Cirugía de la fibrilación auricular
Palabras clave:
Fibrilación auricular. Cirugía. Minimamente invasiva. Ablación.Resumen
La cirugía de la fibrilación auricular se basa en la creación de cicatrices de aislamiento en la aurícula con el propósito de evitar los fenómenos de reentrada que inician y perpetúan la arritmia, permitiendo la reconducción del estímulo normal desde el nodo sinusal hasta el nodo auriculo-ventricular. La técnica quirúrgica iniciamente descrita (basadas en incisiones y sutura), compleja y poco utilizada por el riesgo de complicaciones, potenció el desarrollo de otros procedimientos actuales, en los que se utilizan diversas energías que permiten realizar cicatrices de manera segura y menos invasiva. En la actualidad, la cirugía de fibrilación auricular no se realiza rutinariamente en todos los centros quirúrgicos; tampoco existe un consenso en relación con los tipos de técnicas utilizadas. Aunque, en general, los resultados son buenos, dependen de diversos factores como la duración de la arritmia, el tamaño de la aurícula y el tipo de cirugía realizada. Además, existe cierta variabilidad en la descripción de la comunidad científica de los resultados y los procedimientos utilizados, lo que hace que su análisis sea confuso. Proponemos una revisión de las diferentes técnicas descritas, los resultados y su aplicación en técnicas mínimamente invasivas.Descargas
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1. KANNEL WB, ABBOTT RD, SAVAGE DD, MCNAMARA PM. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 1982; 306: 1018-1022.
https://doi.org/10.1056/NEJM198204293061703
2. CAMERON A, SCHWARTZ MJ, KRONMAL RA, KOSINSKI AS. Prevalence and significance of atrial fibrillation in coronary artery disease (CASS Registry). Am J Cardiol 1988; 61: 714-717.
https://doi.org/10.1016/0002-9149(88)91053-3
3. KRAHN AD, MANFREDA J, TATE RB, MATHEWSON FA, CUDDY TE. The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. Am J Med 1995; 98: 476-484.
https://doi.org/10.1016/S0002-9343(99)80348-9
4. The AFFIRM Investigators: Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study. Circulation 2004; 109: 1509-1513.
https://doi.org/10.1161/01.CIR.0000121736.16643.11
5. HART RG, PEARCE LA, MILLER VT, ANDERSON DC, ROTHROCK JF, ALBERS GW, et al. Cardioembolic vs noncardioembolic strokes in atrial fibrillation: frequency and effect of antithrombotic agents in the Stroke Prevention in Atrial Fibrillation studies. Cerebrovasc Dis 2000; 10: 39-43.
https://doi.org/10.1159/000016023
6. Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation. Stroke prevention in atrial fibrillation II study. Lancet 1994; 343: 687-691.
https://doi.org/10.1016/S0140-6736(94)91577-6
7. EAFT (European Atrial Fibrillation Trial) Study Group. Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet 1993; 342: 1255-1262.
https://doi.org/10.1016/0140-6736(93)92358-Z
8. MOROCUTTI C, AMABILE G, FATTAPPOSTA F, NICOLOSI A, MATTEOLI S, TRAPPOLINI M et al. Indobufen versus warfarin in the secondary prevention of major vascular events in nonrheumatic atrial fibrillation. SIFA (Studio Italiano Fibrillazione Atriale) Investigators. Stroke 1997; 28: 1015-1021.
https://doi.org/10.1161/01.STR.28.5.1015
9. VAN WAGONER DR. Recent insights into the pathophysiology of atrial fibrillation. Semin Thorac Cardiovasc Surg 2007; 19: 9-15.
https://doi.org/10.1053/j.semtcvs.2007.01.006
10. COX JL. The surgical treatment of atrial fibrillation. IV. Surgical technique. J Thorac Cardiovasc Surg 1991; 101: 584-592.
https://doi.org/10.1016/S0022-5223(19)36685-1
11. SALTMAN AE. Minimally invasive surgery for atrial fibrillation. Semin Thorac Cardiovasc Surg 2007; 19: 33-38.
https://doi.org/10.1053/j.semtcvs.2006.12.002
12. WOLF RK, SCHNEEBERGER EW, OSTERDAY R, MILLER D, MERRILL W, FLEGE JB JR et al. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg 2005; 130: 797-802.
https://doi.org/10.1016/j.jtcvs.2005.03.041
13. HAISSAGUERRE M, SHAH DC, JAIS P, HOCINI M, YAMANE T, DEISENHOFER II et al. Mapping-guided ablation of pulmonary veins to cure atrial fibrillation. Am J Cardiol 2000; 86: 9-19.
https://doi.org/10.1016/S0002-9149(00)01186-3
14. NATALE A. Radiofrequency ablation of the pulmonary veins: can it stop atrial fibrillation at its source? Cleve Clin J Med 2001; 68: 17, 21-22, 24.
https://doi.org/10.3949/ccjm.68.1.17
15. SCHEINMAN MM. Mechanisms of atrial fibrillation: is a cure at hand? J Am Coll Cardiol 2000; 35: 1687-1692.
https://doi.org/10.1016/S0735-1097(00)00589-1
16. WOLF PA, DAWBER TR, THOMAS E JR, KANNEL WB. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham Study. Neurology 1978; 28: 973-977.
https://doi.org/10.1212/WNL.28.10.973
17. BLACKSHEAR JL, ODELL JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg 1996; 61: 755-759
https://doi.org/10.1016/0003-4975(95)00887-X
18. ALLESSIE MA, BOYDEN PA, CAMM AJ, KLÉBER AG, LAB MJ, LEGATO MJ et al. Pathophysiology and prevention of atrial fibrillation. Circulation 2001; 103: 769-777.
https://doi.org/10.1161/01.CIR.103.5.769
19. HAISSAGUERRE M, JAIS P, SHAH DC, TAKAHASHI A, HOCINI M, QUINIOU G et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998; 339: 659-666.
https://doi.org/10.1056/NEJM199809033391003
20. WILLIAMS JM, UNGERLEIDER RM, LOFLAND GK, COX JL. Left atrial isolation: new technique for the treatment of supraventricular arrhythmias. J Thorac Cardiovasc Surg 1980; 80: 373-380.
https://doi.org/10.1016/S0022-5223(19)37762-1
21. LEITCH JW, KLEIN G, YEE R, GUIRAUDON G. Sinus node-atrioventricular node isolation: long-term results with the "corridor" operation for atrial fibrillation. J Am Coll Cardiol 1991; 17: 970-975.
https://doi.org/10.1016/0735-1097(91)90881-9
22. VAN HEMEL NM, DEFAUW JJ, KINGMA JH, JAARSMA W, VERMEULEN FE, DE BAKKER JM et al. Long-term results of the corridor operation for atrial fibrillation. Br Heart J 1994; 71: 170-176.
https://doi.org/10.1136/hrt.71.2.170
23. SANKAR NM, FARNSWORTH AE. Left atrial reduction for chronic atrial fibrillation associated with mitral valve disease. Ann Thorac Surg 1998; 66: 254-256.
https://doi.org/10.1016/S0003-4975(98)00281-1
24. COX JL, SCHUESSLER RB, LAPPAS DG, BOINEAU JP. An 8 ½-year clinical experience with surgery for atrial fibrillation. Ann Surg 1996; 224: 267-273.
https://doi.org/10.1097/00000658-199609000-00003
25. MCCARTHY PM, CASTLE LW, MALONEY JD, TROHMAN RG, SIMMONS TW, WHITE RD et al. Initial experience with the maze procedure for atrial fibrillation. 3rd. J Thorac Cardiovasc Surg 1993; 105: 1077-1087.
https://doi.org/10.1016/S0022-5223(19)33782-1
26. FERNÁNDEZ I, UGARTE J, MÁRQUEZ J, GALLEGO JC, SANMARTÍN M, BAUTISTA A et al. MAZE procedure for atrial fibrillation: initial experience. Rev Esp Cardiol 1998; 51: 901-907.
https://doi.org/10.1016/S0300-8932(98)74837-7
27. PRASAD SM, MANIAR HS, CAMILLO CJ, SCHUESSLER RB, BOINEAU JP, SUNDT TM 3RD et al. The Cox maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures. J Thorac Cardiovasc Surg 2003; 126: 1822-1828.
https://doi.org/10.1016/S0022-5223(03)01287-X
28. BANDO K, KOBAYASHI J, KOSAKAI Y, HIRATA M, SASAKO Y, NAKATANI S et al: Impact of Cox maze procedure on outcome in patients with atrial fibrillation and mitral valve disease. J Thorac Cardiovasc Surg 2002; 124: 575-583.
https://doi.org/10.1067/mtc.2002.124392
29. KHARGI K, HUTTEN BA, LEMKE B, DENEKE T. Surgical treatment of atrial fibrillation; a systematic review. Eur J Cardiothorac Surg 2005; 27: 258-265.
https://doi.org/10.1016/j.ejcts.2004.11.003
30. THOMAS SP, WALLACE EM, ROSS DL. The effect of a residual isthmus of surviving tissue on conduction after linear ablation in atrial myocardium. J Interv Card Electrophysiol 2000; 4: 273-281.
https://doi.org/10.1023/A:1009838201448
31. DOLL N, BORGER MA, FABRICIUS A, STEPHAN S, GUMMERT J, MOHR FW et al. Esophageal perforation during left atrial radiofrequency ablation: Is the risk too high? J Thorac Cardiovasc Surg 2003; 125: 836-842.
https://doi.org/10.1067/mtc.2003.165
32. ROBBINS IM, COLVIN EV, DOYLE TP, KEMP WE, LOYD JE, MCMAHON WS et al. Pulmonary vein stenosis after catheter ablation of atrial fibrillation. Circulation 1998; 98: 1769-1775.
https://doi.org/10.1161/01.CIR.98.17.1769
33. MELBY SJ, ZIERER A, BAILEY MS, COX JL, LAWTON JS, MUNFAKH N et al. A new era in the surgical treatment of atrial fibrillation: the impact of ablation technology and lesion set on procedural efficacy. Ann Surg 2006; 244: 583-592.
https://doi.org/10.1097/01.sla.0000237654.00841.26
34. PRUITT JC, LAZZARA RR, DWORKIN GH, BADHWAR V, KUMA C, EBRA G. Totally endoscopic ablation of lone atrial fibrillation: initial clinical experience. Ann Thorac Surg 2006; 81: 1325-1330.
https://doi.org/10.1016/j.athoracsur.2005.07.095
35. MANASSE E, MEDICI D, GHISELLI S, ORNAGHI D, GALLOTTI R. Left main coronary arterial lesion after microwave apicardial ablation. Ann Thorac Surg 2003; 76: 276-277.
https://doi.org/10.1016/S0003-4975(03)00141-3
36. GAMMIE JS, LASCHINGER JC, BROWN JM, POSTON RS, PIERSON RN 3RD, ROMAR LG et al. A multi-institutional experience with the CryoMaze procedure. Ann Thorac Surg 2005; 80: 876-880.
https://doi.org/10.1016/j.athoracsur.2005.03.075
37. SIE HT, BEUKEMA WP, ELVAN A, RAMDAT MISIER AR. New strategies in the surgical treatment of atrial fibrillation. Cardiovasc Res 2003; 58: 501-509.
https://doi.org/10.1016/S0008-6363(03)00350-X
38. NINET J, ROQUES X, SEITELBERGER R, DEVILLE C, POMAR JL, ROBIN J et al. Surgical ablation of atrial fibrillation with off-pump, epicardial, high-intensity focused ultrasound: results of a multicenter trial. J Thorac Cardiovasc Surg 2005; 130: 803-809.
https://doi.org/10.1016/j.jtcvs.2005.05.014
39. GAYNOR SL, DIODATO MD, PRASAD SM, ISHII Y, SCHUESSLER RB, BAILEY MS et al. A prospective, single-center clinical trial of a modified Cox maze procedure with bipolar radiofrequency ablation. J Thorac Cardiovasc Surg 2004; 128: 535-542.
https://doi.org/10.1016/j.jtcvs.2004.02.044
40. LALL SC, MELBY SJ, VOELLER RK, ZIERER A, BAILEY MS, GUTHRIE TJ et al. The effect of ablation technology on surgical outcomes alter the Cox-maze procedure: a propensity analysis. J Thorac Cardiovasc Surg 2007; 133: 389-396.
https://doi.org/10.1016/j.jtcvs.2006.10.009
41. SUEDA T, NAGATA H, SHIKATA H, ORIHASHI K, MORITA S, SUESHIRO M et al. Simple left atrial procedure for chronic atrial fibrillation associated with mitral valve disease. Ann Torac Surg 1996; 62:1796-1800.
https://doi.org/10.1016/S0003-4975(96)00613-3
42. WINLAW DS, FARNSWORTH AE, MACDONALD PS, MUNDY JA, Spratt PM. Left atrial reduction: the forgotten Batista. Lancet 1998; 351: 879-880.
https://doi.org/10.1016/S0140-6736(05)70290-7
43. PROTECT AF Investigators. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 2009; 374: 534-542.
https://doi.org/10.1016/S0140-6736(09)61343-X
44. HERNÁNDEZ-ESTEFANÍA R, NEVES J, ABECASIS M, MORADAS FERREIRA M, RIBEIRAS R, CAVACO D. Tratamiento quirúrgico sin circulación extracorpórea de la fibrilación auricular aislada para la prevención secundaria de accidentes cerebrovasculares isquemicos agudos. Cir Cardiov 2006; 13: 163-170.
https://doi.org/10.1016/S1134-0096(06)70309-6
45. KANDERIAN AS, GILLINOV AM, PETTERSSON GB, BLACKSTONE E, KLEIN AL. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol 2008; 52: 924-929.
https://doi.org/10.1016/j.jacc.2008.03.067
46. CALKINS H, BRUGADA J, PACKER DL, CAPPATO R, CHEN SA, CRIJNS HJ et al. HRS/EHRA/ECAS expert consensus statement on cateter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. Heart Rhythm 2007; 4: 816-861.
https://doi.org/10.1016/j.hrthm.2007.04.005
47. EDGERTON JR, JACKMAN WM, MACK M. Minimally invasive pulmonary vein isolation and partial autonomic denervation for surgical treatment of atrial fibrillation. J. Interv Card Electrophysiol 2007; 20: 89-93.
https://doi.org/10.1007/s10840-007-9177-y
48. GILLINOV AM, SALTMAN AE. Ablation of atrial fibrillation with concomitant cardiac urgery. Semin Thorac Cardiovasc Surg 2007; 19: 25-32.
https://doi.org/10.1053/j.semtcvs.2007.01.002
49. COX JL, AD N, PALAZZO T. Impact of the maze procedure on the stroke rate in patients with atrial fibrillation. J Thorac Cardiovasc Surg 1999; 118: 833-840.
https://doi.org/10.1016/S0022-5223(99)70052-8
50. BANDO K, KASEGAWA H, OKADA Y, KOBAYASHI J, KADA A, SHIMOKAWA T et al. The impact of pre- and postoperative atrial fibrillation on outcome after mitral valvulo- plasty for nonischemic mitral regurgitation. J Thorac Cardiovasc Surg 2005; 129: 1032-1040.
https://doi.org/10.1016/j.jtcvs.2004.10.037
51. CHOO SJ, PARK NH, LEE SK, KIM JW, SONG JK, SONG H et al. Excellent results for atrial fibrillation surgery in the presence of giant left atrium and mitral valve disease. Eur J Cardiothorac Surg 2004; 26: 336-341.
https://doi.org/10.1016/j.ejcts.2004.04.003
52. SHEN J, BAILEY M, DAMIANO RH JR. Surgery for lone atrial fibrillation: Present state-of-the-art innovations (Phila) 2009; 4: 248-255.
https://doi.org/10.1097/imi.0b013e3181bb370f
53. EDGERTON JR, EDGERTON ZJ, WEAVER T, REED K, PRINCE S, HERBERT MA et al. Minimally invasive pulmonary vein isolation and partial autonomic denervation for surgical treatment of atrial fibrillation. Ann Thorac Surg 2008; 86: 35-39.
https://doi.org/10.1016/j.athoracsur.2008.03.071
54. MCCLELLAND JH, DUKE D, REDDY R. Preliminary results of limited thoracotomy: new approach to treat atrial fibrillation. J Cardiovasc Electrophysiol 2007; 18: 1289-1295.
https://doi.org/10.1111/j.1540-8167.2007.00977.x
55. BARNETT SD. Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis. J Thorac Cardiovasc Surg 2006; 131: 1029-1935.
https://doi.org/10.1016/j.jtcvs.2005.10.020
56. GILLINOV AM, BAKAEEN F, MCCARTHY PM, BLACKSTONE EH, RAJESWARAN J, PETTERSSON G et al. Surgery for paroxysmal atrial fibrillation in the setting of mitral valve disease: a role for pulmonary vein isolation? Ann Thorac Surg 2006; 81: 19-26.
https://doi.org/10.1016/j.athoracsur.2005.04.060
57. HARADA A, SUGIMOTO T, ASANO T, YAMADA K. Intraoperative map-guided operationfor chronic atrial fibrillation. Ann Thorac Surg 1998; 66: 1401-1403.
https://doi.org/10.1016/S0003-4975(98)00723-1
58. HARADA A, KONISHI T, FUKATA M, HIGUCHI K, SUGIMOTO T, SASAKI K. Intraoperative map guided operation for atrial fibrillation due to mitral valve disease. Ann Thorac Surg 2000; 69: 446-450.
https://doi.org/10.1016/S0003-4975(99)01091-7
59. NITTA T, OHMORI H, SAKAMOTO S, MIYAGI Y, KANNO S, SHIMIZU K. Map-guided surgery for atrial fibrillation. J Thorac Cardiovasc Surg 2005; 129: 291-299.
https://doi.org/10.1016/j.jtcvs.2004.09.012
60. MEHALL JR, SCHNEEBERGER EW, WOLF RK. Bilateral VATS pulmonary vein isolation, left atrial appendage excision, directed partial cardiac denervation and EP mapping (MiniMAZE-Wolf Technique). CTS Net. Clinical resources [revista electrónica] 2005 [consultado 19-12-2010]: Disponible en:http://www.ctsnet.org/sections/clinicalresources/adultcardiac/expert_tech-22.html
61. LOCKWOOD D, NAKAGAWA H, PEYTON MD, EDGERTON JR, SCHERLAG BJ, SIVARAM CA et al. Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: Techniques for assessing conduction block across surgical lesions. Heart Rhythm 2009; 12: 50-63.
https://doi.org/10.1016/j.hrthm.2009.09.010
62. PRUITT JC, LAZZARA RR, DWORKIN GH, BADHWAR V, KUMA C, EBRA G. Totally endoscopic ablation of lone atrial fibrillation: initial clinical experience. Ann Thorac Surg 2006; 81: 1325-1331.
https://doi.org/10.1016/j.athoracsur.2005.07.095
63. AD, N, PALAZZO T, COX J. The Cryosurgical Maze Procedure. CTS Net. Clinical resources [revista electrónica] 2005 [consultado 20-12-2010]: Disponible en: http://www.ctsnet.org/sections/clinicalresources/adultcardiac/expert_tech-5.html
64. GUANG Y, ZHEN-JIE C, WEI YONG L, TONG L, YING L. Evaluation of clinical treatment of atrial fibrillation associated with rheumatic mitral valve disease by radiofrequency ablation. Eur J Cardiothorac Surg 2002; 21: 249-254.
https://doi.org/10.1016/S1010-7940(01)01118-6
65. MELO J, ADRAGAO P, NEVES J, FERREIRA M, TIMOTEO A, SANTIAGO T et al. Endocardial and epicardial radiofrequency ablation in the treatment of atrial fibrillation with a new intra-operative device. Eur J Cardiothorac Surg 2000. 18: 182-186.
https://doi.org/10.1016/S1010-7940(00)00489-9
66. HORNERO F, MONTERO JA, CANOVA S, BUENO M. Biatrial radiofrequency ablation for atrial fibrillation: epicardial and endocardial surgical approach. Interact Cardiovasc Thorac Surg 2002; 1: 72-77.
https://doi.org/10.1016/S1569-9293(02)00033-6
67. BENUSSI S, NASCIMBENE S, AGRICOLA E, CALORI G, CALVI S, CALDAROLA A et al. Surgical ablation of atrial fibrillation using the epicardial radiofrequency approach: mid-term results and risk analysis. Ann Thorac Surg 2002; 74: 1050-1056.
https://doi.org/10.1016/S0003-4975(02)03850-X
68. MANTOVAN R, BUJA G, BERTAGLIA E, CESARI F, GEROSA G, VALFRE C et al. North-Eastern Italien study on radiofrequency surgical treatment of atrial fibrillation investigators. J Cardiovasc Electrophysiol 2003; 14: 1289-1295.
https://doi.org/10.1046/j.1540-8167.2003.03077.x
69. RAMAN J, ISHIKAWA S, STORER MM, POWER J Surgical radiofrequency ablation of both atria for atrial fibrillation; results of a multicenter trial. J Thorac Cardiovasc Surg 2003; 126: 1357-1366.
https://doi.org/10.1016/S0022-5223(03)01185-1
70. KNAUT M, TUGTEKIN SM, SPITZER S, GULIELMOS V. Combined atrial fibrillation and mitral valve surgery using microwave technology. Semin Thorac Cardiovasc Surg 2002; 14: 226-231.
https://doi.org/10.1053/stcs.2002.33754
71. NAKAJIMA H, KOBAYASHI J, BANDO K, NIWAYA K, TAGUSARI O, SASAKO Y et al. The effect of cryo-maze procedure on early and intermediate term outcome in mitral valve disease: case matched study. Circulation 2002; 106: 46-50.
https://doi.org/10.1161/01.cir.0000032883.55215.49
72. MANASSE E, GAITA F, GHISELLI S, BARBONE A, GARBEROGLIO L, CITTERIO E et al. Cryoablation of the left posterior atrial wall: 5 patients and 3 years of mean follow-up. Eur J Cardiothorac Surg 2003; 24: 731-740.
https://doi.org/10.1016/S1010-7940(03)00496-2
73. SCHAFF HV, DEARANI JA, DALY RC, ORSZULAK TA, DANIELSON GK. Cox maze procedure for atrial fibrillation mayo clinic experience. Semin Thorac Cardiovasc Surg 2000; 12: 30-37.
https://doi.org/10.1016/S1043-0679(00)70014-1
74. SHEMIN RJ, COX JL, GILLINOV AM, BLACKSTONE EH, BRIDGES CR. Workforce on evidence-based surgery of the Society of Thoracic Surgeons. Guidelines for reporting data and outcomes for the surgical treatment of atrial fibrillation. Ann Thorac Surg 2007; 83: 1225-1230.
https://doi.org/10.1016/j.athoracsur.2006.11.094
75. MELO JQ, NEVES J, ADRAGAO P, RIBEIRAS R, FERREIRA MM, BRUGES L.When and how to report results of surgery on atrial fibrillation. Eur J Cardiothorac Surg 1997; 12: 739-744.
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