Invited Commentary

Atrial Arrhythmias after Pulmonary Resection: The Important Role of Pulmonary Vein Resection

The authors have looked very carefully for different risk factors which may be responsible for the occurrence of postoperative atrial fibrillation (AF) after pulmonary resection. They could show that extent and location of pulmonary vein resection was the most significant variable. One possible interpretation is the digitated ingrowth of atrial myocardium into the proximal part of the veins, but a word of caution is warranted, because some more information would be appreciated for a final interpretation. The inhomogeneous borderline between two different tissues is well known to be of special electrical vulnerability. Whether this critical interface was partly or totally resected or not is difficult to evaluate retrospectively, and it would be desirable to plan a prospective follow up study, in which this question should be addressed with serial histologies of the border of resection. Even more, an influence of the ganglionated plexi must be discussed and further evaluated. Interestingly enough their distribution does correlate to a certain degree with the resection patterns found responsible for an increased atrial fibrillation rate. One may suggest that the operative trauma in close proximity to some of the plexus can cause an upregulation of the intrinsic activity of those plexus (ICANS) and subsequently lead to AF. Determining this would necessitate a detailed electrophysiological investigation or alternatively a pharmacological intervention against the extrinsic pathway of the cardiac autonomic nervous system (ECANS). With this histological respectively electrophysiological information, one would get some more insight into this multifactorial pathophysiology, which could be of great interest not only for thoracic but also for cardiac surgeons.