Tesis

Keberhasilan Bedah Reduksi Atrium Kiri dan Bedah Ablasi (Prosedur Maze) dalam Restorasi Kontraktilitas Atrium Kiri Pasca Bedah Katup Mitral Rematik = The Success rate of Left Atrial Reduction Surgery and Surgical Ablation (Maze Procedure) on Restoration of Left Atrial Contractility after Rheumatic Mitral Valve Surgery

Latar Belakang : Sebagai standard prosedur tatalaksana Fibrilasi Atrium (FA) secara bedah, bedah ablasi diketahui efektif mengembalikan irama sinus, namun kurang efektif dalam restorasi kontraktilitas pada pasien mitral rematik. Bedah reduksi cukup efektif dalam mengembalikan irama sinus, namun efektifitasnya dalam restorasi kontraktilitas atrium belum diketahui. Jika terbukti efektif, prosedur tersebut dapat menjadi alternatif yang lebih murah dan sederhana namun memberikan manfaat yang besar dari konversi irama dan restorasi kontraktilitas atrium pada pasien mitral rematik. Tujuan : Mengetahui angka keberhasilan bedah reduksi atrium kiri dalam restorasi kontraktilitas atrium pada penyakit katup mitral rematik dan membandingkan angka keberhasilan tersebut dengan prosedur bedah ablasi. Metode : Data klinis, elektrokardiografi (EKG) dan ekokardiografi pasien penyakit katup mitral rematik yang telah dilakukan bedah katup mitral dan bedah ablasi atau bedah reduksi periode Juli 2014-November 2017 diambil dan dilakukan analisis secara retrospektif. Data diambil dalam waktu 1 bulan dan ≥ 6 bulan pasca bedah. Kontraktilitas atrium efektif didefinisikan sebagai ditemukannya gelombang A dengan kecepatan puncak ≥ 10 cm/s pada fase diastolik akhir dari pemeriksaan Pulse Wave (PW) doppler pada mitral inflow atau fraksi pengisian atrium ≥ 20%. Hasil : Didapatkan 90 sampel yang dibagi menjadi 45 subjek bedah ablasi dan 45 subjek bedah reduksi. Restorasi kontraktilitas atrium dini pada kelompok bedah reduksi sebesar 8,9%, sedangkan bedah ablasi sebesar 26,7% (p=0,027). Indeks volume atrium kiri (LAVi) pasca bedah berhubungan secara independen dengan restorasi kontraktilitas atrium dini pada kedua kelompok pada analisis multivariat [PR=0,97, IK 95% 0,95-0,99 (p=0,007)]. Didapatkan nilai potong LAVi pasca bedah ≤ 76 ml/m2 yang berhubungan bermakna dengan restorasi kontraktilitas atrium dini (AUC 0,76, sensitivitas 81%, spesifisitas 70%). Kesimpulan : Keberhasilan bedah reduksi rendah dalam restorasi kontraktilitas atrium kiri pada pengamatan dini pasca bedah katup mitral rematik dan secara bermakna lebih rendah dibandingkan keberhasilan bedah ablasi.
Kata kunci : restorasi kontraktilitas atrium, bedah ablasi, prosedur Maze, bedah reduksi, mitral rematik


Background : As a benchmark for surgical management of Atrial Fibrillation (AF), the surgical ablation with Maze procedure have less satisfactory result in restoring atrial contractility after conversion to sinus rhythm in rheumatic mitral valve disease. The surgical reduction of left atrium has an acceptable success rate in conversion of sinus rhythm, yet, the efficacy of this procedure to restore atrial contractility is still unknown. If the surgical reduction of left atrium had been proven to be effective in restoring atrial contractility, it will become the more economic and simpler strategy to manage AF and reduce the risk of hemodynamic compromise and thromboembolism in these population. Objectives: To analyze the success rate of left atrial reduction surgery on restoration of left atrial contractility in rheumatic mitral valve disease and to compare the success rate with surgical ablation. Methods: Patient clinical profile, electrocardiography (ECG), and echocardiography data were collected and analyzed retrospectively from July 2014 to November 2017. Data were collected within 1 month, and after 6 months postsurgery. The effective atrial contraction was defined as the presence of A wave during late diastole with peak velocity ≥ 10 cm/s in Pulse Wave (PW) doppler examination of mitral inflow or the atrial filling fraction ≥ 20%. Results: At early follow-up, there were total 90 samples that eligible for analysis. The samples were classified into 2 groups, consist of 45 samples in both arms. The success rate of surgical reduction of left atrium in restoring atrial contractility was 8,9% while in surgical ablation group was 26,7% (p=0,027). The post operative left atrial volume index (LAVi) was the only variable that independently associated with higher rate of success in restoration of early atrial contractility in both group after adjustment for various potential confounding variables in multivariate analysis [PR=0,97, 95% CI 0,95-0,99 (p=0,007)]. The cut off value of post operative LAVi that associated with restoration of contractility was ≤ 76 ml/m2 (AUC 0,76, sensitivity 81%, specificity 70%). Conclusions: The surgical reduction of left atrium had low success rate in restoring atrial contractility after rheumatic mitral valave surgery in early observation. This was significantly lower than surgical ablation.
Keywords: atrial contractility, surgical ablation, Maze procedure, surgical reduction, rheumatic mitral valve disease.