Johnson Jetal, 1967, Barnhorst D.A. et al. 1975., Deeg P. et al. 1977, Kawazoe J. et al, 1983). Piccoh G.P. et al. (1984) made a comparative analysis of outcomes of surgically treated patients who underwent mitral valve replacement. They found total mortality at 8,5 %, with mortality in a group of patients with giant left atrium (GLA) being as high as 20 %. Many researchers were able to demonstrate that the repair of atriomegaly would have positive effect on both early, and late postoperative period with improved life expectancy in such patients.
The purpose of the study was to reliably measure the LA volume and specify indications for atrioplasty. To achieve this goal, the following tasks were set:
1. Develop a new method for measuring the LA volume.
2. Compare the obtained data with those in the control group where measurements were made using echocardiography.
Material and methods. From 2005 to 2014, 176 patients suffering from mitral valve diseases complicated with atriomegaly and atrial fibrillation were operated upon at the cardiac surgery unit, National Scientific Center of Surgery. Seventy-three were male (41.5 %) and 103 were female (58,5 %), with median age of 41,5 ± 27,5 years. The breakdown of patients by the degree of heart failure was as follows: 124 (70,4 %) patients were in NYHA Class III, the remaining 52 (29,5 %) in NYHA Class IV; 119 patients (67,6 %) were in ACC 2 stage with remaining 57 (32,3 %) in ACC 3 stage. All patients had the history of atrial fibrillation in excess of three years. The LA sizes were obtained using the heart ultrasound (see Table).
Echocardiographic indicators
|
Parameters |
EDS, cm |
ESS, cm |
EDV, ml |
ESV, ml |
LA, cm |
EF, % |
|
Before operation |
6,7 ± 0,1 |
4,9 ± 0,5 |
258 ± 30 |
127 ± 1,5 |
7,8 ± 0,3 |
50,8 ± 1 |
|
After operation |
5,9 ± 0,5 |
4,1 ± 0,3 |
173 ± 48,5 |
72 ± 10,5 |
4,8 ± 1,0 |
58 ± 1 |
Note: EDS – end-diastolic size, ESS – end-systolic size, EDV – end-diastolic volume, EDV – end-systolic volume, LA – left atrium, EF – ejection fraction.
We performed mitral valve replacement with suture ligation of the left atrial appendage in 111 patients (63 %), Another 62 patients (35,2 %) received the Kawazoe atrioplasty, three patients (1,7 %) had Mercedes type atrioplasty, and in five cases, we performed additionally the maze procedure. The LA cavity was measured in 27 control patients (41,5 %) using echocardiography: LA volume was 270 ± 60 mL preoperatively, and 140 ± 25 mL postoperatively.
Intraoperatively, we measured the left atrial volume in 38 (58,5 %) patients in Group 2 using the methodology developed in our clinic: 520 ± 50 mL before and 175 ± 20 mL after the operation. We would question the reliability of the echocardiographic measurement of the LA volume when the preoperative reading had been 265 ± 40 vs. 140 ± 15 mL postoperatively.
The method we developed is as simple as that: a surgical glove would be placed into the left atrium preoperatively, then filled with saline, and the volume of fluid instilled would be accurately measured. The same manipulation would be done after the completion of atrioplasty.
Results: Left atrioplasty resulted in shrinkage of the left atrium from 8,6 cm to 5,4 cm, on average (Group 1). In immediate postoperative period, only 87 (49,3 %) patients required inotropic support with Dopamine up 5 mg per kg body weight per minute. The remaining patients did not need any cardiotonic agents. Atrial fibrillation disappeared in 94 (53,4 %) patients.
Conclusions: 1. Left atrioplasty does result in a marked reduction in the LA size, resolves the left postero-basal left ventricular compression syndrome, reduces the tracheal bifurcation angle, and decompresses the left main bronchus and the lower lobes of the right lung. This explains the drop in frequency and duration of acute heart failure early postoperatively.
2. Secondary to decompression of the left main bronchus and the lower lobes of the right lung, the length of postoperative lung ventilation would shorten, the lungs would spread better; hence, the incidence of postoperative pulmonary atelectasis, pneumonia and tracheobronchitis would drop. As a result, the patients would have a shorter stay in the ICU, rehab quicker and generally, have a shorter length of stay in the hospital.
The work is submitted to the International Scientific Conference “Fundamental research”, CROATIA (Istria) 23 July–30 July 2015, came to the editorial office оn 20.07.2015.