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European Journal of Cardio-Thoracic Surgery, Vol 11, 76-80, Copyright © 1997 by European Association for Cardio-thoracic Surgery

ARTICLES

Spontaneous cardioversion and mitral valve repair: a role for surgical cardioversion (Cox-maze)?

SR Large, AR Hosseinpour, C Wisbey and FC Wells
Surgical Unit, Papworth Hospital, Papworth Everard, Cambs., UK.

OBJECTIVE: The objectives of this study are to describe: (1) The incidence of change in pre-operative rhythm (cardioversion) with mitral valve repair early and at 1 year's review after surgery (late). (2) The characteristics of those patients who remain in atrial fibrillation (AF) or sinus rhythm (SR) at late follow up. (3) The characteristics of those patients whose rhythm is seen to change (cardiovert) from SR to AF, or AF to SR and to remain so at 1 year. In this way it is hoped to more clearly define those patients who would benefit from the combination of mitral valve repair and surgical cardioversion (Cox-maze procedure). METHODS: Retrospective study was made of the case notes of all patients undergoing mitral repair at our hospital during the 3 years between January 1st, 1991 and December 31st, 1993. Early (hospital discharge) and late (1 year) post operative e.c.g. rhythm was compared to pre-operative e.c.g. rhythm. The study explored the association of cardioversion with pre-operative rhythm, patient age, aetiology of mitral valve lesion (mitral regurgitation or stenosis) and echo cardiographic estimations of left atrial size and left ventricular dimensions. RESULTS: Patients (89) underwent repair with a 30 day mortality of 2.2% (2 of 89). Of these, 55 were male with an average age of 65 +/- 12 years. Regurgitation was the valvular lesion in 93% and 18% were associated with coronary artery disease, 48 (55%) were in SR before surgery. Both deaths occurred in patients with AF as a pre- operative rhythm. Of the 39 survivors originally in AF, only one was of recent onset ( < 6 months). The frequency of an enlarged left atrium (> or = 5.0 cm) was significantly greater in those with AF compared to SR (P < 0.001). Atrial fibrillation was also associated with increasing age (P = 0.006) and increasing left ventricular end systolic diameter (LVESD; P = 0.018). Spontaneous cardioversion of pre-operative rhythm was common at the time of hospital discharge (AF to SR: 46% and SR to AF: 25%). At the 1 year review after mitral repair only 8 (21%) of those originally in AF were then in sinus rhythm. Eight (17%) of those originally in SR were in AF. A lower left ventricular end systolic diameter (LVESD) was associated with spontaneous cardioversion of AF to SR by one year (P = 0.005). Similarly, patients originally in SR with a lower LVESD continued in SR. Those with a higher value were seen to cardiovert to AF (P < 0.05). CONCLUSIONS: Immediately prior to surgery the presence of AF was associated with a tendency to larger left atrial size, older age and a greater LVESD. Cardioversion was common for both patients in AF (46%) and SR (25%) early following conservative mitral surgery. The prevalence of late cardioversion was of a similar order in both those originally in AF (21%) and SR (17%). The maintenance of, or cardioversion to SR seemed to be characterised only by the LVESD. This analysis captures many of the problems of retrospective review. A multi- centre, prospective study is proposed to achieve the aim of an accurate formula predicting long standing cardioversion with mitral valve surgery.

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