title: Dilated left atrium as a predictor of late outcome after pulmonary vein isolation concomitant with aortic valve replacement and/or coronary artery bypass grafting†.
abstract: OBJECTIVE
  Left atrial (LA) dimension can predict atrial fibrillation (AF) recurrence after catheter-based or surgical ablation. Pulmonary vein isolation (PVI) may be a surgical option during aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG), though consensus regarding patient selection and late outcome is lacking.
  
  
  METHODS
  We studied 160 patients (mean age 70 ± 9 years) with paroxysmal AF who underwent radiofrequency-based PVI during AVR and/or CABG, and were followed up postoperatively for at least 6 months. Mean preoperative LA dimension was 44 ± 7 mm. Serial echocardiography was performed to evaluate left ventricular (LV) and LA dimensions, E/e', estimated systolic pulmonary artery (PA) pressure and degree of valvular regurgitation. Follow-up was completed with a mean duration of 47 ± 25 months.
  
  
  RESULTS
  At the latest follow-up, 133 patients (83%) remained in sinus rhythm. Preoperative LA dimension was independently associated with increased risk of AF recurrence at 6 months after surgery [adjusted odds ratio 1.3 per 1-mm increase in LA dimension, 95% confidence interval (CI) 1.1-1.6, P < 0.001]. Receiver-operating characteristic curve analysis demonstrated an optimal cut-off value for preoperative LA dimension of 45 mm to predict sinus rhythm restoration (98% for <45 mm vs 55% for ≥45 mm, P < 0.001). Patients with LA dimension ≥45 mm had a significantly lower 5-year survival rate (62 ± 7 vs 82 ± 7%, P = 0.025) and freedom from adverse events defined as cerebral infarction/haemorrhage, admission for heart failure, catheter ablation and permanent pacemaker implantation (58 ± 7 vs 91 ± 4%, P < 0.001). Multivariate analysis showed that preoperative LA dimension ≥45 mm was independently associated with adverse events (adjusted hazards ratio 2.4, 95% CI 1.2-5.1, P = 0.019). Serial echocardiography demonstrated improvement in LV systolic function irrespective of LA dimension, whereas patients with LA dimension ≥45 mm showed less improvement in LA dimension and systolic PA pressure (interaction effect P < 0.001) and persistent higher E/e' (group effect P < 0.001), along with aggravated tricuspid regurgitation.
  
  
  CONCLUSIONS
  In patients with paroxysmal AF related to aortic valve disease and/or coronary artery disease, a dilated left atrium (≥45 mm) was associated with inferior AF- and event-free survival after PVI, accompanied by persistent abnormalities in cardiac and haemodynamic function. These findings may assist patient selection for PVI during AVR and/or CABG.
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan Department of Cardiovascular Surgery, Japan Labor Health and Welfare Organization Osaka Rosai Hospital, Sakai, Japan.
authors.forename: Satoshi
authors.initials: S
authors.lastname: Kainuma
authors.affiliation: Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Japan.
authors.forename: Masataka
authors.initials: M
authors.lastname: Mitsuno
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Koichi
authors.initials: K
authors.lastname: Toda
authors.affiliation: Department of Cardiovascular Surgery, Japan Labor Health and Welfare Organization Osaka Rosai Hospital, Sakai, Japan.
authors.forename: Toshihiro
authors.initials: T
authors.lastname: Funatsu
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Teruya
authors.initials: T
authors.lastname: Nakamura
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Shigeru
authors.initials: S
authors.lastname: Miyagawa
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Yasushi
authors.initials: Y
authors.lastname: Yoshikawa
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Satsuki
authors.initials: S
authors.lastname: Fukushima
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Daisuke
authors.initials: D
authors.lastname: Yoshioka
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Tetsuya
authors.initials: T
authors.lastname: Saito
authors.affiliation: Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Nishi
authors.affiliation: Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan.
authors.forename: Toshiki
authors.initials: T
authors.lastname: Takahashi
authors.affiliation: Department of Cardiovascular Surgery, Osaka National Hospital, Osaka, Japan.
authors.forename: Masayuki
authors.initials: M
authors.lastname: Sakaki
authors.affiliation: Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Fukui, Japan.
authors.forename: Osamu
authors.initials: O
authors.lastname: Monta
authors.affiliation: Department of Cardiovascular Surgery, Rinku General Medical Center, Izumisano, Japan.
authors.forename: Hajime
authors.initials: H
authors.lastname: Matsue
authors.affiliation: Department of Cardiovascular Surgery, Sakurabashi Watanabe Hospital, Osaka, Japan.
authors.forename: Takafumi
authors.initials: T
authors.lastname: Masai
authors.affiliation: Department of Cardiovascular Surgery, Sakakibara Heart Institute of Okayama, Okayama, Japan.
authors.forename: Taichi
authors.initials: T
authors.lastname: Sakaguchi
authors.affiliation: Department of Cardiovascular Surgery, Sakakibara Heart Institute of Okayama, Okayama, Japan.
authors.forename: Hidenori
authors.initials: H
authors.lastname: Yoshitaka
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Takayoshi
authors.initials: T
authors.lastname: Ueno
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Toru
authors.initials: T
authors.lastname: Kuratani
authors.affiliation: Departments of Biostatistics, Hyogo College of Medicine, Nishinomiya, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Daimon
authors.affiliation: Department of Cardiovascular Surgery, Japan Labor Health and Welfare Organization Osaka Rosai Hospital, Sakai, Japan.
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Taniguchi
authors.affiliation: Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Japan.
authors.forename: Yuji
authors.initials: Y
authors.lastname: Miyamoto
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan yshksw2@gmail.com.
authors.forename: Yoshiki
authors.initials: Y
authors.lastname: Sawa
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000209:etiology*; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D005260:Female; D006325:Heart Atria / Q000503:physiopathology*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011667:Pulmonary Veins / Q000601:surgery; D012372:ROC Curve; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Left atrial remodelling; Non-mitral valve disease; Paroxysmal atrial fibrillation; Pulmonary vein isolation