• Satoshi Kainuma, Masataka Mitsuno, Koichi Toda, Toshihiro Funatsu, Teruya Nakamura, Shigeru Miyagawa, Yasushi Yoshikawa, Satsuki Fukushima, Daisuke Yoshioka, Tetsuya Saito, Hiroyuki Nishi, Toshiki Takahashi, Masayuki Sakaki, Osamu Monta, Hajime Matsue, Takafumi Masai, Taichi Sakaguchi, Hidenori Yoshitaka, Takayoshi Ueno, Toru Kuratani, Takashi Daimon, Kazuhiro Taniguchi, Yuji Miyamoto, Yoshiki Sawa, and Osaka Cardiovascular Surgery Research (OSCAR) Group.
• 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.
• Eur J Cardiothorac Surg. 2015 Nov 1; 48 (5): 765-77; discussion 777.

ObjectivesLeft 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.MethodsWe 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.ResultsAt 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.ConclusionsIn 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.© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

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