Accepted Manuscript

A Modified Atrial Volume Reduction Technique for a Giant Left Atrium

Liang-Wan Chen, MD, Zhi-huang Qiu, MD, Xi-Jie Wu, MD

PII: S0003-4975(18)30367-9
DOI: 10.1016/j.athoracsur.2018.02.038
Reference: ATS 31423

To appear in: The Annals of Thoracic Surgery

Received Date: 28 November 2017

Revised Date: 9 January 2018
Accepted Date: 12 February 2018

Please cite this article as: Chen LW, Qiu Zh, Wu XJ, A Modified Atrial Volume Reduction Technique for
a Giant Left Atrium, The Annals of Thoracic Surgery (2018), doi: 10.1016/j.athoracsur.2018.02.038.

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A Modified Atrial Volume Reduction Technique for a Giant Left Atrium

Running Head: A Modified Atrial Volume Reduction

Liang-Wan Chen, MD, Zhi-huang Qiu, MD, and Xi-Jie Wu, MD

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Department of Cardiac Surgery, Union Hospital, Fujian Medical University, China

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Address correspondence to Liang-Wan Chen, MD, Department of Cardiac Surgery,

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Union Hospital, Fujian Medical University, China. Email: chenliangwan@tom.com
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Abstract

We describe a modified volume reduction technique for a giant left atrium (GLA),

consisting of circumferential resection of a strip of left atrial wall with the appendage,

plicated pericardium replacing the posterior atrial wall and the remaining right side

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free wall anastomosed to the interatrial septum instead of the interatrial groove. Our

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initial application showed that this technique can safely reduce a GLA to the desired

volume and obtain the high rate of sinus rhythm restoration after a maze operation.

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A giant left atrium (GLA) exists in some patients with mitral valve disease and

concomitant permanent atrial fibrillation. It can cause hemodynamic disturbance,

respiratory dysfunction, atrial thrombus and recurrence of atrial fibrillation after mitral

valve surgery combined with a maze operation. Reduction of it’s volume has been

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proven to be an effective approach for reducing patients’operative mortality and

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morbidity. Various techniques, varing from partial left atrial wall plication or resection

and suture to cardiac autotransplantation, have been employed to reduce the size of a

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GLA[1]. However, there are two disadvantages of these techniques: (1) they can not

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reduce the interatrial septum, (2) reduction of the posterior wall between the right and
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left pulmonary veins’ orifices has inherent risk of bleeding from the suture line, mainly

because the enlarged atrial wall is thin and fragile and hemostasis is difficult in this
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invisible surgical field due to pulmonary veins’ fixation. Therefore, all these techniques
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can not safely reduce a GLA to the desired volume. In this report we present a
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modified volume reduction technique for a GLA, in which all parts of the left atrial

wall could be effectively and safely reduced, including the interatrial septum and the
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posterior wall between the pulmonary veins.

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Technique

After a median sternotomy, cardiopulmonary bypass was established by standard aorta

and inferior vena cava cannulation, whereas a bidirectional right-angle venous cannula

was placed within the innominate vein(Fig1 A). Myocardial protection was obtained

with multiple administration of cold blood cardioplegia. The superior vena cava was
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circumferentially mobilized from the right pulmonary artery and pericardium and was

transected at least 3 cm cephalad to its entry into the right atrium. Two circular

incisions were performed in the left atrial wall between the pulmonary veins and the

mitral annulus(Fig1 A). The first one was made in the right atrial free wall, about 5 mm

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inside the right pulmonary veins and parallel to the interatrial groove, and extended

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around the pulmonary veins. The second incision was made in the interatrial groove

and extended around the posterior mitral annulus (leaving about a 2 cm margin from

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the annulus) (Fig1 A, B). With those two incisions, a circumferential band of the left

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atrial wall with the base of the left atrial appendage was excised(Fig1 C). All the
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resected margin of the left atrium was thoroughly cauterized to prevent bleeding from

the small vessels of the epicardial tissue. After the posterior wall between the orifices
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of right and left pulmonary veins was resected(Fig1 C), a reduction of the pericardial
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surface behind the posterior left atrial wall was obtained by longitudinally plication
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with an everting double running suture(Fig1 D). Care was taken to avoid injury to

mediastinal structures. Then, left isthmic ablation with radiofrequency and mitral valve
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surgery were performed. Finally, the resected margin around the mitral annulus was
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directly anastomosed to the cut edge of the left side free wall and the pericardium with
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continuous suture of 3-0 polypropylene while the remaining of the right side free wall

was anastomosed to the longitudinal axis of the atrial septum via fossa ovarium(Fig1 E,

F), which resulted in the plicated pericardium replacing the posterior atrial wall and the

left atrial surface of the interatrial septum reduced. The remainder of the operation,

including a right-side maze with radiofrequency, were performed as per usual standard.
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From August 2014 to June 2017, 11 consecutive patients (ie, 7 men and 4 women;

mean age, 51.2±7.4 years; range, 31 to 63 years) with left atrial anteroposterior

dimension larger than 100 mm and permanent atrial fibrillation (mean duration of atrial

fibrillation, 7.8±4.1 years; range, 6.3 to 9.7 years) underwent the modified atrial

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volume reduction during their mitral valve surgery combined with a maze operation at

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our department. The mean times for cardiopulmonary bypass and for aortic clamping

were 92.5±12.7 and 40.8±6.9 minutes, respectively. Normal sinus rhythm was restored

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quickly after removal of the aortic cross-clamp in all cases. We did not encounter any

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difficult bleeding from the left atrial anastomoses, and no patient required reoperations
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for bleeding. There were no hospital deaths. Antiarrhythmic therapy was discontinued

6 weeks after surgery. The left atrial anteroposterior dimension was 117±9.8mm (range,
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103 to 128) preoperatively, 36.4±6.3 mm (range, 32 to 41) before discharge, and

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37±6.4 mm (range, 34 to 41) at 3 months after surgery. At a follow-up period of 3 to 38

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months (15.3±12 months), all patients were New York Heart Association class I and all

remained in sinus rhythm confirmed by both 12-lead electrocardiogram and 24-hour

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Holter monitor.
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Comment

This limited experience demonstrates that our modified technique can safely reduce a

GLA to the desired volume and obtain the high rate of sinus rhythm restoration after a

maze operation. Compared with other left atrial volume reduction techniques in

previous reports, our technique has two new items: the plicated pericardium
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replacing the left atrial posterior wall between pulmonary veins and the remaining right

side free wall anastomosed to the interatrial septum instead of interatrial groove.

In a left atrial maze operation, the posterior left atrial wall between the orifices of

right and left pulmonary veins is totally isolated from the remaining left atrium, and

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consequently is electrically and functionally silent. This functionally silent posterior

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atrial wall should be kept to as small as possible. However, it’s reduction with all

techniques described in previous reports carried high risk of bleeding. In our modified

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technique, the posterior atrial wall was resected and replaced by the pericardium

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behind it, based on the posterior wall functionally silent and the pericardium much
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stronger for prevention of suture line tear than the enlarged atrial wall. After the

pericardium was plicated, this artificial posterior left atrial wall made of pericardium
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could be reduced to a very small surface.

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In our modified technique, after the remaining right side free wall was anastomosed
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to the longitudinal axis of the interatrial septum via fossa ovarium, the left atrial

surface of the interatrial septum was reduced to a small size while the right atrial
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surface kept unchanged. Therefore, this right side free wall anastomosed to the
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interatrial septum technique is particularly suitable for the volume reduction of a GLA
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with relatively normal right atrial size.

The superior vena cava was routinely transected in our technique. We developed a

bidirectional right-angle venous cannula and placed it within the innominate vein,

which allowed the superior vena cava long enough for safe transection and easy

anastomosis without sinus node damaged[2]. Whether the superior vena caval
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transection routinely could be justified from the viewpoint of better surgical field

exposure remains controversial, but we believe that it may well be worthwhile. With

this superior vena caval transection, a comfortable access to all parts of the left atrium

and mitral valve has gained, which making suturing of the atrium after resection and

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mitral manipulation easier and safer. Therefore, a relatively short mitral procedure time

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was obtained and no intraoperative bleeding was found in our experience.

Furthermoore, the reattachment of the superior vena cava could be finished after the

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aortic clamp released and requires only 2 to 3 minutes.

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In conclusion, our modified atrial volume reduction is an easy and safe technique for
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a GLA, it can reduce a GLA to the desired volume and obtain the high rate of sinus

rhythm restoration after a maze operation.

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References

1. Apostolakis E, Shuhaiber JH. The surgical management of giant left atrium.

European Journal of Cardio-thoracic Surgery 2008;33: 182-190.

2. Chen LW, Wu XJ, Liao DS, et al. An alternative approach for repair of supracardiac

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and infracardiac total anomalous pulmonary venous drainage in neonates and infants:

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superior approach with caval transection. J Card Surg 2015;30:278-280.

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Figure Legends

Fig 1. The left atrial reduction procedure. (A) Superior vena cava was transected. (B)

The first incision was performed around the pulmonary veins, and second incision

around the mitral annulus. (C) The posterior wall between the orifices of right and left

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pulmonary veins was resected. (D) The pericardial surface behind the posterior left

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atrial wall was obtained by longitudinally plication. (E) The resected margin around

the mitral annulus was directly anastomosed to the cut edge of the left side free wall

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and the pericardium. (F) The remaining of the right side free wall was anastomosed to

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the longitudinal axis of the atrial septum via fossa ovarium.
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