Surgical treatments for giant left atrium in patients with valvular diseases
Siyi He Hui Ouyang Jinbao Zhang
Department of cardiovascular surgery, Chengdu Military General Hospital
Objectives: Once associated with giant left atrium (GLA), poor prognosis will easily occur in patients with valvular diseases. GLA could cause postoperative respiratory and circulatory dysfunction by compression of left ventricle and pulmonary, leading to increased mortality. Various surgical procedures have been employed to GLA, but the efficacy remains unclear. The present study concludes several left atrial reduction operations in single cardiovascular center, intending to give a comprehensive description of surgical treatments for GLA.
Methods: All consecutive patients with left atrial diameter greater than 60mm were enrolled in the present research. We conducted a retrospective study from 2009.02 to 2014.12 and a prospective RCT study in comparison of modified left atrial circuit plication procedure (circuit-LAP group) with other left atrial reduction operations (control group) from 2012.06 to 2014.01. Modified left atrial circuit plication was proceeded as follows: from initiation of left atrial roof, left atrial appendage is firstly closed, the suture line is subsequently alongside mitral valve ring and central section of pulmonary veins, and finally ends in the first stitching. All patients were followed up for 12 months.
Results: 166 left atrial appendage closing, 205 partial left atrial plication, 2 cut-and-sew procedure, 311 modified left atrial circuit plication were used. Once patients received surgical treatments, CPB time and aortic clamping time was significantly increased, but there was no obvious difference in incidence of postoperative complications and mortality. In the perspective study, 75 patients were enrolled in control group while 69 patients were enrolled in circuit-LAP group. These two groups had almost the same CPB time, aortic clamping time and ratio of auto-rebeating. The volume of left atrium was reduced more in circuit-LAP group respectively in the follow-up time of 0, 3, 6, 12 months. Compared with control group, circuit-LAP could significantly increase LVEDD, LVEF as well as E/A value measured by ultrasound, implying that this procedure was beneficial for improvement of cardiac function. As for clinical outcomes, reduced incidence of Low Cardiac Output Syndrome, IABP implantation, and decreased mechanical ventilation time, ICU stay time, hospitalization time could be observed in circuit-LAP group. However, there was no significant difference in ratio of acute kidney injury, ventilator-associated pneumonia, infectious endocarditis, ventricular arrhythmias as well as mortality. In addition, the ratio of sinus rhythm recovery was significantly higher in circuit-LAP group compared with control group in the follow-up time of 3, 6, 12 months.
Conclusions: Surgical left atrial reduction operations are safe and effective for treatment of giant left atrium, of which modified left atrial circuit plication is associated with better prognosis.