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J Thorac Cardiovasc Surg 2003;125:1539-1540
© 2003 The American Association for Thoracic Surgery
Brief Communications |
From the Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan.
Received for publication Aug 21, 2002. Accepted for publication Sept 25, 2002. Address for reprints: Ko Bando, MD, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan (E-mail: kobando{at}hsp.ncvc.go.jp).
When a successful maze procedure provides normal sinus rhythm, avoidance of mechanical valve will provide active life without anticoagulation. This is especially true among patients with Marfan syndrome, because most of the late mortality and morbidity after cardiac surgery in Marfan syndrome have been related to the prosthetic valve, anticoagulation therapy, and aortic lesions, including bleeding or dissection.
1 However, the maze procedure has not usually been performed with reconstruction of the combined aortic and mitral valves, on the assumption that prolonged bypass time could result in adverse outcomes. We report here the successful surgical treatment of a patient with aortic and mitral insufficiency and chronic atrial fibrillation.
Clinical summary
A 43-year-old woman had a family history of Marfan syndrome. On the electrocardiogram, sustained atrial fibrillation with an f wave of 0.15 mV in the V1 lead was found. On echocardiography, severe mitral regurgitation from both anterior and posterior leaflet prolapse, primarily in the posteromedial portion, was detected. The sinus of Valsalva was dilated to 55 mm in diameter, and the aortic annulus was dilated to 35 mm (Figure 1). Aortic regurgitation was mild.
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Discussion
1As aortic surgery has improved, the life span of patients with Marfan syndrome has been prolonged, but it is still not satisfactory. 1-3 Avoidance of mechanical valves and anticoagulation therapy may improve quality of life for these patients. The necessary reconstructive procedures may be technically demanding, however, and selection of appropriate patients may be difficult. In the aortic position, valve-sparing procedures have been recommended for patients with normal leaflets without the use of a mechanical valve in the mitral position. 4 In the mitral position, understanding of the complicated anatomy of diseased mitral valve has improved the quality of mitral valve repair, and intermediate-term durability has been reported as similar to that seen with non-Marfan degenerative disease. 2,3
In our case, successful repair of valves and sinus rhythm were all required to avoid anticoagulation therapy after the operation. Our current maze procedure consists of pulmonary venous isolation and interruption of the macro reentry circuit with cryoablation through a standard right-sided left atriotomy. 5 With this technique, crossclamp time was reduced by 30 minutes yet achieved a recovery rate of sinus rhythm comparable to that seen with the conventional maze procedure in mitral valve disease. 5
Most patients with Marfan syndrome are relatively young at the maze operation. The aggressive surgical approach may therefore be valuable to decrease the late complications associated with anticoagulation, thus improving quality of life.
References
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