgroups ( with and without AF )


Patients' Intraoperative Findings in RF subgroups ( with and without AF )


Comparison of patients' echocardiographic data with and without AF in the RF group


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


Percentage of SR restoration in RF group according to the left atrial diameters


CONCLUSION


  • 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


  • It helped in restoration and maintenance of a normal sinus rhythm in a considerable percentage of patients with long standing AF secondary to mitral valve disease at an average follow-up period of six months.

  • Atrial transport function was restored in 83.6% of the patients in SR.


  • It is effective and does not require either new technical resources or additional training of surgical teams.

  • The preoperative left atrial diameter and preoperative AF duration are important determinant that might be influencing the sinus conversion rate.


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