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Thoracic general: Siyamek Neragi-Miandoab, Shoshana Weiner, and David J. Sugarbaker Incidence of atrial fibrillation after extrapleural pneumonectomy versus pleurectomy in patients with malignant pleural mesothelioma Interactive CardioVascular and Thoracic Surgery published on Sep 5, 2008 as doi:10.1510/icvts.2008.181099 [Abstract] [Journal Format PDF]

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eComment. Postoperative atrial fibrillation following extrapleural pneumonectomy - which atrium is the driving force?

Karsten Knobloch   (24 September 2008)

eComment. Postoperative atrial fibrillation following extrapleural pneumonectomy - which atrium is the driving force? 24 September 2008
Karsten Knobloch Plastic, Hand and Reconstructive Surgery, Hannover Medical School, 30625 Hannover, Germany Send ecomment to journal: Re: eComment. Postoperative atrial fibrillation following extrapleural pneumonectomy - which atrium is the driving force? kknobi{at}yahoo.com Karsten Knobloch	Interactive CardioVascular and Thoracic Surgery 2008, doi:10.1510/icvts.2008.181099A © 2008 European Association of Cardio-Thoracic Surgery I appreciate the retrospective analysis of Dr. Neragi-Miandoab and coworkers [1] assessing the risk for atrial fibrillation (AF) following extrapleural pneumonectomy in contrast to pleurectomy. An odds ratio of 7.1 (95% CI 2.9-17.8) was reported for AF following extrapleural pneumonectomy followed by age (OR=2.9, 95% CI 1.2-6.8). The authors suggested that right atrial stress is to be attributed for this arrhythmia. Short atrial effective refractory periods (ERP) and increased dispersion of refractoriness are known predisposing factors for atrial fibrillation or atrial flutter (AFL) in experimental models as well as in patients [2]. The baseline differences in ERP between left and right atrium may result from quantitative or qualitative differences in the expression of different ion channels. Often, the left atrium is driving atrial fibrillation, while the right atrium typically is involved in atrial flutter. It is well known that atrial flutter is a macro re-entry phenomenon almost always located in the right atrium in humans and animals [3]. It would be of great interest to know whether atrial flutter was encountered among the patients undergoing extrapleural pneumonectomy? Interestingly, given the differential distribution of ion channels such as Ikr, Iks, Ikur, IkAch between both atria, antiarrhythmic drugs exert differential effects on the atrium, too [4]. ACE inhibitors, by exerting antifibrotic activity by TGF-beta-inhibition, might reduce the incidence of atrial fibrillation too, which should be considered in this regard as well [5]. References [1] Neragi-Miandoab S, Weiner S, Sugarbaker D. Incidence of atrial fibrillation after extrapleural pneumonectomy versus pleurectomy in patients with malignant pleural mesothelioma. Interact CardioVasc Thorac Surg doi:10.1510/ictvs.2008.181099. [2] Boutjdir M, Le Heuzey JY, Lavergne T, Chauvaud S, Guize L, Carpentier A, Peronneau P. Inhomogeneity of cellular refractoriness in human atrium: factor or arrhythmia? Pacing Clin Electrophysiol 1986;9:1095-1100. [3] Olshansky B, Okumura K, Hess PG, Waldo AL. Demonstration of an area of slow conduction in human atrial flutter. J Am Coll Cardiol 1990;16:1639-1648. [4] Knobloch K, Brendel J, Peukert S, Rosenstein B, Busch AE, Wirth KJ. Electrophysiological and antiarrhythmic effects of the novel I(Kur) channel blockers, S9947 and S20951, on left vs. right pig atrium in vivo in comparison with the I(Kr) blockers dofetilide, azimilide, d,l-sotalol and ibutilide. Naunyn Schmiedebergs Arch Pharmacol 2002;366:482-7. [5] Knobloch K, Gohritz A, Spies M, Vogt PM. ACE inhibitors as antifibrotic agents in atrial fibrillation: potential relevance in cardiac surgery. Interact CardioVasc Thorac Surg 2008;7:475-6.