Nova abordagem técnica e eletrofisiológica para tratamento da fibrilação atrial

Abstract

Introduction: The maze procedure for primary atrial fibrillation treatment, initially proposed by Cox, is somewhat complex, and it increases the morbidity risk compared to isolated mitral valve surgery. Objective: To describe the surgical technique, the concepts of electrophysiology adopted and the preliminary results of a new surgical and electrophysiological approach, including specific atrial circuit blocking as defined by Frame and optimization of the surgical tactic for atrial fibrillation treatment. Method: Eight patients with chronic atrial fibrillation and mitral valve dysfunction, associated in one case with tricuspid valve regurgitation were operated on. The following modifications of the classic Cox procedure were employed: 1-Exclusion of the left atrium appendage by an internal suture closing its left atrial ostium; 2-Exclusion of the right atrium appendage by a purse-string suture used for fixation of the superior vena cava draining cannula; 3-Single atrial incision; 4-Trans-endocardium electrocauterization in the left atrium wall around all pulmonary vein ostia; 5-Substitution of the incisions and sutures in the left atrium by trans-endocardium electrocauterization. Results: The cardiopulmonary bypass time varied from 64 to 133 min (mean 107.5 min) and the cardioplegic time from 40 to 105 min. (mean 76.7 min). At the end of the surgery all patients were in regular atrial rhythm. The postoperative period was uneventful with all patients discharged from hospital showing regular atrial rhythm, without definitive pacemaker implantation. In the six-month postoperative follow up after surgery, six patients were in regular atrial rhythm (75%) with preserved atrial contractions, and two (25%) with clinically controlled atrial fibrillation (NYHA II). Also there were no embolic complications nor thrombotic evidence in the Doppler echocardiography control. Conclusion: It is concluded in this initial series of cases that the electrophysiological approach and the surgical technique employed improved the surgical treatment of the atrial fibrillation making correction of mitral and tricuspid valve injuries possible without additional morbidity.

Treatment of Chronic Atrial Fibrillation During Surgery for Rheumatic Mitral Valve Disease

“…Jatene et al [13] performed the Cox surgery for treatment of atrial fibrillation in 45 patients with rheumatic mitral valve disease due to its usual occurrence in our country, but in this study instead of Cox surgery, we used the technique reported by Gomes & Gomes [9] also to treat rheumatic mitral valve disease associated with atrial fibrillation.…”

“…Gomes & Gomes [9] technique replaces the resection of the right and left atrial appendages. It uses a purse string suture, in the introduction of the cannula in the superior vena cava in the right atrium and by the closing of the ostium of the left atrial appendage by intra-atrial suture respectively; and facilitates to a broad internal exposure of the left atrium by the single atrial incision.…”

“…Gomes & Gomes [9] obtained regular atrial rhythm with hemodynamic stabilization at the end of CPB in all patients.…”

“…The innovative highlight was the publication of Gomes & Gomes [9] , who described pioneering surgical procedure of simultaneous correction of mitral valve disease associated with atrial fibrillation.…”

Tratamento cirúrgico da fibrilação atrial crônica com eletrocautério convencional em cirurgia valvar mitral

“…Studies in which the electrocautery was used to perform the ablation lines in the endocardium were successfully in reverting to sinus rhythm, presenting similar results to the Cox's technique, besides reestablishing the left atrium function and significantly reducing its shape size [9][10][11].…”