Intraoperative options for treating atrial fibrillation associated with mitral valve disease.

A trial fibrillation is present in approximately 50% of all patients undergoing surgery for the treatment of mitral valve disease.1-3 For more than 40 years, cardiac surgeons have been forced to ignore this associated atrial fibrillation at the time of open mitral valve surgery because there has been no effective way to treat it. After the success of the maze procedure in treating atrial fibrillation,4-6 several surgeons began to add the maze procedure as an adjunct to mitral valve surgery to treat both problems.7-9 When properly performed, the results with this combined approach have been excellent, with no increase in perioperative morbidity or operative mortality and with documented long-term advantages over simply leaving patients in atrial fibrillation.8,9 Despite these results, adding the maze procedure to mitral valve surgery significantly prolongs and complicates the operation; therefore, most surgeons have understandably been reluctant to perform the combined procedure. During the past 2 to 3 years, cardiologists have become extremely aggressive in their efforts to treat atrial fibrillation by modifications of the percutaneous radiofrequency catheters that have been so successful in treating other types of arrhythmias, especially the Wolff-Parkinson-White syndrome.10-13 It was only a matter of time until some surgeons used these same percutaneous endocardial catheters to treat atrial fibrillation intraoperatively when performing mitral valve surgery. This new surgical intervention was quickly recognized by medical device companies as a new market and, as a result, new radiofrequency devices have been adapted specifically for intraoperative use. In this issue of the Journal [J Thorac Cardiovasc Surg 2001;122:249-56], the group from Maastricht, The Netherlands, describes the use of intraoperative radiofrequency catheters to ablate atrial fibrillation in patients who required surgery primarily for mitral valve disease. This study is particularly important because it comes from perhaps the premier electrophysiology group in the world, especially in the area of atrial fibrillation. Clinical electrophysiology was born in the laboratory of Professor Dirk Durrer of Amsterdam and led to his becoming the first to perform an intraoperative electrophysiologic map of the human heart in 1957. In 1967, Dr Durrer’s brilliant protege, Professor Hein J. J. Wellens, one of the authors of this article, described the technique of programmed electrical stimulation that provided a method for reproducibly inducing and terminating reentrant arrhythmias. This landmark achievement made possible the systematic characterization of most clinical arrhythmias and has remained largely unchanged since that time. Thus, it behooves us all to listen when this group speaks of electrophysiology matters! The authors describe their experience with the use of intraoperative radiofrequency catheters to create linear lesions in both atria in an effort to ablate atrial fibrillation associated with other surgical heart disease in 122 patients, 108 of whom had associated mitral valve surgery. The pattern of lesions placed in the atria was described as “a modification of the maze III procedure.” Actuarial freedom from atrial flutter or atrial fibrillation at 39 months was 78.5% 5.1%. These results are consistent with those obtained by Melo’s group in Portugal,14 Mohr’s group in Leipzig, Germany,15 and Alfieri’s group in Italy,16 all of whom also use radiofrequency energy to create the lesions in the atria. Similar results have also been attained by Stephan Schuler in Dresden, Germany,17 using microwave energy Received for publication April 10, 2001; accepted for publication April 16, 2001.