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Kim KM, Chung S, Kim SY, Kim DJ, Kim JS, Lim C, Park KH. Comparison of Radiofrequency Ablation and Cryoablation for the Recovery of Atrial Contractility and Survival. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 51:266-272. [PMID: 30109205 PMCID: PMC6089620 DOI: 10.5090/kjtcs.2018.51.4.266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 02/18/2018] [Accepted: 02/28/2018] [Indexed: 02/03/2023]
Abstract
Background Limited comparative data are available on the efficacy of cryoablation versus radiofrequency ablation in patients with atrial fibrillation. This study aimed to compare radiofrequency ablation and cryoablation with regard to clinical outcomes and the restoration of sinus rhythm or atrial contractility. Methods A total of 239 patients who underwent surgical ablation between August 2003 and December 2016 at our institution were included. The patients were divided into 2 groups according to the energy device that was used (group A: n=140, radiofrequency ablator; group B: n=99, cryoablator). Echocardiographic data, overall survival, and major cardiovascular and cerebrovascular event (MACCE)-free survival were compared between the 2 groups. Results At 1 year of follow-up, the atrial contractility recovery rate was 32.2% (19 of 59) in group A and 48.8% (21 of 44) in group B. In addition, cryoablation was found to be a predictive factor for the recovery of atrial contractility (cryoablation vs. radiofrequency ablation: odds ratio, 2.540; 95% confidence interval, 1.063–6.071; p=0.036). The left ventricular ejection fraction was significantly higher in group B (53.1%±11.5% vs. 59.1%±6.3%, p=0.001). The median follow-up duration was 36 months. The 5-year overall survival rate was 80.1%±3.6% in group A and 92.1%±2.9% in group B (p=0.400). The 5-year MACCE-free survival rate was 70.3%±4.0% in group A and 70.9%±5.6% in group B (p=0.818). Conclusion Cryoablation was associated with a higher atrial contractility restoration rate and better left ventricular function than radiofrequency ablation. However, no significant relationship was observed between the energy source and overall or MACCE-free survival.
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Affiliation(s)
- Kang Min Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
| | - Suryeun Chung
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
| | - Sang Yoon Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
| | - Dong Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
| | - Jun Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
| | - Cheong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
| | - Kay-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
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Abo-Salem E, Lockwood D, Boersma L, Deneke T, Pison L, Paone RF, Nugent KM. Surgical Treatment of Atrial Fibrillation. J Cardiovasc Electrophysiol 2015; 26:1027-1037. [PMID: 26075595 DOI: 10.1111/jce.12731] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/25/2015] [Accepted: 05/27/2015] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation (AF) is the most common chronic arrhythmia in the adult population. Ablation lines have largely replaced the historical and challenging cut and sew techniques. Surgical ablation of AF is commonly performed in cases with other indications for cardiac surgery and less commonly as a stand-alone therapy. Pulmonary vein isolation is the cornerstone of this procedure. Extended left atrial ablation lines may increase efficacy in cases with longstanding persistent or permanent AF. Additional efficacy by adding right atrial ablation is controversial but is often performed in cases undergoing right atrial or atrial septal surgery. Left atrial volume reduction is recommended in cases with large left atria and AF undergoing another cardiac surgery. Arrhythmia recurrence is not uncommon after surgical ablation of AF and varies among studies due to heterogeneity in patient population, lesion set and endpoints. Freedom from AF recurrence was 65-87% at 12 months and 58-70% at 2 years follow-up. Long-term monitoring is recommended due to an increased prevalence of asymptomatic recurrences. The strongest predictors of AF recurrence are longstanding or persistent AF and a large left atrium. The most common mechanisms of recurrence are pulmonary vein reconnection, nonpulmonary vein triggers, and gaps in the ablation lines. About 20% of atrial tachyarrhythmia recurrences are atrial flutter or atrial tachycardia. There are not enough data in the surgical literature to support withdrawal of anticoagulation after surgical AF ablation. Patients selected for stand-alone surgical ablation usually have low risk profiles and low postoperative mortality rates (0.2%).
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Affiliation(s)
- Elsayed Abo-Salem
- Division of Cardiovascular Health and Diseases, University of Cincinnati, Cincinnati, Ohio
| | - Deborah Lockwood
- Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Lucas Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Thomas Deneke
- Department of Cardiology, BG-Kliniken Bergmannsheil, University of Bochum, Bochum, Germany
| | - Laurent Pison
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ralph F Paone
- Department of Surgery, Texas Tech University HSC, Lubbock, Texas, USA
| | - Kenneth M Nugent
- Division of Pulmonary and Critical Care Medicine, Texas Tech University HSC, Lubbock, Texas, USA
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3
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Surgical Treatment of Concomitant Atrial Fibrillation: Focus onto Atrial Contractility. BIOMED RESEARCH INTERNATIONAL 2015; 2015:274817. [PMID: 26229956 PMCID: PMC4502278 DOI: 10.1155/2015/274817] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 04/12/2015] [Accepted: 05/01/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Maze procedure aims at restoring sinus rhythm (SR) and atrial contractility (AC). This study evaluated multiple aspects of AC recovery and their relationship with SR regain after ablation. METHODS 122 mitral and fibrillating patients underwent radiofrequency Maze. Rhythm check and echocardiographic control of biatrial contractility were performed at 3, 6, 12, and 24 months postoperatively. A multivariate Cox analysis of risk factors for absence of AC recuperation was applied. RESULTS At 2-years follow-up, SR was achieved in 79% of patients. SR-AC coexistence increased from 76% until 98%, while biatrial contraction detection augmented from 84 to 98% at late stage. Shorter preoperative arrhythmia duration was the only common predictor of SR-AC restoring, while pulmonary artery pressure (PAP) negatively influenced AC recuperation. Early AC restoration favored future freedom from arrhythmia recurrence. Minor LA dimensions correlated with improved future A/E value and vice versa. Right atrial (RA) contractility restoring favored better left ventricular (LV) performance and volumes. CONCLUSIONS SR and left AC are two interrelated Maze objectives. Factors associated with arrhythmia "chronic state" (PAP and arrhythmia duration) are negative predictors of procedural success. Our results suggest an association between postoperative LA dimensions and "kick" restoring and an influence of RA contraction onto LV function.
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4
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Park SJ, On YK, Kim JS, Choi JO, Ju ES, Jeong DS, Park PW, Jeon ES. Transforming growth factor β1-mediated atrial fibrotic activity and the recovery of atrial mechanical contraction after surgical maze procedure. Int J Cardiol 2013; 164:232-7. [DOI: 10.1016/j.ijcard.2013.01.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 09/04/2012] [Accepted: 01/19/2013] [Indexed: 11/24/2022]
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5
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Nakamura K, Funabashi N, Uehara M, Ueda M, Murayama T, Takaoka H, Komuro I. Left atrial wall thickness in paroxysmal atrial fibrillation by multislice-CT is initial marker of structural remodeling and predictor of transition from paroxysmal to chronic form. Int J Cardiol 2011; 148:139-47. [DOI: 10.1016/j.ijcard.2009.10.032] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Accepted: 10/18/2009] [Indexed: 10/20/2022]
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6
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Kolek M, Brat R. CARDIAC RHYTHM AND ATRIAL TRANSPORT FUNCTION AFTER SURGICAL ABLATION OF ATRIAL FIBRILLATION USING CRYOENERGY: PREDICTORS AND EFFECTIVENESS OF THE PROCEDURE. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2010; 154:55-68. [DOI: 10.5507/bp.2010.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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7
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Surgery for Lone Atrial Fibrillation: Present State-of-the-Art. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2009; 4:248-255. [PMID: 20473355 DOI: 10.1097/imi.0b013e3181bb370f] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
For two decades, the cut-and-sew Cox-Maze III procedure was the gold standard for the surgical treatment of atrial fibrillation (AF), and proved to be effective at curing lone AF and preventing its most dreaded complication, stroke. However, this procedure was not widely adopted due to its complexity and technical difficulty. Over the last 5-10 years, the introduction of new ablation technology has led to the development of the Cox-Maze IV procedure, as well as, more limited lesion sets, with the ultimate goal of performing a minimally-invasive lesion set on the beating heart, without the need for cardiopulmonary bypass. This review summarizes the current state of the art and future directions in the surgical treatment of lone atrial fibrillation. The hope is that as we learn more about the mechanisms of AF and develop preoperative diagnostic technologies capable of precisely locating the areas responsible for AF, it will become possible to tailor specific lesion sets and ablation modalities to individual patients, making the surgical treatment of lone AF available to a larger population of patients.
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Shen J, Bailey M, Damiano RJ. Surgery for Lone Atrial Fibrillation: Present State-of-the-Art. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2009. [DOI: 10.1177/155698450900400504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jeanne Shen
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO USA
| | - Marci Bailey
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO USA
| | - Ralph J. Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO USA
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9
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Song BG, Cho SJ, Lee SY, Kim JH, Choi SM, Park YH, Choi JO, Lee SC, On YK, Park SW, Kim JS, Park P. Atrial Mechanical Function After Maze Procedure for Atrial Fibrillation Concomitant With Mitral Valve Surgery. Korean Circ J 2008. [DOI: 10.4070/kcj.2008.38.11.606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Bong Gun Song
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Jin Cho
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Yeub Lee
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Hyuk Kim
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Min Choi
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Hwan Park
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Chol Lee
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Keun On
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woo Park
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Soo Kim
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - PyoWon Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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10
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Marui A, Tambara K, Tadamura E, Saji Y, Sasahashi N, Ikeda T, Nishina T, Komeda M. A novel approach to restore atrial function after the maze procedure in patients with an enlarged left atrium. Eur J Cardiothorac Surg 2007; 32:308-12. [PMID: 17574430 DOI: 10.1016/j.ejcts.2007.02.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2006] [Revised: 02/14/2007] [Accepted: 02/15/2007] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE Left atrial (LA) volume reduction surgery concomitant with the maze procedure has been reported to facilitate sinus rhythm recovery even in patients with refractory atrial fibrillation (AF) with an enlarged LA. However, it is unknown whether the procedures can also restore effective atrial function of the enlarged LA with over-stretched myocardium. METHODS The maze procedures in association with mitral valve surgery were performed to 57 AF patients with an enlarged LA (LA diameter >or=60mm). Among them, 32 patients had concomitant LA volume reduction surgery (VR group). Another 25 patients did not have the volume reduction (control group). RESULTS Three months postoperatively LA end-diastolic volume (LAEDV, ml) assessed by magnetic resonance (MR) imaging was larger in the VR group than that in the control group (291+/-117 vs 223+/-81 ml, p<0.05). Postoperatively, sinus rhythm recovery rate was better (84 vs 68%, p<0.05) and LAEDV was drastically smaller (118+/-48 vs 203+/-76 ml, p<0.001) in the VR group than those in the control group. Among the patients with sinus rhythm recovery in both groups, LA contraction ejection fraction (%) improved in the VR group but not in the control group (22.3+/-7.8 vs 10.3+/-4.7%, p<0.001). CONCLUSIONS The LA volume reduction surgery concomitant with the maze procedure restored contraction of the enlarged LA; however, the maze procedure alone did not restore LA contraction in spite of successful sinus rhythm recovery. LA volume reduction surgery may be desirable to the patients with refractory AF with over-stretched LA.
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Affiliation(s)
- Akira Marui
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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11
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Abstract
The surgical maze procedure was the first successful curative procedure for atrial fibrillation. However it is a technically difficult procedure and has not been widely adopted. Subsequently, radiofrequency ablation has been used to replace the surgical incisions of the maze operation in new open-heart and percutaneous catheter based procedures. These procedures have an acceptable level of efficacy and safety, and should be considered for patients with problematic atrial fibrillation. This review summarises the development of these procedures, their current role in the treatment of atrial fibrillation, patient selection and after care.
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Affiliation(s)
- Stuart P Thomas
- The Department of Cardiology, Westmead Hospital, Westmead, and The University of Sydney, NSW, Australia.
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12
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Damiano RJ, Schuessler RB, Voeller RK. Surgical Treatment of Atrial Fibrillation: A Look into the Future. Semin Thorac Cardiovasc Surg 2007; 19:39-45. [PMID: 17403456 DOI: 10.1053/j.semtcvs.2007.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2007] [Indexed: 11/11/2022]
Abstract
The surgical treatment of atrial fibrillation began in 1987, when Dr. James Cox introduced the maze procedure. This operation proved to be extremely effective in curing atrial fibrillation and preventing its most dreaded complication, stroke. However, many surgeons found the operation to be too difficult and invasive. Over the last 5 to 10 years, various groups have tried to develop less invasive approaches using a number of different energy sources to create linear lines of ablation to replace the surgical incisions. This has led to a plethora of new operations for this arrhythmia. There is significant confusion in the literature at the present time as to what is the best lesion pattern and what is the best energy source. It is our feeling that a great deal of this confusion is due to our lack of understanding of the mechanisms of atrial fibrillation and the effect of ablation technology on atrial hemodynamics and electrophysiology. Future progress will require a better understanding of this arrhythmia and continued research into the safety and efficacy of ablation devices.
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Affiliation(s)
- Ralph J Damiano
- Department of Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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13
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Damiano Jr RJ, Schuessler RB, Voeller RK. Future Directions in Atrial Fibrillation Surgery. J Arrhythm 2007. [DOI: 10.4020/jhrs.23.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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14
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Damiano RJ, Schuessler RB, Voeller RK. Future Directions in Atrial Fibrillation Surgery. J Arrhythm 2007. [DOI: 10.1016/s1880-4276(07)80011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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15
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Yamanaka K, Fujita M, Doi K, Tsuneyoshi H, Yamazato A, Ueno K, Zen E, Komeda M. Multislice Computed Tomography Accurately Quantifies Left Atrial Size and Function After the MAZE Procedure. Circulation 2006; 114:I5-9. [PMID: 16820627 DOI: 10.1161/circulationaha.105.000968] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Although the MAZE procedure allows for the recovery of sinus rhythm and left atrial (LA) mechanical function in the great majority of patients with chronic atrial fibrillation (AF), the effects of MAZE on the precise LA geometry and wall motion remain to be elucidated. We hypothesized that LA size and mechanical function in patients with chronic AF and mitral valvular disease are well restored after MAZE.
Methods and Results—
We studied 14 patients (MAZE group: mean±SD age, 63.9±8.6 years; 8 men and 6 women) who underwent MAZE for chronic AF and mitral valve surgery and 10 patients with sinus rhythm (coronary artery bypass graft [CABG] group: age, 70.0±7.9 years; 5 men and 5 women) who underwent CABG at Takeda Hospital between February 2002 and September 2005. MAZE was conducted by the endocardial application of radiofrequency ablation with a temperature-controlled multipolar radiofrequency catheter. LA volume and booster function were quantitatively evaluated by multislice computed tomography at 17.9±10.0 months (MAZE group) and 15.3±13.6 months (CABG group) postoperatively. All patients with MAZE were free of AF and other atrial arrhythmias during the follow-up period. In the CABG group, LA maximal and minimal volumes and ejection fraction were 109±12 mL, 82±11 mL, and 26±10%, respectively. In the MAZE group, LA maximal volume was 139±17 mL (
P
=0.187 versus CABG), and LA minimal volume was 121±16 mL (
P
=0.082 versus CABG), with an ejection fraction of 15±7% (
P
=0.004 versus CABG). In both groups, all parts of the LA wall contracted toward the geometric center of the LA. The extent of wall motion was significantly worse in the MAZE group compared with the CABG group. In both groups, LA booster function was inversely correlated with LA maximal volume.
Conclusions—
MAZE with radiofrequency ablation is safe and effective for the restoration of sinus rhythm in patients with chronic AF and mitral valve disease. However, chronic AF associated with mitral valve disease deteriorates LA mechanical function diffusely throughout the LA wall. Further studies with the use of multislice computed tomography are needed to sequentially evaluate LA function after MAZE in patients with and without mitral valve surgery.
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Affiliation(s)
- Kazuo Yamanaka
- Division of Cardiovascular Surgery, Takeda Hospital, Japan
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16
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Kim HK, Kim YJ, Kim KI, Jo SH, Kim KB, Ahn H, Sohn DW, Oh BH, Lee MM, Park YB, Choi YS. Impact of the maze operation combined with left-sided valve surgery on the change in tricuspid regurgitation over time. Circulation 2006; 112:I14-9. [PMID: 16159806 DOI: 10.1161/circulationaha.104.524496] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) has been reported to be a predisposing factor for the progression of TR in patients with previous mitral or combined mitral/aortic valve surgery. We hypothesized that the maze operation (MAZE) can prevent the progression of tricuspid regurgitation (TR) in these patients. METHODS AND RESULTS We analyzed 170 patients (age, 45.5+/-10.9 years) who had undergone mitral or combined mitral/aortic valve surgery. On the basis of preoperative rhythm, patients were divided into 3 groups; GrI was composed of 44 patients with sinus rhythm, GrII of 48 who had undergone MAZE, and GrIII of 78 with AF who had not undergone MAZE. Echocardiographic examinations were performed before, immediately after, and 92.2+/-17.2 (range, 50 to 131) months after surgery. Preoperative and immediate postoperative clinical and echocardiographic parameters were similar among the groups. Insignificant TR at the immediate postoperative examination worsened with time in 7.3% of GrI (3 of 41), 12.8% of GrII (6 of 47), and 38.8% of GrIII (26 of 67) patients at the final examination (P=0.63 for GrI versus GrII, P=0.001 for GrI versus GrIII, P=0.005 for GrII versus GrIII). The incidence of significant TR at the final echocardiographic examination was higher in GrIII (39.7%) compared with GrI (9.1%) and GrII (14.6%) (P=0.001 for GrI versus GrIII, P=0.005 for GrII versus GrIII), whereas GrI and GrII did not show any difference (P=0.63). By multivariate analysis, the only factor identified to prevent TR progression was the group factor (GrI and GrII versus GrIII, P=0.002 and P=0.005, respectively). In a subgroup analysis of GrII according to the presence or absence of atrial mechanical activity, the absence of atrial mechanical activity was identified as an independent parameter for the progression of TR (P=0.001). CONCLUSIONS AF predisposes patients undergoing mitral valve surgery to the progression of TR, which can be prevented by MAZE. This additional benefit of MAZE is largely dependent on the restoration and maintenance of atrial mechanical function.
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Affiliation(s)
- Hyung-Kwan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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17
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Robotic atrial septal defect repair and endoscopic treatment of atrial fibrillation. Semin Thorac Cardiovasc Surg 2003. [DOI: 10.1016/s1043-0679(03)70021-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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Jessurun ER, van Hemel NM, Kelder JC, Defauw JAMT, Brutel de la Rivière A, Ernst JMPG, Jaarsma W. The effect of maze operations on atrial volume. Ann Thorac Surg 2003; 75:51-6. [PMID: 12537192 DOI: 10.1016/s0003-4975(02)04117-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Unmodified maze III operations show long-term eradication of atrial fibrillation (AF) in more than 85% of patients with or without structural heart disease. The effect of this procedure on atrial volumes is not known. METHODS Two patient populations were studied: (1) patients undergoing unmodified maze III operations combined with surgical structural heart disease, mostly mitral valve operations (group A; n = 32); and (2) patients with only AF selected for unmodified maze III operations (group B; n = 32). In groups A and B, transthoracic Doppler echocardiographic studies were prospectively made preoperatively, and at 3 and 12 months postoperatively. Left and right atrial dimensions and volumes and atrial contractions were determined and compared with base line patient characteristics and 12 months arrhythmia outcomes. RESULTS One year postoperatively all patients were alive. In groups A and B, 92% were free of AF and other atrial arrhythmias. A significant reduction of left atrial volume at 1 year postoperatively was apparent in group A, whereas the left atrial volume did not change significantly in group B. The reduction observed in group A was not related to postoperative age, type or duration of AF, or late atrial arrhythmia outcome. In both groups the right atrial volume remained unchanged at 12 months postoperatively. CONCLUSIONS The unmodified maze III operation does not affect atrial volume in patients without structural heart disease. In patients with structural heart disease, the mitral valve operation contributes to the reduction of left atrial volume and dimension by improving the hemodynamic condition.
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Affiliation(s)
- Emile R Jessurun
- Department of Cardiology Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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19
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Benussi S, Nascimbene S, Agricola E, Calori G, Calvi S, Caldarola A, Oppizzi M, Casati V, Pappone C, Alfieri O. Surgical ablation of atrial fibrillation using the epicardial radiofrequency approach: mid-term results and risk analysis. Ann Thorac Surg 2002; 74:1050-6; discussion 1057. [PMID: 12400744 DOI: 10.1016/s0003-4975(02)03850-x] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The minor technical and time requirements with respect to the maze operation combined with a comparable efficacy has led to an increasing popularity of left atrial approaches to treat atrial fibrillation. We report our experience with a left atrial procedure based on extensive use of epicardial radiofrequency ablation in an effort to minimize cardiac arrest time. METHODS A total of 132 consecutive patients with atrial fibrillation (121 chronic, 11 paroxysmal) undergoing open heart surgery had combined intraoperative ablation. An original set of left atrial lesions was performed using a radiofrequency linear catheter. Most of the ablations were performed epicardially before aortic cross-damping. Patients with contraindications to the epicardial approach had the whole lesion set performed endocardially. RESULTS The mean cardiac arrest time spent for open heart ablations was significantly shorter (5.2 +/- 0.9 minutes with modem catheters) when the epicardial approach was used (107 of 132 patients, 81%). Hospital mortality was 0.8%. Freedom from atrial fibrillation was 77% 3 years after the operation. Of all the variables analyzed, only age at surgery and early postoperative arrhythmias increased the risk of recurrent atrial fibrillation. Overall 3-year survival was 94%. The 3-year actuarial freedom from stroke was 98%. No patient required implantation of a permanent pacemaker. Atrial contractility was recovered in all patients with stable sinus rhythm. CONCLUSIONS Left atrial radiofrequency ablation allows recovery of sinus rhythm and atrial function in the great majority of patients with atrial fibrillation who undergo open heart surgery. The epicardial radiofrequency approach is a safe and effective means to cure atrial fibrillation with negligible technical and time requirements.
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Affiliation(s)
- Stefano Benussi
- Division of Cardiac Surgery, S Raffaele University Hospital, Milan, Italy
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20
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Muraki S, Tsukamoto M, Kobayashi T, Fukada J, Morishita K, Abe T. Preserved atrial response to dobutamine stress after the modified maze procedure for chronic atrial fibrillation: echocardiographic assessment of atrial function. J Card Surg 2002; 17:148-54. [PMID: 12220067 DOI: 10.1111/j.1540-8191.2002.tb01190.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The maze operation is effective in varying degrees for the restoration of atrial function at rest. However, the atrial mechanical function under stressed conditions has not been investigated. METHODS Thirteen patients who regained normal sinus rhythm after the modified maze procedure for atrial fibrillation (Af) associated with valvular disease were enrolled in this study. A two-staged, low-dose protocol (at doses of 5 and 10 microg/kg/min) of dobutamine stress echocardiography (DSE) was performed to assess the probability of the appearance of atrial wave in 20 consecutive beats (Paw), the velocity of atrial filling wave (Av), and the early filling wave (Ev) with their ratio (A/E), as well as the left atrial area fraction (LAAF) which represents an ejection fraction of the left atrium. RESULTS Under resting conditions, Paw was 72% and 50% at tricuspid (T) and mitral (M) position, respectively. During dobutamine stress (5 microg/kg/min), Paw tended to increase both at T and M position (86% and 60%, respectively). Av was significantly accelerated by dobutamine stress (10 microg/kg/min) in both T (from 0.36 to 0.54 m/s) and M (from 0.46 to 0.69 m/s) valvular flow, which was accompanied by a significant increase in A/E (from 0.69 and 0.31 to 0.87 and 0.40, respectively). Although heart rate was significantly increased during dobutamine stress, LAAF remained at the same level (0.18, 0.22 and 0.19 at rest, 5 and 10 microg/kg/min) and atrial output was expected to be enhanced by dobutamine stress. CONCLUSION Restoration of atrial mechanical function after the maze operation is accompanied by preserved response to dobutamine stress.
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Affiliation(s)
- Satoshi Muraki
- Second Department of Surgery, Sapporo Medical University School of Medicine, Japan.
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21
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Bauer EP, Szalay ZA, Brandt RR, Pitschner HF, Bachmann G, Brunner-La Rocca HP, Klövekorn WP. Predictors for atrial transport function after mini-maze operation. Ann Thorac Surg 2001; 72:1251-4; discussion 1255. [PMID: 11603445 DOI: 10.1016/s0003-4975(01)02977-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Restoration of atrial transport function (ATF) is a major goal of the maze procedure. This prospective study was undertaken to evaluate predictors of left atrial transport function in patients undergoing a mini-variant of the maze III procedure 3 and 12 months postoperatively. METHODS Mini-maze operation was performed in 72 patients with a mean age of 64 +/- 8.7 years during a 5-year period. Seventy of 72 (97%) had combined procedures. Clinical and electrophysiologic examination was carried out before surgery, and 3 and 12 months postoperatively. RESULTS Early mortality was 1.4% (1 of 72 patients) and late death occurred in 5.6% (4 of 71 patients). After 3 months, 54 of 68 (80%) patients showed sinus rhythm, and 48 of 60 (80%) after 12 months. ATF was restored in 87% (echocardiography) and 82% (magnetic resonance imaging) after 3 months, and in 86% (echocardiography) and 78% (magnetic resonance imaging) after 12 months. Independent predictors for ATF restoration after 12 months were better preoperative left ventricular function (p = 0.02), and smaller preoperative left atrial diameter (p = 0.005). Correlation between echocardiography and magnetic resonance imaging was 80% after 12 months. CONCLUSIONS Restoration of ATF after mini-maze procedure is achieved in over 80%. Independent predictors for ATF restoration are smaller preoperative left atrial diameter and better preoperative left ventricular ejection fraction.
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Affiliation(s)
- E P Bauer
- Department of Cardiothoracic Surgery, Kerckhoff-Clinic Foundation, Bad Nauheim, Germany.
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22
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Yuda S, Nakatani S, Kosakai Y, Yamagishi M, Miyatake K. Long-term follow-up of atrial contraction after the maze procedure in patients with mitral valve disease. J Am Coll Cardiol 2001; 37:1622-7. [PMID: 11345375 DOI: 10.1016/s0735-1097(01)01193-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to determine the effectiveness of the maze procedure for maintaining sinus rhythm and atrial contraction for a long period in patients with mitral valve disease. BACKGROUND Although the maze procedure for atrial fibrillation (AF) has been effective in restoring sinus rhythm in patients with mitral valve disease, the long-term results of this procedure have not been determined. METHODS We echocardiographically studied 94 consecutive patients with mitral valve disease before, as well as early (3.1 +/- 3.3 months) and late (2.2 +/- 0.9 years) after, the maze procedure. Peak velocity and the time-velocity integral of the left ventricular (LV) diastolic filling wave during atrial contraction (A wave), as well as the atrial filling fraction (calculated as the ratio of the time-velocity integral of the A wave to total diastolic filling), were obtained from transmitral flow recordings. Peak A wave velocity > or =10 cm/s was considered to indicate echocardiographic evidence of effective atrial contraction. RESULTS Regular rhythm with P waves was restored in 70 patients (74%) in the early stage and in 59 patients (63%, p = 0.09) in the late stage after the maze procedure. Forty-seven patients (50%) in the early stage and 36 patients (38%, p = 0.14) in the late stage showed effective atrial contraction by Doppler echocardiography. Left atrial (LA) and LV end-diastolic diameters significantly decreased after the procedure (from 59 +/- 13 to 48 +/- 7 mm, p < 0.01; and from 54 +/- 9 to 47 +/- 5 mm, p < 0.01, respectively) and did not show significant changes during the follow-up period. Once atrial contraction was resumed, its degree did not change between the early and late stages after the maze procedure (17 +/- 6% vs. 17 +/- 6% for atrial filling fraction). CONCLUSIONS Sinus rhythm and atrial contraction recovered early after the maze procedure in most patients and were maintained for more than two years. Once active atrial contraction was resumed, the degree of contraction did not change thereafter. These results demonstrate that the maze procedure is effective for a long period in patients with mitral valve disease.
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Affiliation(s)
- S Yuda
- Division of Cardiology, National Cardiovascular Center, Osaka, Japan
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23
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Abstract
BACKGROUND The extended operative time needed for surgery with complicated atrial incisions may preclude application of the Cox-Maze III procedure (CM-III) as a concomitant operation. And after the CM-III, left atrial (LA) contraction has been reported to recover in reduced magnitude compared with right atrial (RA) contraction. METHODS To decrease operative time, we have modified the CM-III (modification I) by: obliterating the LA appendage instead of excising it; cryoablating the bridge between the LA appendage and margin of the pulmonary vein encircling incision; extending the lateral incision of RA onto the RA appendage without excising it, and extending the incision more inferiorly toward the inferior vena cava; and omitting the T-incision of RA. We compared the clinical results of the conventional CM-III (group 1, n = 18) with those of the modified CM-III group (group 2, n = 23) performed in patients with rheumatic mitral valve (MV) disease. To enlarge the contractile area of the LA, we modified the CM-III to encircle the right and left pulmonary veins separately (modification II), and compared the LA contractilities of the conventional CM-III (group A, n = 15) with those of the second modification (group B, n = 9). RESULTS Modification I: Mean aortic cross-clamp (ACC) times (135 +/- 29 versus 104 +/- 18 minutes, p < 0.005) and cardiopulmonary bypass (CPB) times (240 +/- 33 versus 185 +/- 42 minutes, p < 0.001) were significantly decreased in group 2 compared with those in group 1. In group 1, sinus rhythm was restored in 16 patients (88.9%). RA contractility was demonstrated in 100% of patients with sinus rhythm (16 of 16) and LA contractility in 75% (12 of 16) in the latest follow-up echocardiography. In group 2, sinus rhythm was restored in 21 patients (91.3%). RA contractility was demonstrated in 100% of patients with sinus rhythm (21 of 22) and LA contractility in 76.2% (16 of 21). Modification II: Mean ACC times were increased in group B compared with group A (133 +/- 32 versus 172 +/- 39 minutes, p = 0.02). The A velocities at LA contraction and the ratio of atrial contraction to peak early diastolic filling velocity (A/E ratio) of the trans-mitral flow were 0.14 +/- 0.20 m/sec and 0.23 +/- 0.11 in group A, and 0.58 +/- 0.33 m/sec and 0.47 +/- 0.19 in group B, respectively, both showing a significant increase in group B compared with group A (p < 0.05). CONCLUSIONS Our first modification of the CM-III showed comparable sinus conversion rates and incidence of atrial contractility restoration with significantly shorter ACC and CPB times than the conventional CM-III. The second modification of the CM-III significantly increased the LA contractility when compared with the conventional CM-III, although the second modification required a longer ACC time.
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Affiliation(s)
- K B Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Seoul National University, Korea.
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Lönnerholm S, Blomström P, Nilsson L, Oxelbark S, Jideus L, Blomström-Lundqvist C. Effects of the maze operation on health-related quality of life in patients with atrial fibrillation. Circulation 2000; 101:2607-11. [PMID: 10840012 DOI: 10.1161/01.cir.101.22.2607] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Maze surgery for atrial fibrillation (AF) is a curative therapy, but its effect on health-related quality of life has not been studied. METHODS AND RESULTS Maze operations were performed in 48 patients with drug-refractory AF. The majority of patients (80%) had lone AF, and the primary indication for surgery in all patients was AF. The SF-36 Health Survey was used to assess quality of life before operation and at 6 months and 1 year after surgery. Twenty-five patients were available for the 1-year follow-up and completed all questionnaires. Before maze surgery, the SF-36 scores were significantly lower than in the general Swedish population, reflecting significant impairment in well-being, physical and social functioning, and mental health. After maze surgery, the quality of life was significantly improved at 6 months and at 1 year on all scales except for bodily pain, which, however, was not significantly decreased before surgery. At both 6 months and 1 year after maze surgery, quality of life, measured by the SF-36, reached the levels of the general Swedish population. CONCLUSIONS The maze operation can significantly improve the health-related quality of life in selected groups of patients with both paroxysmal and chronic AF refractory to antiarrhythmic therapy.
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Affiliation(s)
- S Lönnerholm
- Department of Cardiology, Uppsala University Hospital, Uppsala, Sweden
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Kim KB, Cho KR, Sohn DW, Ahn H, Rho JR. The Cox-Maze III procedure for atrial fibrillation associated with rheumatic mitral valve disease. Ann Thorac Surg 1999; 68:799-803; discussion 803-4. [PMID: 10509965 DOI: 10.1016/s0003-4975(99)00777-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The surgical results of the Cox-Maze III procedure (CM-III) for atrial fibrillation (AF) associated with rheumatic mitral valve (MV) disease are not as good as the results from surgery for AF alone. METHODS To assess the efficacy and safety of the CM-III in AF associated with rheumatic MV disease, we retrospectively analyzed 75 patients who underwent the CM-III combined with a rheumatic MV procedure between April 1994 and December 1997. Fourteen cases were reoperations because of prosthetic valve failure. RESULTS Mean aortic cross-clamp (ACC) times and cardiopulmonary bypass (CPB) times were 151+/-43 and 251+/-73 min, respectively. Concomitant procedures were mitral valve replacement (MVR) in 25 patients, MVR and aortic valve replacement (AVR) in 14 patients, MV repair in 10 patients, MVR and tricuspid annuloplasty (TAP) in 6 patients, MVR and AV repair in 3 patients, MVR and coronary artery bypass grafting (CABG) in 2 patients, MVR and AVR and CABG in 1 patient, redo-MVR in 8 patients, redo-MVR and TAP in 4 patients, and redo-MVR and redo-AVR in 2 patients. There were two in-hospital mortalities (2 of 75, 2.7%). Seventy-three survivors were followed for a mean duration of 30+/-13 months (12-56 months). Normal sinus rhythm was restored in 90.4% (66 of 73). Three patients remained in AF and 2 patients were in junctional rhythm. Permanent pacemakers were implanted in 2 patients due to sick sinus syndrome. Right atrial (RA) contractility was demonstrable in 100% (66 of 66) and left atrial (LA) contractility in 62.1% (41 of 66) of the patients in the latest follow-up echocardiography. RA and LA contractilities were restored a mean 69+/-93 and 126+/-136 days after the operation, respectively. LA contractility was restored significantly later at a lower rate than RA contractility in rheumatic MV disease. There were no differences in ACC time, CPB time, incidence of postoperative bleeding complications, and sinus conversion rates between non-redo and redo cases in spite of the significantly longer duration of preoperative AF in redo cases (p<0.05). CONCLUSIONS The CM-III for AF associated with rheumatic MV disease demonstrated a high sinus conversion rate with acceptable operative risk even in cases of reoperation.
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Affiliation(s)
- K B Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Seoul National University, Korea
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Cox JL. Atrial transport function after the maze procedure for atrial fibrillation: a 10-year clinical experience. Am Heart J 1998; 136:934-6. [PMID: 9842000 DOI: 10.1016/s0002-8703(98)70143-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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