Atrial Fibrillation and Mitral Valve Repair

Angelika Jovin, MD; Dana A. Oprea, MD; Ion S. Jovin, MD; Sabet W. Hashim, MD; Jude F. Clancy, MD

Disclosures

Pacing Clin Electrophysiol. 2008;31(8):1057-1063. 

In This Article

Postoperative AF

AF and atrial flutter occur frequently after most types of cardiac surgery.[65] AF has been reported in up to 15% to 40% of patients in the early postoperative period following coronary artery bypass graft surgery (CABG),[66,67,68] in 37% to 50% after valve surgery,[66,69,70] in as many as 60% undergoing valve replacement plus CABG,[66,69] and in 11% to 24% after cardiac transplantation.[69,71]

The pathophysiology of postoperative AF is probably related to the combination of two factors: preexisting age-related degenerative changes in the atrial myocardium, which would explain the increasing risk with older age, and perioperative conditions that result in abnormalities of several electrophysiologic parameters that promote the development of AF, such as dispersion of atrial refractoriness, atrial conduction velocity, and atrial transmembrane potentials.[8] Postoperative AF most often occurs 1 to 5 days after surgery and usually has a self-limited course.[66,67]

In a study performed of patients undergoing mitral valve repair or replacement, predictors for postoperative AF were increased age, chronic obstructive pulmonary disease, use of digoxin, resting pulse rate, high resting systolic blood pressure, topical ice slush, and cardiac venting. AF is thought to be associated with an increase in adverse events and mortality,[72] although earlier data suggest that the survival for patients in AF and SR is not different after surgery.[22] Chronic AF persists in 85% of patients despite surgical correction and tends to determine long-term survival. Preserved SR after mitral valve surgery probably promotes survival because of prevention of tachycardia-related cardiomyopathy due to uncontrolled AF and because of prevention of stroke.[73,74,75,76] The presence of preoperative chronic or intermittent AF, older age at operation, and increased heart rate are the strongest predictors for AF after mitral valve surgery. Increased left atrial diameter and a reduced left ventricular ejection fraction were not found to be independent predictors initially but a new study found that a left atrial volume index ≥75 mL/m[2] reflects an increased risk of subsequent AF and patients should be closely monitored.[77] For patients with preoperative AF, increased mean pulmonary artery pressure, older age, and a history of chronic versus intermittent AF prior to mitral valve repair were the most important predictors for AF after successful mitral valve reconstruction.[41] In the recently published guidelines of the European Association for Cardio-Thoracic Surgery, the evidence regarding on the prevention and management of AF after cardiothoracic surgery, ß-blockers are recommended as first-line treatment.[65]

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