Title: Limitations of Indication for Left Atrial Plication

Authors: Girish Gowda S L, MCh, Seetharama Bhat P S, MCh, C N Manjunath, DM

 DOI:  https://dx.doi.org/10.18535/jmscr/v6i3.94

Abstract

Introduction: Patients with Rheumatic mitral valve disease with mitral stenosis, mitral regurgitation, or a combination of both can have enlargement of the left atrium (LA) with atrial fibrillation, hemodynamic complications and even atrial thrombus formation in LA. Currently, there is no consensus regarding the management of dilated LA based on its size.

Materials and Methods: Patients who met Piccoli criteria, that is anteroposterior diameter of left atrium of over 65 mm on echocardiography with mitral valve disease of rheumatic etiology were divided into 2 groups prospectively : 37 patients underwent LA plication (group 1) and 46 patients without LA plication (group 2). Pre operative and postoperative functional and hemodynamic parameters data was collected of both the groups. Mean follow-up period was 10.33 months. Mean left atrial diameter was 8.77 +/- 1.62 cms preoperatively and 6.05 +/- 1.21 cm postoperatively in group 1. In group 2, the mean values were 7.88 +/- 0.81 and 6.28 +/- 1.14 cms respectively. Postoperatively patients were followed up with echocardiography and ECG to see for conversion to sinus rhythm 

Results: Postoperatively no differences were observed in ejection fraction and left ventricular end-diastolic diameter between the 2 groups. The postoperative decreases in pulmonary arterial pressure and the left atrial plication were not significantly different. Aortic cross clamp time was significantly less in group 2. In group 1, 23 patients with LA size > 8 cms were in AF preoperatively of which 20 patients attained sinus rhythm. In group 2, 22 patients with LA size > 8 cms were in AF preoperatively of which 8 patients attained sinus rhythm (p <0.05), where as 8 patients out of 11 patients in group 2 with LA size of <8 cms attained normal sinus rhythm. In group 1, 30 patients with preoperatively LA size > 8 cms, 25 patients attained LA size <6.5 cms. In group 2, 22 patients with preoperatively LA size > 8 cms, 8 patients attained LA size <6.5 cms (p<0.05). There is no added advantage of left atrial plication if the left atrial diameter is below 8 cms

Keywords: Left atrial reduction, giant left atrium, atrial fibrillation.

References

  1. Piccoli GP, Massini C, Di Eusanio G, Ballerini L, Iacobone G, Soro A, et al. Giant left atrium and mitral valve disease: early and late results of surgical treatment in 40 cases. J Cardiovasc Surg (Torino) 1984;25:328–36.
  2. Kawazoe K, Beppu S, Takahara Y, Nakajima N, Tanaka K, Ichihashi K, Fujita T, Manabe H. Surgical treatment of giant left atrium combined with mitral valvular disease. Plication procedure for plication of compression to the left ventricle, bronchus and pulmonary parenchyma. J Thorac Cardiovasc Surg 1983;85:885—92
  3. The Electrocautery Maze. How I Do ItPrasanna Simha M, PSS Bhat, N Prabhudeva.The Heart Surgery Forum 4 (4): 340 -345, 2001
  4. Plaschkes J, Borman J, Merin G, Milwidsky H. Giant left atrium in rheumatic heart disease: a report of 18 cases treated by mitral valve replacement. Ann Surg 1971;174:194—201.
  5. Benjamin E, D’Agostino R, Belanger A,Wolf PA, Levy D. LA size and the risk of stroke and death: the Framingham Heart Study. Circulation 1995 ;92 : 835—41.
  6. Johnson J, Danielson GK, MacVaug H III, Joyner CR. Plication of the giant left atrium at operation for severe mitral regurgitation. Surgery 1967;61:118–21.
  7. Reed D, Abbott R, Smucker M, Kaul S. Prediction of outcome after mitral valve replacement in patients with symptomatic chronic mitral regurgitation. The importance of left atrial size. Circulation 1991;84:23- 34
  8. Kawaguchi AT, Kosakai Y, Isobe F, Sasako Y, Eishi K, Kakano K, et al. Surgical stratification of patients with atrial fibrillation secondary to organic lesions. Eur J Cardiothoracic Surg 1996; 10:983-90.
  9. Ortiz de Murúa JA, Ávila MC, Ochoa C, de la Fuente L, Moreno de Vega JC, del Campo F, et al. Factores predictors independientes del éxito agudo y al año de la cardioversión eléctrica en pacientes con fibrilación auricular crónica. Rev Esp Cardiol 2001;54:958-64.
  10. Sugiki H, Murashita T, Yasuda K, Doi H. Novel technique for volumeplication of giant left atrium: simple and effective ‘spiral resection’ method. Ann Thorac Surg 2006;81:378—80.
  11. Scherer M, Dzemali O, Aybec T, Wicmser-Greinecker G, Moritz A. Impact of left atrial size on chronic atrial fibrillation in mitral valve surgery. J Heart Valve Dis 2003;12:469—74.
  12. Somerville J, Chambers R. systemic embolism in mitral stenosis: relation to the size of the left atrial appendix. Br Med J 1964;2:1167—9.
  13. Scherer M, Therapidis P, Miscovic A, Moritz A. Left atrial size plication improves the sinus rhythm conversion rate after radiofrequency ablation for continuous atrial fibrillation in patients undergoing concomitant cardiac surgery. Thorac Cardiovasc Surg 2006;54:34—8.
  14. Chen M, Chang J, Guo G, Chang HW. Atrial size plication as a predictor of the success of radiofrequency maze procedure for chronic atrial fibrillation in patients undergoing concomitant valvular surgery. J Cardiovasc Electrophysiol 2001;12:867-74.
  15. Kosakai Y, Kawaguchi AT, Isobe F, Sasako Y, Nakano K, Eishi K, Tanaka N, Kito Y, Kawashima Y. Cox-maze procedure for chronic atrial fibrillation associated with mitral valve disease. J Thorac Cardiovasc Surg1994;108:1049-55
  16. Plaschkes J, Borman JB, Merin G, Milwidsky H. Giant left atrium in rheumatic heart disease: a report of 18 cases treated by mitral
  17. Beppu S, Kawazoe K, Nimura Y, Nagata S, Park YD, Sakakibara H, et al. Echocardiographic study of abnormal position and motion of the posterobasal wall of the left ventricle in cases of giant left atrium. Am J Cardiol 1982;49:467–72.
  18. Appelbaum A, Kouchoukos NT, Blackstone EH, Kirklin JW. Early risks of open heart surgery for mitral valve disease. Am J Cardiol 1976;37:201–9.
  19. Grunkemeier GL, Macmanus Q, Thomas DR, Starr A. Regression analysis of late survival following mitral valve replacement. J Thorac Cardiovasc Surg 1978;75:131–7.
  20. Salomon NW, Stinson EB, Griepp RB, Shumway NE. Patient-related risk factors as predictors of results following isolated mitral valve replacement. Ann Thorac Surg 1977;24:514–30.

Corresponding Author

Dr Girish Gowda S L

Department of Cardiothoracic and Vascular Surgery,

Sri Jayadeva Institute of Cardiovascular Sciences and Research,

Bangalore, Karnataka, Pin-560069, INDIA

Contact number- 09449046932, Email: This email address is being protected from spambots. You need JavaScript enabled to view it.