ABC | Volume 110, Nº4, April 2018

Original Article Mid-Term Results of Surgical Treatment of Atrial Fibrillation in Valvular Heart Disease Assesed by Speckle Tracking Echocardiography Natalia Lorenzo, 1 Irene Mendez, 2 Mikel Taibo, 2 Gianfranco Martinis, 2 Sara Badia, 2 Guillermo Reyes, 2 Rio Aguilar 2 Hospital Universitario Infanta Cristina, 1 Parla, Madrid - Espanha Hospital Universitario de La Princesa, 2 Madrid - Spain Mailing Address: Natalia Lorenzo Muñoz • Avenida 9 de junio, 2. 28981, Parla, Madrid – Spain E-mail: natalialorenzo84@gmail.com Manuscript received May 24, 2017, revised manuscript July 07, 2017, accepted July 10, 2017 DOI: 10.5935/abc.20180040 Abstract Background: Atrial fibrillation frequently affects patients with valvular heart disease. Ablation of atrial fibrillation during valvular surgery is an alternative for restoring sinus rhythm. Objectives: This study aimed to evaluate mid-term results of successful atrial fibrillation surgical ablation during valvular heart disease surgery, to explore left atrium post-ablation mechanics and to identify predictors of recurrence. Methods: Fifty-three consecutive candidates were included. Eligibility criteria for ablation included persistent atrial fibrillation <10 years and left atrium diameter < 6.0 cm. Three months after surgery, echocardiogram, 24-hour Holter monitoring and electrocardiograms were performed in all candidates who maintained sinus rhythm (44 patients). Echo-study included left atrial deformation parameters (strain and strain rate), using 2-dimensional speckle-tracking echocardiography. Simultaneously, 30 healthy individuals (controls) were analyzed with the same protocol for left atrial performance. Significance was considered with a P value of < 0.05. Results: After a mean follow up of 17 ± 2 months, 13 new post-operative cases of recurrent atrial fibrillation were identified. A total of 1,245 left atrial segments were analysed. Left atrium was severely dilated in the post-surgery group and, mechanical properties of left atrium did not recover after surgery when compared with normal values. Left atrial volume (≥ 64 mL/m 2 ) was the only independent predictor of atrial fibrillation recurrence (p = 0.03). Conclusions: Left atrial volume was larger in patients with atrial fibrillation recurrence and emerges as the main predictor of recurrences, thereby improving the selection of candidates for this therapy; however, no differences were found regarding myocardial deformation parameters. Despite electrical maintenance of sinus rhythm, left atrium mechanics did not recover after atrial fibrillation ablation performed during valvular heart disease surgery. (Arq Bras Cardiol. 2018; 110(4):312-320) Keywords: Ablation Techniques; Atrial Fibrillation; Heart Valve Diseases; Cryosurgery; Echocardiography. Introduction Atrial fibrillation (AF) is a serious and frequent problem in valvular heart disease (VHD) affecting more than 30% of these patients. VHD leads to pressure and/or volume overload of the atria, especially in the left atrium (LA) in left-sided disease. AF is associated with higher morbidity and mortality in general population, but evenmore inVHDpatients, requiring lowthreshold of anticoagulation because of higher risk of thromboembolism. AF alsoaffects thedecisionmaking for selectionof prosthesis type. 1,2 AF ablation during cardiac surgery has been demonstrated as a safe and effective procedure restoring sinus rhythm (SR). Although the original Cox-Maze procedure was described in patients with lone AF, its use has expanded to patients with associated organic heart disease. 3 According to some authors, success rates of the procedure can exceed 80%. However, there are few data on the results of this technique in valvular patients with persistent AF. 4,5 Myocardial strain and strain rate (strainR) represent the magnitude and rate, respectively, of myocardial deformation. Both atrial strain and strainR, obtained using either Doppler tissue imaging (DTI) or two-dimensional speckle-tracking echocardiography, have proved to be feasible and reproducible techniques to evaluate LA mechanics. 6 The aims of this study were to evaluate mid-term results after successful surgical ablation (SA) of AF in VHD patients, to explore LAmechanics using ultrasound strain and strainR imaging after SA of AF during VHD surgery and to identify clinical and echocardiographic predictors of recurrence during follow-up. Methods Patient eligibility We prospectively included candidates to surgical ablation, who underwent valvular heart surgery between May 2008 and May 2012 in our institution. 312