title: Surgery for paroxysmal atrial fibrillation in the setting of mitral valve disease: a role for pulmonary vein isolation?
abstract: BACKGROUND
  It is unknown whether pulmonary vein isolation or a complete Cox-Maze procedure is needed to ablate paroxysmal atrial fibrillation in patients with mitral valve disease. Our objective was to assess the impact of different surgical treatments for this arrhythmia in patients undergoing mitral valve surgery.
  
  
  METHODS
  From July 1993 to January 2004, 152 patients underwent combined surgical treatment of paroxysmal atrial fibrillation and mitral valve disease. Ablation procedures included pulmonary vein isolation alone (n = 31, 20%), pulmonary vein isolation with left atrial connecting lesions (n = 80, 53%), and Cox-Maze (n = 41, 27%). The latter had longer durations of atrial fibrillation than the former (p < 0.0001). Rhythm documented on 1,225 postoperative electrocardiograms was used to estimate prevalence of, and risk factors for, atrial fibrillation across time. Ablation failure was defined as occurrence of atrial fibrillation any time beyond 6 months after operation.
  
  
  RESULTS
  Prevalence of postoperative atrial fibrillation peaked at 22% at 2 weeks and declined to 9% at 1 year. Risk factors included older age (p = 0.09), larger left atrium (p = 0.05), and rheumatic (p = 0.003) and degenerative etiologies (p = 0.03). Freedom from ablation failure was 84% at one year. Ablation procedure did not affect prevalence of atrial fibrillation or incidence of ablation failure.
  
  
  CONCLUSIONS
  Pulmonary vein isolation alone may be adequate treatment for patients with paroxysmal atrial fibrillation undergoing mitral valve surgery, particularly when it is of short duration. A randomized trial is necessary to examine this strategy, especially in patients with longer duration of paroxysmal atrial fibrillation.
authors.affiliation: Center for Atrial Fibrillation, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. gillinom@ccf.org
authors.forename: A Marc
authors.initials: AM
authors.lastname: Gillinov
authors.forename: Faisal
authors.initials: F
authors.lastname: Bakaeen
authors.forename: Patrick M
authors.initials: PM
authors.lastname: McCarthy
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
authors.forename: Jeevanantham
authors.initials: J
authors.lastname: Rajeswaran
authors.forename: Gosta
authors.initials: G
authors.lastname: Pettersson
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.forename: Farzad
authors.initials: F
authors.lastname: Najam
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Hill
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.forename: Delos M
authors.initials: DM
authors.lastname: Cosgrove
authors.forename: Nassir
authors.initials: N
authors.lastname: Marrouche
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D017115:Catheter Ablation; D015897:Comorbidity; D003327:Coronary Disease / Q000453:epidemiology; D003452:Cryosurgery; D004562:Electrocardiography; D005260:Female; D006349:Heart Valve Diseases / Q000150:complications / Q000453:epidemiology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D015995:Prevalence; D011667:Pulmonary Veins / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology / Q000209:etiology; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000453:epidemiology