Chronic Atrial Fibrillation Ablation with Harmonic Scalpel during Mitral Valve Surgery

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1 ORIGINAL ARTICLE Chronic Atrial Fibrillation Ablation with Harmonic Scalpl during Mitral Valv Surgry Alxandr Visconti Brick 1 MD, PhD; Domingo M. Brail 2 MD, PhD DOI: / Abstract Objctiv: To valuat surgical tratmnt of chronic atrial fibrillation with ultrasound in patints with mitral valv disas, considring proprativ clinical charactristics of patints undrgoing surgical procdur and follow-up in th immdiat postoprativ priod, in hospital and up to 60 months aftr discharg. Mthods: W studid 100 patints with chronic atrial fibrillation and mitral valv disas who undrwnt surgical tratmnt using ultrasound ablation. Patint data wr rviwd by consulting th control rports, including signs and symptoms, undrlying disas, functional class, hospital stay, surgical procdur tim, ablation tim, immdiat complications, and complications at dischargd and up to 60 months latr. Actuarial curv (Kaplan-Mir) was usd for th study of prmannc without rcurrnc aftr 12, 24, 36, 48 and 60 months. Rsults: 86 of th patints had rhumatic mitral valv disas, 14 had dgnration of th mitral valv, 40 had mitral rgurgitation, and 36 had mitral stnosis. Main symptoms includd palpitations rlatd to tachycardia by chronic atrial fibrillation (70), congstiv hart failur (70), and prvious pisods of acut pulmonary dma (27). Early rsults showd that 94 of th patints undrgoing ultrasound ablation rvrsd th rat of chronic atrial fibrillation, 86 bing in sinus rhythm and 8 in atriovntricular block. At hospital discharg, maintnanc of sinus rhythm was obsrvd in 86 of patints and thr was rcurrnc of chronic atrial fibrillation in 8 of patints. At follow-up aftr 60 months, 83.8 of patints maintaind th sinus rhythm. Conclusion: Surgical tratmnt of chronic atrial fibrillation with ultrasound concomitant with mitral valv surgry is fasibl and satisfactory, with maintnanc of sinus rhythm in most patints (83.8) aftr 60 months of follow-up. Kywords: Atrial fibrillation. Arrhythmias, cardiac. Ablation tchniqus. High-intnsity focusd ultrasound ablation. Cardiovascular surgical procdurs. Mitral Valv Disas. Abbrviations, acronyms & symbols AF CAF CPB ISMICS NYHA US INTRODUCTION = Atrial fibrillation = Chronic atrial fibrillation = Cardiopulmonary bypass = Intrnational Socity of Minimally Invasiv Cardiothoracic Surgry = Nw York Hart Association = Ultrasound Atrial fibrillation (AF) is th most common and th most complx supravntricular arrhythmia, charactrizd by loss of atrial contraction, and its diagnosis is asily accomplishd by clinical manifstation, cardiac auscultation, and lctrocardiogram. Th prvalnc of AF is stimatd at 0.4 in th gnral population and it incrass proportionatly with ag, occurring in lss than 1 of thos blow 60 yars old and mor than 6 in patints ovr 80 yars old [1]. Rgarding gndr, its incidnc is highr in mn [2]. Th occurrnc of AF may b associatd with othr cardiopulmonary disass, such as valvular disas, spcially with th involvmnt of th mitral valv [3]. AF is trmd chronic whn it prsists for mor than a yar or continus aftr th first pisod. Th non-pharmacological tratmnt of AF includs tchniqus such as intraoprativ cryoablation of th His bundl and th atriovntricular junction [4] ; lctrical cardiovrsion, with a high rcurrnc rat; lft atrial isolation [5] ; cathtr ablation of th His bundl and prmannt pacmakr implantation; cathtr ablation of th atriovntricular junction and prmannt pacmakr implantation; and Corridor opration. 1 Surgry Dpartmnt of Faculdad d Mdicina da Univrsidad d Brasília (FM- UnB), Brasília, DF, Brazil. 2 Faculdad d Mdicina d São José do Rio Prto (FAMERP), São José do Rio Prto, SP, Brazil and Univrsidad d Campinas (UNICAMP), Campinas, SP, Brazil. This study was carrid out at Faculdad d Mdicina da Univrsidad d Brasília (FM-UnB), Brasília, DF, Brazil. No financial support. No conflict of intrst. Corrspondnc Addrss: Alxandr Visconti Brick Univrsidad d Brasília (UNB) Campus Darci Ribiro Av. L3 Nort, Asa Nort Brasília, DF, Brazil Zip cod: avbrick@cardiol.br Articl rcivd on Octobr 27 th, Articl accptd on Novmbr 14 th,

2 Brick AV & Brail DM - Chronic Atrial Fibrillation Ablation with Harmonic Scalpl Elctrophysiological mapping studis with computrizd lctrod systm wr prformd by Cox t al. [6], who dvlopd th surgical tchniqu known as maz procdur. It consists of making incisions and suturs on th atrial wall, allowing th sprad of lctrical stimulation in th atria within a maz, and stting atrial rat. Th applicability of surgical tchniqus is invrsly proportional to thir complxity. In ordr to rduc th complxity of th Cox opration [7], svral tchnical changs wr introducd, such as modifications in th locations of atrial incisions; rduction of sction lins and suturs on th atrial wall, known as Mini Cox [8] ; and a unilatral procdur, only in th lft atrium, calld Cox at Lft. In Brazil, Jatn t al. [9] valuatd th rsults of lat volution of th Cox maz procdur for chronic atrial fibrillation (CAF) in patints with mitral valv disas. In addition, it has bn dmonstratd that, in patints with CAF and valvular disas, a combination of valv rpair and compltion of th Maz tchniqu dvisd by Cox allows for th rturn to sinus rhythm [10]. Although of provn fficincy, th maz tchniqu, as it is gnrally prformd, uss dissction and opning of th atrial wall, followd by sutur, which incrass cardiopulmonary bypass (CPB) tim and th chanc of complications in th postoprativ priod. Th us of cathtr ablation for th tratmnt of supravntricular arrhythmias stimulatd th us of nrgy sourcs to caus linar ablativ lsions, with ithr ndocardial or picardial application or both, rplacing th sction and sutur of th atrial wall [11,12]. Nw nrgy sourcs capabl of causing prmannt blockag lins hav bn usd [13] such as radiofrquncy [14-18], microwav [19] (90=17), and ultrasound (US) [20,21]. This author, considring th xprinc with an US scalpl in th surgical tratmnt of rfractory vntricular tachycardia [22], dvisd a nw approach, applying US and using th scalpl (UltraCision ) to form injury lins that would dtrmin th partitioning of th lft and right atria, with lss surgical and CPB tim and consqunt rduction in postoprativ complications. Svral aspcts justifid this rsarch, namly: difficultis in stablishing drug tratmnt or othr drugs indicatd to liminat CAF; complications causd by CAF, spcially thrombombolism with incrasing morbidity and mortality; prsnc of prvious hart disas, most oftn injury of th mitral valv; advancs in th study of th lctrophysiological mchanisms of arrhythmia; dscription of th focal origin mchanism of AF in th pulmonary vins, as wll as foci locatd in th vna cava; and dmonstration that th ablations prformd with US systms, through both ndocardial and picardial, ar likly to caus transmural lsion. Thus, th aim of this study was to valuat th surgical tratmnt of CAF with US in patints with mitral valv disas, considring proprativ clinical charactristics of patints undrgoing surgical tratmnt for CAF and follow-up in th immdiat postoprativ priod, at hospital discharg, and lat postoprativ of up to 60 months. METHODS W rtrospctivly and conscutivly studid 100 patints with CAF and mitral valv disas with indication for surgical tratmnt, rgardlss of rac, from various rgions of th country, agd btwn 18 and 70 yars (43.56±4.94 yars), and with 63 (63) bing fmal and 37 (37), mal. Th patints undrwnt surgry by th author in th priod btwn 1999 and 2004 and wr surgically tratd by ablation with US. All patints wr tratd at Hospital das Forças Armadas and Brasília Hospital, locatd in Brasilia/DF, Brazil. Exclusion critria wr: prgnant womn; childrn undr 16 yars old; AF patints who wr not considrd chronic, with or without valvular hart disas; popl with coronary, congnital and vascular disass; transplant or indication for hart transplantation; patints undrgoing two roprations of th mitral valv; and thos with othr isolatd or associatd valv disass (xcpt th tricuspid valv disas). This study was approvd by th Rsarch Ethics Committ of São José do Rio Prto Mdical School (FAMERP) (Protocol No. CAAE ). Patint data wr rviwd prospctivly by consulting control rcords, including dmographic variabls (gndr and ag). Cardiac variabls includd clinical prsntation (signs and symptoms), undrlying disas, functional class, lngth of hospital stay (days), surgical procdur tim (minuts), ablation tim (minuts), intraoprativ and postoprativ complications (immdiat, at hospital discharg and lat postoprativ, up to 60 months). All patints had indication for mitral valv rpair or rplacmnt, in som cass for tricuspid valv rpair and corrction of CAF. US was usd to prform th intraoprativ ablation lins, in accordanc with Brick t al. [23], using harmonic scalpl UltraCision, tradmark of Ethicon Endo Surgry, Division of Johnson & Johnson Profssional Products (São Paulo, SP, Brazil). Aftr anoxic arrst, longitudinal lft atriotomy was prformd by clamping of th aorta. Th ablation lins wr carrid out in invrtd U-shap, surrounding th four pulmonary vins, by starting and finishing at th fibrous annulus of th hart toward th mitral valv. In patints with thrombi in th atrium and lft atrium, thrombctomy was prformd bfor ablation. Upon compltion of th ablation lins, routin procdurs wr don for tratmnt of mitral disas with rplacmnt or rpair. In th right atrium, aftr longitudinal opning with a bating hart, linar ablations wr prformd in th intratrial sptum: 1- from around th suprior vna cava to around th infrior vna cava; 2- from th infrior vna cava to th bottom dg of th tricuspid valv annulus, passing clos to th coronary sinus ostium, and 3- from th suprior vna cava to th uppr portion of th tricuspid annulus, taking car of th atriovntricular nod. A daily dos of 200 mg of amiodaron was maintaind for six months for atrial rmodling and stabilization. Data wr analyzd using dscriptiv statistics (man, standard dviation, mdian, minimum and maximum). Th actuarial curv (Kaplan-Mir) for th study of prmannc without rcurrnc aftr 12, 24, 36, 48 and 60 months in patints with CAF with confidnc intrval of 95 was usd. Th actuarial curv (Kaplan-Mir) was prformd using th statistical program Statistical Calculations for Windows v.1.8. RESULTS Of th patints studid, 86 had rhumatic mitral valv disas and 14 prsntd dgnration of th mitral valv. Th 23

3 Brick AV & Brail DM - Chronic Atrial Fibrillation Ablation with Harmonic Scalpl analysis of valvular disas showd that 40 of th patints had mitral rgurgitation, 36 had mitral stnosis, 19 had doubl mitral lsion, and 5 had mitral rstnosis (Figur 1). In addition to mitral valv disas, 11 of th patints had associatd tricuspid valv rgurgitation, which was also corrctd with valvuloplasty during th procdur. Main symptoms includd palpitations rlatd to tachycardia by CAF (70), congstiv hart failur (70), prvious pisods of acut pulmonary dma (27), strok du to thrombombolism (13), and priphral mbolism (7); ths patints rquird mbolctomy with Fogarty cathtr (Figur 2). Th functional class of patints, according to Nw York Hart Association (NYHA), was III/IV and th avrag siz of th lft atrium masurd on chocardiography was approximatly 60 mm. Oprations prformd concurrntly with th ablation includd mitral valv rplacmnt for bovin pricardial bioprosthsis of Brail Biomédica (São José do Rio Prto, SP, Brazil) (69), mitral valv rpair (10), ropration with valv rplacmnt (10), and associatd with tricuspid valv (11) (Figur 3). In addition to ablation with US, in all patints, additional procdurs to surgry includd: xclusion of th right and lft atria (90), rduction in th siz of th lft atrium through rsction and/or plication of th lft atrial wall (25), and thrombctomy (15) (Figur 4). Mitral insufficincy Mitral stnosis Doubl mitral lsion Mitral rstnosis Tricuspid insufficincy Mitral valv rplacmnt + Ablation Mitral valv rpair + Ablation Mitral valv rplacmnt + Ropration + Ablation Mitral valv rplacmnt + Tricuspid valv rpair + Ablation Mitral valv rpair + Tricuspid valv rpair + Ablation Fig. 1 - Prcntag distribution of valvular disas in patints with chronic atrial fibrillation. Fig. 3 Procdurs prformd concurrntly with th CAF ablation. Functional class III/IV Palpitations and Congstiv hart failur Acut dma Crbrovascular accidnt Priphral mbolism ABL EXC RA-LA RED LA THROMB Fig. 2 - Prcntag distribution of symptoms and functional class in patints with chronic atrial fibrillation. Fig. 4 - Supplmntary procdurs to surgry of US ablation. ABL=ablation; EXC RA-LA=xclusion of th right and lft atria; RED LA=rduction of th lft atrium; Thromb=thrombctomy 24

4 Brick AV & Brail DM - Chronic Atrial Fibrillation Ablation with Harmonic Scalpl and unmanagabl hart failur. Ths 4 patints had AF in th immdiat postoprativ priod. On patint had strnal dhiscnc. Aftr hospital discharg, patints wr followd-up in outpatint clinics with conduction of CPB, 24-hour Holtr, and chocardiogram, initially and at 15, 30, and 60 days postoprativly. Clinical follow-up of lat postoprativ priod was prformd at 12, 24, 36, 48 and 60 months aftr hospital discharg. Figur 6 shows th rsults of th rlaps in th postoprativ priod. Follow-up tim rangd from 12 to 60 months. At follow-up aftr 60 months, 83.8 of patints maintaind rlaps-fr sinus rhythm (Figur 7). Rvrsal Transint AVB Non-rvrsal Fig. 5 - Rsults obtaind in th immdiat postoprativ priod for patints undrgoing US ablation. AVB=atriovntricular block Early rsults showd that 94 of patints undrgoing US ablation rvrsd th rat of CAF, 86 bing in sinus rhythm and 8 in atriovntricular block, which was transint. Among 6 of th patints, thr was no succss, thr wr 4 roprations, and lft atrium with svr fibrosis causd by rhumatic fvr and/or calcifid (Figur 5). At th nd of th procdur and at th nd of CPB, 96 of patints maintaind adquat cardiac output, vn whn CAF was not rvrsd. Thr was no ropration for blding in th immdiat postoprativ priod. In on patint, thr was injury of th lft atrium wall by US scalpl, corrctd by suturing th lft atrium. Mdian opration tim was 142 minuts with anoxic arrst of 45 minuts. Th tim to prform th ablation lins wr 12.5 and 14 minuts for th right and lft atria, rspctivly (Tabl 1). Analyzing th rsults at hospital discharg, w obsrvd maintnanc of sinus rhythm in 86 of patints and rcurrnc of CAF in 8. Hospital stay rangd from 5 to 12 days, with an avrag of 6.6 days. Four hospital daths wr rcordd, two patints who undrwnt ropration for calcifid mitral rstnosis had rspiratory failur in th postoprativ priod, and two patints who had proprativ functional class IV and an pisod of acut dma volvd with low output syndrom Tabl 1. Rsults on th mdian tim (in minuts) of th surgical tratmnt of patints with chronic atrial fibrillation and mitral valv disas. Tim of CPB tim Tim of Ablation Tim Surgry arrst RA LA CPB=cardiopulmonary bypass; RA=right atrium; LA=lft atrium Patints Hospital rlaps 12-month rlaps 24-month rlaps 36-month rlaps 48-month rlaps 60-month rlaps Fig. 6 - Rsults obtaind postoprativly with rspct to rlaps of chronic atrial fibrillation in patints undrgoing US ablation. Rlaps-fr Kaplan-Mir CI 95 Evolution (months) Patints xposd to risk Fig. 7 - Actuarial curv (Kaplan-Mir) for probability of rmaining without rcurrnc up to 60 months of follow-up in 86 patints with chronic atrial fibrillation who undrwnt surgry with US. 25

5 Brick AV & Brail DM - Chronic Atrial Fibrillation Ablation with Harmonic Scalpl DISCUSSION Th rsults of this rsarch show that th surgical tratmnt of chronic AF with US in patints with mitral valv disas is fasibl. In most patints with CAF, rhumatic mitral valv disas, mitral rgurgitation, palpitation rlatd to tachycardia, and congstiv hart failur ar mor frqunt. Th low rat of intraoprativ and postoprativ complications shows that surgical ablation of CAF with US concomitant with valv surgry is saf and ffctiv. Maintnanc of sinus rhythm rat aftr 60 months of follow-up for ths patints shows th bnfits of surgical ablation with US in th tratmnt of this arrhythmia. Rgarding functional class, all patints showd considrabl improvmnt, staying mostly in class I or II, which indicats that maintnanc of th rhythm with contraction of th atria positivly influncd th rsults. In this study, although thy ar important in th volution of patints and can influnc th final rsults, variabls such as siz of th lft atrium, lft vntricular jction fraction and functional class of CHF (NYHA) aftr surgry wr not analyzd bcaus what mattrd was arrhythmia with maintnanc or not of sinus rhythm. Facd with poor rsults of clinical tratmnt and incrasd incidnc of CAF, th pionring study of Cox t al. [6] dmonstratd th ability to surgically trat AF. Kong t al. [24] compard, through mta-analysis, th ffctivnss of th Maz procdur with concomitant cardiac surgry vrsus drug thrapy for tratmnt of patints with valvular AF. Thy concludd that surgical tratmnt is associatd with rducd AF aftr 1 yar, with no significant incras in th avrag lngth of hospital stay, postoprativ complications or mortality from all causs. Comparing th rsults of svral studis in th litratur on surgical tratmnt of CAF is difficult du to th larg numbr of variabls analyzd and th diffrnt classifications and tratmnt tchniqus. In a rcnt litratur rviw, Brick & Brail [12] idntifid 72 studis on volution and improvmnt of surgry of arrhythmias. Analyzing studis with immdiat rsults, th prcntag of rturn to sinus rhythm rangd from 73 to 96, whil thos of long-trm rsults (12 months on) rangd from 62 to Both showd consqunt clinical improvmnt of th patints who undrwnt ablation, rgardlss of th nrgy sourc usd. In this rsarch, thr was a carful attmpt to standardiz th sampl, liminating patints with othr disass dvloping CAF, such as congnital and coronary artry disas. Only patints with mitral and tricuspid valvs wr concurrntly tratd bcaus prforming ablation also in th right atria is important to liminat possibl sourcs of atrial fluttr. In this study, it was found that 75 of patints in a followup of 60 months wr in sinus rhythm aftr mitral valv surgry associatd with ablation of th CAF using US as nrgy sourc. This rsult is consistnt with th litratur [12]. Mta-analysis of rsults of 62 studis on surgical ablation in patints with AF undrgoing mitral valv surgry show a significantly highr rat of sinus rhythm in ths patints, with no incras in mortality rat [16]. Th idal nrgy sourc would b fast, rliabl, producing transmural lsions that would not damag th surrounding tissus, and capabl of bing usd with CPB in minimally invasiv ndocardial and picardial application. Th first patints who undrwnt surgry by th author for corrction of CAF with unipolar radiofrquncy cathtr wr not includd in this analysis. Th dvlopmnt of bipolar ablation dvics with irrigatd cathtr contributd to th tchnical improvmnt of th procdur with consqunt shortr surgry and satisfactory oprativ rsults, showing a 96 rat of rvrsion to sinus rhythm [6]. It was followd by th mrgnc of th us of th US scalpl, which smd mor appropriat sinc it facilitatd th procdur, with bttr rsults and lss surgry tim. Bnussi t al. [25] dscribd radiofrquncy application in patints with mitral valv disas. Th procdur, similar to that prformd by th author, also surroundd th right and lft pulmonary vins, with xclusion of th lft atrial appndag. Aftr 36 months of dvlopmnt, 77 of th patints (n=132) wr fr of AF. In our sris, aftr 60 months, sinus rhythm maintnanc prcntag, at 83.8, was highr than that obtaind by Bnussi t al. [25]. For this author [6], th us of US with harmonic scalpl (UltraScision ) bgan aftr xprincing initial difficulty with a propr cathtr to prform surgical radiofrquncy ablation and using th US scalpl in surgry for tratmnt of rfractory vntricular tachycardia in Chagas disas patints with lft vntricular anurysm. Currntly, svral dvics hav bn dvlopd using US for both ndo- and picardial application, facilitating th procdur and making surgry lss invasiv and safr. Th succss rat of CAF rvrsal of this study is compard to that of othr authors [15,20,26], using various nrgy sourcs and tchniqus, such as radiofrquncy, cryoablation, and US, and prforming th atrial ablation lins in th sam way. In this sris, analyzing immdiat and hospital outcoms, maintnanc of sinus rhythm was obsrvd in 94 and 86 of patints, rspctivly. Lins t al. [20], whn comparing patints undrgoing US ablation to thos who did not, found that 80 of th patints tratd with US wr fr of AF whras, in th othr group, that occurrd to only 30 of th patints. Th rsults obsrvd in this study ar similar to thos obtaind in th study prsntd hrin, showing that US ablation can b applid in patints with surgical indication for mitral valv disas rpair. In this rsarch, th right atrium approach (biatrial) was prformd in all patints bcaus it was considrd important to trat and prvnt atrial fluttr, which is rlatd to th vna cava and right atrium. Whn comparing rsults obtaind in patints with AF associatd with mitral valv disas who undrwnt lft or biatrial atrial ablation, Kim t al. [27] found that biatrial ablation was mor ffctiv in rstoring and maintaining sinus rhythm without incrasing th risk of postoprativ complications. In this sris, th oprativ rsults wr also saf, with complications rlatd to th ablation procdur (lsion in th lft atrium) in only on patint and immdiat rsults of rvrsion to sinus rhythm of 94 and 83.8 aftr 60 months. Th rduction of rcurrnc rats to maintain sinus rhythm can b obsrvd ovr tim. Th oprativ tims in this study wr satisfactory compard with othr tchniqus for th surgical tratmnt of CAF. Mdian tim of opration was 142 minuts with anoxic arrst of 45 26

6 Brick AV & Brail DM - Chronic Atrial Fibrillation Ablation with Harmonic Scalpl minuts. Th tim to prform th ablation lins was 12.5 minuts in th right atrium and 14 minuts in th lft atrium. Th complications in th postoprativ priod, such as low cardiac output syndrom and rspiratory failur, wr not rlatd to th non-rvrsal of arrhythmia; howvr, du to complications aftr surgry, thos patints did not maintain sinus rhythm. In this study, mortality rat was 4, unrlatd to arrhythmia. AF has bn nglctd for bing considrd bnign. Howvr, it is associatd with many potntially lthal complications, with high morbidity and mortality rats. Som qustions should b askd for th tratmnt of AF, namly: Is it rvrsibl? What is th arrhythmia tim? Ar thr rlatd symptoms? Is thr a structural disas bas? In th cas of mitral valv disas with surgical indication, what is th ag and clinical condition of th patint? And, finally, what is th bst tratmnt option and th impact on morbidity and mortality? In addition to th ndocardial application, US and othr dvics can b usd in off-pump surgry, through picardial application in patints with isolatd fibrillation. Th aim of th Consnsus of th Intrnational Socity for Minimally Invasiv Cardiothoracic Surgry (ISMICS) [28] was to dtrmin whthr surgical ablation of AF during associatd cardiac procdurs improvs postoprativ clinical outcoms. Th group involvd in th study analyzd th bst availabl vidnc, with systmatic data rviw, including randomizd and nonrandomizd controlld studis, always in dscnding ordr of importanc. A systmatic rviw with mta-analysis idntifid 10 randomizd trials (650 patints) and 23 non-randomizd (3997 patints) trials, mostly publishd in English and prformd in th Unitd Stats. Th authors of th consnsus study dfind th following rcommndation: in patints with prsistnt and prmannt AF, surgical ablation is rcommndd to incras th incidnc of sinus rhythm in th short- and long-trm (Class 1, Lvl A); rduc th risk of strok and thrombombolic vnts (Class 2a, lvl B); incras xrcis tolranc and improv vntricular function (Class 2a, lvl A); and incras survival (Class 2a, lvl B) [28]. Th us of th US tchniqu for tratmnt of CAF with mitral valv disas is asy to prform, with a low complication rat and minimum surgical and CPB tim. It can b rproducd by svral cardiac surgry cntrs, rquiring only th US scalpl, which xists in most hospitals that prform laparoscopic surgry. From th classic maz surgry (Cox Maz), changs in AF surgry hav bn occurring using altrnativ nrgy sourcs. Th rsults of th surgical ablation of th CAF in patints with mitral valv disas dpnd on th nrgy sourc usd, th lsion producd bing transmural and applid in th two atria, and, with currnt tchnology, bing minimally invasiv. CONCLUSION Patints with rhumatic mitral valv disas oftn hav mitral valv failur and mitral stnosis, palpitations rlatd to tachycardia by CAF, and congstiv hart failur. Surgical tratmnt of CAF with US concomitant with mitral valv surgry is fasibl and satisfactory, with maintnanc of sinus rhythm in most patints (83.8) aftr 60 months of follow-up. Surgical tratmnt of chronic atrial fibrillation with ultrasound. Authors rols & rsponsibilitis AVB DMB Study dsign; writing of th manuscript or critical rviw of its contnt; final approval of th manuscript Study dsign; writing of th manuscript or critical rviw of its contnt; final approval of th manuscript REFERENCES 1. Wolf PA, Abbott RD, Kannl WB. Atrial fibrillation as an indpndnt risk factor for strok: Framingham Study. 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