Restitution of Sinus Rhythm plus Stentless Mitral Valve Replacement at Three Years Sven Lehmann 1 , Thomas Walther 1 , Volkmar Falk 1 , Sebastian Metz 1 , Nico Doll 1 , Gerd Hindricks 2 , Friedrich W. Mohr 1 Departments of 1 Cardiac Surgery and 2 Electrophysiology, Heartcenter, University of Leipzig, Leipzig, Germany Atrial fibrillation (AF) is the most commonly reported sustained arrhythmia, and is associated with substantial morbidity and mortality (1,2). A number of interven- tional concepts that are based on eliminating the initiat- ing trigger or modifying the maintaining substrate have evolved within the past years. Catheter-based interven- tions for controlling the ventricular rate, including atri- oventricular junction ablation or atrioventricular nodal modification, have the disadvantage of persistence of AF (3). Surgical techniques such as the corridor opera- tion (4) or left atrial isolation (5) effectively restore sinus rhythm, but not biatrial transport function. The maze procedure (6,7) and the so-called radial approach (8,9), although highly effective, are technically demanding and time-consuming, and therefore have not found widespread application. Significant mitral valve disease is often associated with chronic AF and left atrial enlargement due to pres- sure or volume overload. Valve replacement must be performed whenever mitral valve reconstruction is not feasible, as in some cases with degenerative disease. In these patients, valve selection remains controversial as no ideal prosthesis is yet available. Whereas stented conventional bioprostheses are at a high risk for struc- tural failure, mechanical valves are associated with the need for lifelong anticoagulation, thromboembolic events, and hemorrhage (10). Recently, a stentless mitral valve (SMV) (Quattro™; St. Jude Medical Inc., St. Paul, MN, USA) has been implant- ed, and has shown good mid-term clinical results (11,12). This pericardial valve is flexible, and is support- ed by chordae that are attached to the native papillary muscles. By virtue of its design, the Quattro valve pre- serves annuloventricular continuity, and no long-term anticoagulation is required when sinus rhythm is pres- Presented as a poster at the Second Biennial Meeting of the Society for Heart Valve Disease, 28th June-1st July 2003, Palais des Congrès, Paris, France Address for correspondence: PD Dr. Thomas Walther, University Leipzig, Heartcenter, Department of Cardiac Surgery, Strümpellstr. 39, 04289 Leipzig, Germany e-mail: walt@medizin.uni-leipzig.de © Copyright by ICR Publishers 2004 Background and aim of the study: The study aim was to examine results after stentless mitral valve (SMV) replacement (Quattro™) and restitution of physio- logical cardiac rhythm by intraoperative left atrial ablation therapy. Methods: Twenty patients (13 females; mean age 69.7 ± 5.9 years) with severe degenerative mitral valve disease (six with valve stenosis, six with valve incompetence, eight with combined lesion) were prospectively evaluated since 1998. The mean NYHA functional class was 3.2 ± 0.4, and cardiac index 1.8 ± 0.5 l/min/m 2 . Ablation therapy was performed by inducing left atrial linear lesion lines to avoid re- entrant circuits. Results: Surgery was performed using conventional sternotomy (n = 10) or lateral minithoracotomy (n = 10). Sinus rhythm was successfully restituted in 17 patients either postoperatively or in the long term (success rate 85%). However, three patients required DDD-pacemaker implantation, and another three had to be discharged with persistent atrial fibrilla- tion. Intermittent medical therapy (sotalol or amio- darone) was required in nine patients postoperatively, in four patients at six months, and in two patients at one-year follow up. One patient was reoperated on for paravalvular leak after one year, but subsequently died due to sepsis. In the other patients, echocardiographic control proved good SMV function with atrial contraction. Conclusion: Restitution of physiological cardiac function is possible by combined stentless MV implantation and left atrial ablation therapy. A per- sistent benefit, without need for additional re-inter- vention, was shown at mid-term follow up. The Journal of Heart Valve Disease 2004;13:410-413