© 1999 by European Society of Cardiology
Effect of cardiac exposure by median sternotomy on atrial fibrillation cycle length
Department of Cardiology, University Hospital Lund, Sweden; *Department of Cardiothoracic Surgery, University Hospital Lund, Sweden
BACKGROUND: Epicardial mapping is a powerful tool that has enabled us to gain insight into the electrical phenomena perpetuating atrial fibrillation and has guided the design of surgical and catheter-based therapeutic strategies. However, epicardial data are acquired during abnormal physiological conditions; the patients are anaesthetized, their chests opened, dislocating the heart and exposing it to air of room temperature, and the autonomic tone is modulated due to the surgery. The effect of intra-operative conditions on atrial electrophysiological properties have not been investigated before. Thus in the present study we assessed the atrial cycle length, shown to be an index of atrial refractoriness, and the ventricular rate before and during open-heart surgery in 10 patients with chronic atrial fibrillation and an underlying heart disease.
METHODS AND RESULTS: Using a newly introduced and validated ECG method known as frequency analysis of fibrillatory ECG (FAF-ECG), the atrial cycle length and the ventricular rate were determined just before surgery. After anaesthesia and median sternotomy, epicardial mapping of the entire right atrial free wall was performed. The mean ventricular rate as well as the dominant atrial fibrillation cycle length consistently increased, the former from 71 to 92 beats.min–1(mean of all patients, P<0·05) and the latter from 156 to 172 ms (P<0·05).
CONCLUSIONS: Atrial fibrillation cycle length, an index of atrial refractoriness, is increased as an effect of anaesthesia and heart exposure during open-heart surgery in patients with chronic atrial fibrillation, implying that atrial activation might be altered, which must be considered when interpreting data from epicardial conduction analysis.
Key Words: Human, atrium, fibrillation, cycle length, open-heart surgery, anaesthesia
Correspondence: Magnus Holm, Department of Cardiology, University Hospital, 221 85 Lund, Sweden.
[1] Allessie M, Lammers W, Smeets J, Bonke F, Hollen J. Total mapping of atrial excitation during acetylcholine-induced atrial flutter and fibrillation in the isolated canine heart. In Kulbertus HE, Olsson SB, Schlepper M (Eds.). Atrial fibrillation 1982; Mölndal, Sweden A Lindgren & Söner AB pp. 44–61.
[2] Allessie MA, Lammers WJEP, Bonke FIM, Hollen J. Experimental evaluation of Moe's multiple wavelet hypothesis of atrial fibrillation. In Zipes DP and Jalife J (Eds.). Cardiac arrhythmias 1985; New York Grune & Stratton pp. 265–276.
[3] Cox JL, Canavan TE, Schuessler RB. The surgical treatment of atrial fibrillation. II. Intraoperative electrophysiologic mapping and description of the electrophysiologic basis of atrial flutter and atrial fibrillation. J Thorac Cardiovasc Surg 1991; 101: 406–426.[Abstract]
[4] Konings K, Kirchhof C, Smeets J, Wellens H, Penn O, Allessie M. High-density mapping of electrically induced atrial fibrillation in humans. Circulation 1994; 89: 1665–1680.
[5] Kumagai K, Khrestian C, Waldo AL. Simultaneous multisite mapping studies during induced atrial fibrillation in the sterile pericarditis model. Insight into the mechanism of its maintenance. Circulation 1997; 95: 511–521.
[6] Holm M, Johansson R, Brandt J, Lührs C, Olsson SB. Epicardial right atrial free wall mapping in chronic atrial fibrillation. Documentation of repetitive activation with a focal spread — a hitherto unrecognised phenomenon in man. Eur Heart J 1997; 18: 290–310.
[7] Cox JL, Schuessler RB, Cain ME. Surgery for atrial fibrillation. Semin Thorac Cardiovasc Surg 1989; 1: 67–73.[Medline]
[8] Cox JL, Schuessler RB, Boineau JP. The surgical treatment of atrial fibrillation. I. Summary of the current concepts of the mechanisms of atrial flutter and atrial fibrillation. J Thorac Cardiovasc Surg 1991; 101: 402–405.[Abstract]
[9] Cox JL, Schuessler RB, D'Agostino HJJ. The surgical treatment of atrial fibrillation. III. Development of a definite surgical procedure. J Thorac Cardiovasc Surg 1991; 101: 569–583.[Abstract]
[10] Cox JL, Boineau JP, Schuessler RB. Operations for atrial fibrillation. Clin Cardiol 1991; 14: 827–834.[Web of Science][Medline]
[11] Cox JL, Boineau JP, Schuessler RB, Kater KM, Lappas DG. Five-year experience with the maze procedure for atrial fibrillation. Ann Thorac Surg 1993; 56: 814–823.[Abstract]
[12] Cox JL, Boineau JP, Schuessler RB, Jaquiss RD, Lappas DG. Modification of the maze procedure for atrial flutter and atrial fibrillation. I. Rationale and surgical results. J Thorac Cardiovasc Surg 1995; 110: 473–484.
[13] Cox JL, Jaquiss RD, Schuessler RB, Boineau JP. Modification of the maze procedure for atrial flutter and atrial fibrillation. II. Surgical technique of the maze III procedure. J Thorac Cardiovasc Surg 1995; 110: 485–495.
[14] Cox JL, Boineau JP, Schuessler RB. Electrophysiologic basis, surgical development, and clinical results of the maze procedure for atrial flutter and atrial fibrillation. Adv Card Surg 1995; 6: 1–67.[Medline]
[15] Cox JL, Schuessler RB, Lappas DG, Boineau JP. An 8 1/2-year clinical experience with surgery for atrial fibrillation. Ann-Surg 1996; 224: 267–273.[CrossRef][Web of Science][Medline]
[16] Swartz JF, Pellersels G, Silvers J. A catheter-based curative approach to atrial fibrillation in human (Abstr). Circulation 1994; 90: I–335.
[17] Haissaguerre M, Jais P, Shah DC. Right and left atrial radiofrequency catheter therapy of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 1996; 7: 1132–1144.[Web of Science][Medline]
[18] Haissaguerre M, Shah DC, Jais P, Clementy J. Role of catheter ablation for atrial fibrillation. Curr Opin Cardiol 1997; 12: 18–23.[Web of Science][Medline]
[19] Lammers WJEP, Allessie MA, Rensma PL, Schalij MJ. The use of fibrillation cycle length to determine spatial dispersion in electrophysiological properties and to characterize the underlying mechanism of fibrillation. N Trend Arrhyth 1986; II: 109–112.
[20] Capucci A, Biffi M, Boriani G. Dynamic electrophysiological behavior of human atria during paroxysmal atrial fibrillation. Circulation 1995; 92: 1193–1202.
[21] Kim K-B, Rodefeld MD, Schuessler RB, Cox JL, Boineau JP. Relationship between local atrial fibrillation interval and refractory period in the isolated canine atrium. Circulation 1996; 94: 2961–2967.
[22] Holm M, Pehrson S, Ingemansson M. Non-invasive assessment of the atrial cycle length during atrial fibrillation in man. Introducing, validating and illustrating a new ECG method. Cardiovasc Res 1998; 38: 69–81.
[23] Ingemansson MP, Holm M, Olsson SB. Autonomic modulation of the atrial cycle length by the head-up tilt test. Non-invasive evaluation in patients with chronic atrial fibrillation. Heart 1998; 80: 71–76.
[24] Royster RL, Keeler K, Haisty K, Johnston WE, Prough DS. Cardiac electrophysiologic effects of fentanyl and combinations of fentanyl and neuromuscular relaxants in pentobarbital-anesthetized dogs. Anesth Analg 1988; 67: 15–20.
[25] Lau W, Kovoor P, Ross DL. Cardiac electrophysiologic effects of midazolam combined with fentanyl. Am J Cardiol 1993; 72: 177–182.[CrossRef][Web of Science][Medline]
[26] Yip ASB, McGuire MA, Davis L. Lack of effect of midazolam on inducibility of arrhythmias at electrophysiologic study. Am J Cardiol 1992; 70: 593–597.[CrossRef][Web of Science][Medline]
[27] Weber G, Stark G, Stark U. Direct cardiac electrophysiologic effects of sufentanil and vecoronium in isolated guinea-pig hearts. Acta Anaesthesiol Scand 1995; 39: 1071–1074.[Web of Science][Medline]
[28] Napolitano CA, Raatikainen MJP, Martens JR, Dennis DM. Effects of intravenous anesthetics on atrial wavelength and atrioventricular nodal conduction in guinea pig heart. Anesthesiology 1996; 85: 393–402.[CrossRef][Web of Science][Medline]
[29] Sarrion AJ, Chorro GFJ, Negueruela CA. Efecto del anestesico inhalatorio isoflurano sobre la electrofisiologia cardiaca. (Effect of the inhalation of anesthetic isoflurane on heart electrophysiology). Rev Esp Cardiol 1992; 45: 462–470.[Medline]
[30] Satoh T and Zipes DP. Unequal atrial stretch in dogs increases dispersion of refractoriness conductive to developing atrial fibrillation. J Cardiovasc Electrophysiol 1996; 7: 833–842.[Web of Science][Medline]
[31] Ravelli F and Allessie M. Effects of atrial dilatation on refractory period and vulnerability to atrial fibrillation in the isolated Langendorff-perfused rabbit heart. Circulation 1997; 96: 1686–1695.
[32] Smeets JLRM, Allessie MA, Lammers WJEP, Bonke FIM, Hollen J. The wavelength of the cardiac impulse and reentrant arrhythmias in isolated rabbit atrium. The role of heart rate, autonomic transmitters, temperature, and potassium. Circ Res 1986; 58: 96–108.
[33] Wiener R and Rosenblueth A. The mathematical formulation of the problem of conduction of impulses in a network of connected excitable elements, specifically in cardiac muscle. Arch Inst Cardiol Mex 1946; 16: 205–265.
[34] Allessie MA, Konings K, Kirchhof CJHJ, Wijffels M. Electrophysiologic mechanisms of perpetuation of atrial fibrillation. Am J Cardiol 1996; 77: 10A–23A.[CrossRef][Medline]
[35] Bjornstad H, Tande PM, Refsum H. Cardiac electrophysiology during hypothermia. Implications for medical treatment. Arctic Med Res 1991; 50: 71–75.
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