Long-Term Results after the Box Pulmonary Vein Isolation Procedure for Chronic Atrial Fibrillation in Mitral Valve Surgery

Abstract

Background: We hypothesized that chronic atrial fibrillation (AF) originated from the pulmonary veins, and was maintained by irregular activations of the posterior left atrium. We had performed the box pulmonary vein isolation procedure for the elimination of chronic AF associated with solitary mitral valve disease from 1999 to 2004. This paper evaluated the long-term results of this procedure over more than 6 years, and discussed the role of the pulmonary veins and posterior left atrium in maintaining AF. Methods: Fifty-three patients were examined after box pulmonary vein isolation procedure concomitant with solitary mitral valve surgery retrospectively. We divided the patients into two groups with or without the elimination of AF (AF group and non-AF group). The disappearance of AF was determined by electrocardiography, and atrial function was evaluated by transthoracic echocardiography. The elimination of chronic AF and the recovery of atrial systolic function after surgery were evaluated over more than 6 years of follow-up. Results: In a total of 462.8 patient years of follow-up (range 6.3 to 11.5 years, mean: 8.9 ± 2.7 years), AF disappeared in 77.3% of the patients (41/53) at 3 months and in 70.6% (36/51) of the patients at 6 years after the box pulmonary vein isolation, respectively. Among the preoperative variables, a long duration of AF and a large diameter of the left atrium were the predictive factors for recurrences of AF (p <0.05). There was no left atrial tachycardia even though we did not perform ablation towards the mitral valve annulus. Conclusions: The box pulmonary vein isolation procedure can terminate chronic AF associated with solitary mitral valve disease, and maintain a sinus rhythm for more than 6 years in 70% of chronic AF patients. This study implicates the pulmonary veins and posterior left atrium in maintaining chronic AF associated with mitral valve disease.

2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation

“…Thus, with the focus on the PV triggers, surgeons began performing an increasing number of minimal-access PVI procedures. 197 , 1369 , 1370 , 1371 However, investigators showed that this treatment was inadequate for patients with persistent and long-standing persistent AF. 1355 This led to the belief that the persistent forms of AF needed both substrate modification and trigger isolation , and this provided the impetus to develop the Dallas lesion set, which replicated all the LA lesions of the Cox-Maze III, yet allowed them to be placed on the surface of the full-beating LA.…”

Pulmonary vein isolation for persistent atrial fibrillation. Long-term results

“…14,15 Additional incisions and use of cryolesion were used in these previous studies. 14, 15 Sueda and colleagues 16 reported a series of 53 patients who had the PV isolated in MV surgery with a surgical technique very similar to ours. They reported a freedom from AF recurrence rate of 70.6% at 6 years after the operation.…”

Outcome of stand-alone thoracoscopic epicardial left atrial posterior box isolation with bipolar radiofrequency energy for longstanding persistent atrial fibrillation

“…Restricting the ablation lines to the area of the left atrium which is most affected by structural remodelling, the posterior LA wall, is appealing. Creation of a box including the posterior LA wall and PVs during mitral valve surgery in patients with (longstanding) persistent AF resulted in AF-free survival of 71 % after 6 years follow-up [ 9 ].…”

“…Bilateral thoracoscopic chest tubes were inserted. Two guidance catheters were introduced through the oblique and transverse sinuses from the left to the right-sided chest tube as previously described [ 9 ]. A bipolar RF clamp (Cardioblate Gemini S, Medtronic Inc., Minneapolis) was attached to the guidance catheters and positioned to encircle the left PVs and posterior left atrium (Fig.…”