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J Thorac Cardiovasc Surg 1997;113:214-215
© 1997 Mosby, Inc.

BRIEF COMMUNICATIONS

RECOVERY OF ATRIAL FUNCTION AFTER COMBINED TREATMENT WITH SURGICAL REPAIR FOR ORGANIC HEART DISEASE AND MAZE PROCEDURE FOR ATRIAL FIBRILLATION

Morioka, Japan

From the Second Department of Internal Medicine^a and the Third Department of Surgery,^b Iwate Medical University, Morioka, Japan.

Received for publication March 6, 1996 Accepted for publication May 6, 1996 Address for reprints: Kenji Ueshima, The Second Department of Internal Medicine, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020, Japan.

The maze procedure, a new surgical treatment for lone atrial fibrillation, was initially described by Cox and associates. ¹ Recently, combined treatment for organic heart disease and atrial fibrillation has been reported, but there have been few studies on atrial activity after combined treatment with surgical repair for organic heart disease and the maze procedure for atrial fibrillation. It is important to know how well atrial function recovers after combined surgical methods. Therefore we investigated the recovery of atrial function after the combined surgical treatment of organic heart disease and atrial fibrillation.

METHODS

Twelve patients who received cardiac operation with a successful maze procedure were enrolled in this study. The patients consisted of four men and eight women, with a mean age of 60 ± 11 years. Organic heart diseases were mitral stenosis in two patients, mitral regurgitation in eight, and atrial septal defect in two. All patients underwent symptom-limited cardiopulmonary exercise testing with use of an upright bicycle ergometer with measurements of atrial natriuretic peptide (ANP) before and after exercise testing and Doppler echocardiography 1 week before the operation (control phase), 1 month after the operation (early phase), and 3 months after the operation (late phase).

Ventilatory threshold was determined in a standard manner by the V-slope method. Peak velocities of the early filling (E) wave, atrial filling (A) wave, and A/E ratio were determined by Doppler echocardiography. The time-velocity integrals of the E (Ea) and A (Aa) waves were then obtained by planimetry of the flow velocity profile. Left atrial active contractile fraction (LAACF) was expressed as the ratio of the atrial component during active atrial contraction (Aa) to the total diastolic time velocity integral (Ea + Aa) and calculated as LAACF = Aa/(Ea + Aa).

Results

(Table I) Peak heart rate was 156 ± 26 beats/min before operation because of rapid ventricular response of atrial fibrillation. Although sinus rhythm was obtained in the early phase, peak heart rate was only 119 ± 19 beats/min. However, peak heart rate increased to 127 ± 9 beats/min in the late phase. Peak oxygen uptake and ventilatory threshold in the early phase increased significantly as compared with values in the control phase, and peak oxygen uptake showed a significant increase in the late phase.

After operation, A/E and LAACF values in the late phase significantly increased as compared with the values in the early phase.

DISCUSSION

The attenuated heart rate response to exercise was obtained 1 month after operation. Because this heart rate response can be similar to that of the transplanted heart, ² the attenuated heart rate response to exercise early after the maze procedure may be caused by denervation of the sinoatrial node as a result of multiple incisions in the atrial wall. If the attenuated heart rate response to exercise early after the maze procedure was caused by denervation of the sinoatrial node, recovery of the heart rate response late after operation can be explained by the time course of reinnervation of the sinoatrial node. ³

ANPs have been extracted from atrial myocytes of mammals, including human beings, and play an important role in natriuresis and vasodilation. Because ANP was excreted markedly after exercise, the determination of plasma ANP level after exercise allows evaluation of the atrial function as the excretion ability. Percent increase of ANP after exercise was higher in the late phase than that in the control and early phases, which suggests that atrial function of ANP excretion was restored over time.

Transient atrial dysfunction occurred in patients with atrial fibrillation who underwent electrical cardioversion, and mechanical atrial function is reduced when conversion is achieved after atrial fibrillation has been sustained for more than a week. ⁴ The mechanism of atrial dysfunction after elimination of atrial fibrillation is unknown. Shapiro and colleagues ⁴ postulated that postischemic stunned atrial myocardium, as in the occurrence of ischemia during ventricular fibrillation, may explain this phenomenon.

The delayed recovery of atrial function may influence the improved exercise capacity in the late phase after combined treatment consisting of surgical repair for organic heart disease and atrial fibrillation.

We conclude that transient attenuation of atrial function, seen as sinoatrial node response, excretion of ANP, and mechanical contractility, occurred in patients after combined treatment with surgical repair for heart disease and the maze procedure for atrial fibrillation. The late recovery of atrial function may improve exercise capacity over time.

References

1. Cox JL, Schuessler RB, D'Agostino HJ, et al. The surgical treatment of atrial fibrillation: III—development of a definitive surgical procedure. 1991;101:569-83.
   
2. Ehrman J, Keteyian S, Fedel F, Rhodas K, Levine TB, Shepard R. Cardiovascular responses of heart transplant recipients to graded exercise testing. J Appl Physiol 1992;73:153-66.
   
3. Peiss CN, Cooper T, William VL, Randall WC. Circulatory responses to electrical and reflex activation of the nervous system after cardiac denervation. Circ Res 1966;19:153-66.[Abstract/Free Full Text]
   
4. Shapiro EP, Effron MB, Lima S, Ouyang P, Siu CO, Bush D. Transient atrial dysfunction after conversion of chronic atrial fibrillation to sinus rhythm. Am J Cardiol 1989;13:617-23.
   

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yoko Yagi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ueshima, K. Articles by Kawazoe, K. Search for Related Content PubMed PubMed Citation Articles by Ueshima, K. Articles by Kawazoe, K.