LV diastolic diameter= 63 mm , LA diameter= 64 , EF= 71% , Chronic Atrial Fibrilation
I am in favour of mitral valve reconstruction + intraoperative atrial fibrillation ablation. The atrium may still become smaller after reconstruction, especially if atrial fibrillation ablation is added. An electrophysiological work-up may be necessary, if afib or atrial tachycardia recurrs. I would even do this in an asymptomatic patient, because this patient carries a high risk of clinical events (heart failure, thrombembolism ...)
Dear Bänsch, I agre with your suggsted treament. So the giant atrium can to keep the patients without dyspnea or fadique during many years.
I think it depends on the underlying etiology: if the mitral valve has some form of organic disease, I believe the decision should be based on the probability of successful repair at an acceptable surgical risk (ie high probability for isolated flail posterior leaflet vs low for rheumatic MV disease or very complex mixomatous valve).
However, some cases sch as the one you are mentioning may recognize mitral annular dilatation (typical of long.standing chronic AF) as the main mechanism for mitral regurgitation; mitral leaflets will be free of significant organic lesions in this case. Most of these patients, who are often elderly and/or with comorbidities, may do well with pharmacological therapy. MitraClip implantation may be an option if anatomy is suitable.
The question is about a 55 year-old-man with mitral regurgitation due to mixomatous degeneration. Annular dilatation is not the etiology. The patient use only warfarin due to atrial fibrilation, without other symptoms.
Atrial size will be reversible if the mitral valve can reconstructed and sinus rhythm be reestablished with ablation.
Then, I think there's quite a straightforward indication for MV repair + arrhythmia surgery!
(+ eventually tricuspid surgery if more than mild TR or TA dilation, as is often the case with chronic AF)
I think that surgical treatment is indicated, but I don't bilieve in an important reduction of the left atrial size. I think that ablation can be attempted, but I don't believe that sinus rhythm wil be reestablished for long time. The surgical reduction of the left atrium and repair of the mitral valve can be the best way.
I have an experience with huge LA 8.4 in case of severe MS after we did MVR without reduction of the LA size the follow up measure were 6.8 after 10 days only . I believe that remodeling can take place once valve changed or repaired .
The timing of surgical correction of chronic mitral regurgitation due to injury
primary valve remains controversial and is because of different behaviors in handling.
The decision to operate on a patient with mitral regurgitation is a complex process that includes careful assessment of the severity of regurgitation, its impact on the remodeling of the atrium and the left ventricle (LV), left ventricular function and pulmonary pressure , symptoms, the possibility of valve repair, associated pathologies and operative risk in each patient.
In my opinion, the left atriomegalia is not a conditioning factor in the surgical timing for mitral regurgitation (MR).
MR, according to the most recent scientific evidence, should be treated even if asymptomatic and with a normal left ventricular function and/or diameters: in younger patients, in centers with a high likelihood of successful repair and in the presence of chordal rupture.
If then the surgeon finds a giant left atrium, surely the association of a reductive remodeling of the same should be performed, both to reduce the risk of cardioembolism, both in case of a concomitant treatment of AF to reduce the risk of arrhythmic recurrence.
if the patient has recieved optimum medical treatment and still continues to be in NYHA class 3or 4, MVR with ablation and partial LA reduction can be considered