The Maze-III procedure combined with valve surgery

Developing a Risk Prediction Model for Early Atrial Fibrillation Recurrence After Maze Procedure

BACKGROUND

The efficiency of maze is a safe procedure in AF patients who underwent concomitant mitral valve surgery was more than 60%. The aim of this study was to define predictors of early AF recurrence after concomitant maze procedure with valvular surgery.

METHODS

In this retrospective study, 234 patients with AF underwent concomitant valvular replacement and maze procedure. Patients were classified into 2 groups of sinus and atrial fibrillation (AF). Baseline characteristics of patients were then compared between 2 groups.

RESULTS

Totally, 234 patients were enrolled, 148 of which maintained sinus rhythm during hospitalization. Left atrial diameter and type of valvular surgery were similar in both groups. Age, number of replaced valves, concomitant coronary artery bypass grafting, and history of preoperative persistent AF and beta-blocker therapy were independent predictors of in-hospital AF recurrence. We used these variables to build a model to anticipate early AF recurrence.

CONCLUSIONS

Being older, multivalvular surgery, and persistent preoperative AF were the predictors of higher risk of early recurrent AF, whereas concomitant coronary artery bypass grafting and using beta-blocker had a protective effect. This model based on preoperative and operative characteristics can help us to better evaluate if the patient benefits from maze procedure coincide with valvular surgery.

Dynamic changes of mitral annulus in patients with degenerative mitral regurgitation and chronic atrial fibrillation undergoing mitral valve reconstruction

OBJECTIVE

This study was designed to assess structural and dynamic changes in the mitral annulus in patients before mitral valve reconstruction for degenerative mitral regurgitation with or without chronic atrial fibrillation.

METHODS

One hundred and fifty one consecutive patients undergoing mitral valve reconstruction for mitral regurgitation due to myxomatous disease between July 2013 and May 2016 were included. Of these, 117 had a sinus rhythm (SR group) and 34 had chronic AF (AF group). Patients who underwent aortic surgery and were found to have no underlying cardiac valve disease nor coronary artery disease were included as the control group (n = 20). Real-time three-dimensional trans-esophageal echocardiography (3D-TEE) was used to assess mitral annulus shape, size, and movements.

RESULTS

Annular areas in the control group were the smallest of the three groups and changed considerably through the cardiac cycle. Mean anteroposterior and intercommissural diameter measurements in the SR group were significantly larger but oscillated less than in the control group. Those diameters were the largest in the AF group and oscillated very little. Dilatation of the annulus in the AF and SR groups was accompanied by flattening and marked loss of oscillation in the height-to-intercommissural-width ratio which should peak in early systole.

CONCLUSIONS

In patients with degenerative mitral regurgitation undergoing mitral valve surgery, preoperative chronic atrial fibrillation is associated with more progressed annular remodeling, characterized by marked enlargement of annular area, circumference, and anteroposterior diameter.

Cox-maze III procedure for atrial fibrillation during valve surgery: a single institution experience

Objectives

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in patients with heart valve disease. Our aim was to summarize our experience and evaluate the efficacy and safety of the Cox maze III procedure combined with valve surgery in patients with AF.

Methods

A retrospective, observational analysis was performed for all consecutive patients underwent maze III procedure combined with valve surgery between October 2015 and June 2019. In this trial, we used a monopolar radiofrequency (RF) ablation in addition to cut and sew technique to treat AF.

Results

66 patients (37 female, 56.1%) with persistent or long-lasting persistent AF associated with valve disease were identified. The mean age was 54.2 ± 8.4 years (range, 30 to 73 years). Overall hospital mortality was 3.0%. The duration of cardiopulmonary bypass and aortic cross clamping was 175.4 ± 32.9 and 115.6 ± 22.8 min respectively. The first 24 h drainage was 488.6 ± 293.3 ml. The postoperative hospital stay was 14.8 ± 8.3 days. The postoperative incidence of permanent pacemaker implantation, reoperation for bleeding, renal failure required hemodialysis, and stroke was 4.5, 1.5, 4.5% and 0 respectively. The frequency of sinus rhythm was 91.7, 93.1, 94.7, 93.3 and 89.5% at 1, 3, 6, 12, and 24 months respectively.

Conclusions

The Cox-Maze III procedure is safe in the surgical treatment of AF associated with valve disease, and efficacious for sinus rhythm maintenance, with low morbidity and mortality.

MARSHALL bundles elimination, Pulmonary veins isolation and Lines completion for ANatomical ablation of persistent atrial fibrillation: MARSHALL-PLAN case series

INTRODUCTION

Beyond pulmonary veins (PV) isolation, the ablation strategy for persistent atrial fibrillation (AF) remains controversial. Substrate ablation may provide a high termination rate but at the cost of impaired atrial physiology and recurrent complex re-entries. To overcome these pitfalls, we investigated a new lesion set based on important anatomical considerations.

METHODS AND RESULTS

The case series included 10 consecutive patients with persistent AF. Three atrial structures were successively targeted: (1) coronary sinus and vein of Marshall (CS-VOM) musculature elimination; (2) PVs isolation; and (3) anatomical isthmuses block. The lesion set completion was the procedural endpoint. Step 1: VOM ethanol infusion was feasible in all cases (mean time of 33.4 ± 9.4 minutes), mean radiofrequency (RF) time for CS-VOM bundles was 14.4 ± 6.9 minutes. Step 2: mean RF time for PV isolation was 27.7 ± 9.3 minutes. Step 3: mean RF time for mitral, roof, and cavotricuspid lines was 5.7 ± 2.3, 8.1 ± 4.3, and 5.9 ± 1.9 minutes, respectively. The lesion set was achieved in all patients. Mean procedure time was 270 ± 29.9 minutes. AF termination and noninducibility were, respectively, obtained in 50% and 90% of the patients. After a 6-month follow-up, all patients were free from arrhythmia recurrence.

CONCLUSION

The present case series reports a new ablation strategy systematically targeting anatomical structures previously identified as possibly involved in the fibrillatory process and the recurrent tachycardias. The resulting lesion set provides good short-term outcomes. Although promising, these preliminary results need to be confirmed in the larger prospective study.

Is It Conceivable to Still Perform the Cut and Sew Cox Maze III Procedure in the Current Era?

To determine whether cut and sew Cox maze III procedure is still associated with adequate safety endpoints when performed in conjunction with other open-heart procedures. Between January 2008 and January 2015, 113 consecutive adult patients were submitted to cut and sew Cox maze III procedure in association with other operations for structural heart disease. Mean age was 49 years and 80 (70.8%) were females. Longstanding or persistent atrial fibrillation has occurred in 87.6% and rheumatic heart disease in 80.7%. Valve surgery was performed in 98.2%. The number of associated procedures was correlated with morbidity and hospital mortality. Overall mean cardiopulmonary bypass and aortic cross-clamping times were 129 ± 26 and 105 ± 23 minutes, respectively. Hospital mortality was 1.77%, re-exploration for bleeding 0.9%, cerebrovascular accident 1.8%, and acute renal failure requiring hemodialysis 2.6%. The greater number of associated procedures did not correlate with poorer safety outcomes. Permanent pacemaker was required in 18.2% of those with three associated procedures, as opposed to 4% with two procedures and no requirement with one procedure (P = .01). Frequency of sinus rhythm was 88%, 88%, and 85% at 6, 12, and 24 months, respectively. In a contemporary single-center cohort of predominantly rheumatic patients, the surgical treatment of atrial fibrillation associated with structural heart disease by means of cut and sew Cox maze III procedure is safe, with low morbidity and mortality rates. Surgical complexity, defined by number of associated procedures, did not translate into poorer safety endpoints, except for greater need of permanent pacemaker.

Comparison of the stand-alone Cox-Maze IV procedure to the concomitant Cox-Maze IV and mitral valve procedure for atrial fibrillation

BACKGROUND

The majority of patients undergoing surgical ablation for atrial fibrillation (AF) worldwide receive a concomitant mitral valve (MV) procedure. This study compared outcomes of the Cox-Maze IV (CMIV) in patients with lone AF to those with AF and MV disease.

METHODS

A retrospective review of 335 patients receiving either a stand-alone CMIV for AF (n=151) or a CMIV with a MV procedure (n=184) was performed from January 2002 through December of 2012. Data were obtained at 3, 6, 12, 24, and 48 months and patients were evaluated for recurrence of AF. Twenty-four preoperative and perioperative variables were evaluated to identify predictors of AF recurrence at one year.

RESULTS

The two groups differed in that stand-alone CMIV patients were younger, had AF of longer duration and had more failed catheter ablations, while patients with AF and MV disease had larger left atria and worse New York Heart Association class (P≤0.001). Operative mortality was higher in the concomitant MV group (1% vs. 5%, P=0.015). Freedom from AF and antiarrhythmic drugs at 12 and 24 months were similar between the two groups (73% and 76% at 12 months; 77% vs. 78% at 24 months). Predictors of recurrence included failure to use a box-lesion to isolate the pulmonary veins and posterior left atria, early recurrence of atrial tachyarrhythmias (ATAs) and the presence of a preoperative pacemaker (P=0.001).

CONCLUSIONS

The efficacy of the CMIV procedure was similar in patients with and without co-existent MV pathology. Patients receiving a concomitant CMIV and MV procedure represented an older and sicker patient population and had higher mortality rates than those receiving a stand-alone CMIV procedure.

Cox-Maze IV results for patients with lone atrial fibrillation versus concomitant mitral disease

BACKGROUND

This study compared Cox-Maze IV (CMIV) outcomes for the treatment of atrial fibrillation (AF) in patients with lone AF vs those with AF and mitral valve (MV) disease.

METHODS

Since 2002, 200 patients have undergone a CMIV procedure for lone AF (n=101) or concomitantly with MV operations (n=99). Preoperative, perioperative, and late outcomes between these groups were compared. Data were collected prospectively and reported at 3, 6, and 12 months.

RESULTS

Lone AF patients had AF of longer duration; patients with AF and MV disease were older, with larger left atria and worse New York Heart Association classification (p<0.05). Operative mortality (1% vs 4%, p>0.05, respectively) was similar between both groups. Perioperative atrial tachyarrhythmias were more prevalent in patients with concomitant MV operations (57% vs 41%, p=0.03); however, freedom from AF and antiarrhythmics was similar for both groups at 12 months (76% and 77%). The only predictor for atrial tachyarrhythmia recurrence or arrhythmic drug dependence was failure to isolate the posterior left atrium (p<0.01).

CONCLUSIONS

Patients with AF and MV disease have distinct comorbidities compared with patients with lone AF. However, the CMIV is safe and effective in both groups and should be considered for patients with AF undergoing MV operations. Patients with MV disease had more atrial tachyarrhythmias at 3 months, but freedom from AF and antiarrhythmics was similar to patients with lone AF at 1 year. The posterior left atrium should be isolated in every patient, because this was the only predictor for failure of the CMIV for either group.

Surgical Maze procedure as a treatment for atrial fibrillation: a meta-analysis of randomized controlled trials

Surgical or modified Maze procedures have been promoted to treat atrial fibrillation (AF); however, few randomized controlled clinical trials (RCTs) examine their outcomes. The purpose of this meta-analysis is to compare the efficacy of surgical Maze procedures performed concomitantly with referral cardiac surgery versus pharmacologic therapy for the treatment of AF. We searched MEDLINE, Cochrane database, FDA web-portal, and clinicaltrials.gov for all RCTs comparing surgical Maze procedures with medical therapy for sinus rhythm maintenance. Primary outcomes were either freedom from AF within 12 months postprocedure off antiarrhythmic drug (AAD), or freedom from AF while taking an AAD. Secondary outcomes included operative mortality, all-cause mortality, hospital length of stay, and postoperative complications. Both fixed- and random-effects models were used for a meta-analysis of 9 randomized controlled trials (n = 472, of which 249 underwent a Maze procedure and 213 underwent referral surgery alone). The surgical Maze procedure significantly increased the odds of freedom from AF within 12 months compared with cardiac surgery alone (OR 5.22, 95% CI 1.71-15.88). There was significant heterogeneity among the trials for freedom from AF (chi-square = 15.98 for 4 degrees of freedom, P= 0.003). Among the two studies that fully reported AAD use, there was no evidence of improved survival free from AF and AAD therapy (OR 1.78, 95% CI 0.73-4.34). Among patients with valvular AF, surgical Maze procedures are associated with a decrease in AF one year postprocedure without significant increase in mean length of hospital stay, perioperative complications, operative, or all-cause mortality. Large RCTs defining rates of freedom from AF without AADs postprocedure, are still needed to evaluate outcomes and determine the appropriate role for surgical Maze procedures in the management of AF.

Current strategies in the surgical treatment of atrial fibrillation: review of the literature and Onze Lieve Vrouw Clinic's strategy

Atrial fibrillation is the most common rhythm disturbance in clinical practice. It is a major source of stroke and morbidity. Although the Cox maze procedure effectively eliminates atrial fibrillation in most patients, the procedure has not found widespread application. As a consequence, new operations that use alternative sources of energy, such as radiofrequency, microwave, cryothermy, laser, and ultrasound have emerged to surgically create lesion sets to treat atrial fibrillation. This article reviews the fundamentals and current strategies in the surgical treatment of atrial fibrillation.

Current Strategies in the Management of Atrial Fibrillation

Treatment of atrial fibrillation (AF) has been undergoing significant changes recently. This is due partly to different mechanisms proposed for persistent and permanent AF and partly due to the introduction of energy-based techniques, providing less invasive procedures. This article aims to review the mechanisms of AF leading to the changes in clinical practice and to review the results of surgery, energy-based, and percutaneous techniques. It is difficult to compare and contrast the results of reported series in the literature due to different definitions of AF; freedom from and recurrence of it. Furthermore, in most series it is difficult to distinguish results of surgery for lone AF and AF associated with valvular heart disease and coronary artery disease.

The Cox maze procedure in mitral valve disease: Predictors of recurrent atrial fibrillation

OBJECTIVES

The Cox maze procedure is the gold standard for ablation of atrial fibrillation in patients undergoing mitral valve surgery, and new approaches to atrial fibrillation ablation must be compared with it. Therefore, we sought to determine the time-related prevalence of atrial fibrillation and its risk factors after combined Cox maze and mitral valve surgery.

METHODS

From November 1991 through January 2004, 263 patients (mean left atrial diameter, 5.8 +/- 1.2 cm) underwent combined mitral valve surgery (repair in 71%) and a cut-and-sew Cox maze procedure for atrial fibrillation (permanent, 74%; persistent, 7%; paroxysmal, 16%). Rhythm documented on 2367 postoperative electrocardiograms was used to estimate the prevalence of atrial fibrillation across time.

RESULTS

Hospital mortality was 1.9%. Postoperative atrial fibrillation prevalence peaked at 36% at 2 weeks, decreasing to 21% at 5 years. Risk factors for higher postoperative atrial fibrillation prevalence varied with time and included longer duration of preoperative atrial fibrillation (P = .003), larger left atrial diameter (P = .01), older age (P = .0002), and higher left ventricular mass index (P = .02).

CONCLUSIONS

In some patients undergoing mitral valve surgery and a Cox maze procedure, atrial fibrillation recurs over time, mandating close, long-term follow-up of heart rhythm. Earlier operation and left atrial size reduction should be considered to improve results in selected patients.

Effectiveness of atrial fibrillation surgery in patients with hypertrophic cardiomyopathy

We report the results of atrial fibrillation surgery in 10 patients with hypertrophic cardiomyopathy, which is the largest case series to date. The Maze procedure, with concomitant septal myectomy if indicated, appears to be feasible in patients with hypertrophic cardiomyopathy and refractory atrial fibrillation.

The effect of maze operations on atrial volume

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.

Surgical outcome of the maze procedure for atrial fibrillation in mitral valve disease: rheumatic versus degenerative

BACKGROUND

The results of the maze procedure are known to be less satisfactory in rheumatic mitral disease than in nonrheumatic mitral valve disease. The aim of this study was to determine whether the etiology of mitral valve disease affected surgical outcome.

METHODS

From July 1997 to January 2001, 129 consecutive patients with chronic atrial fibrillation associated with mitral valve disease had mitral valve operations with the maze procedure. The underlying mitral pathology was rheumatic in 86 patients (group R) and degenerative in 43 (group D). Echocardiograms and electrocardiograms were performed immediately and then repeated 3 months and 6 months postoperatively.

RESULTS

The mean age, duration of atrial fibrillation, and preoperative left atrial size were similar between the groups. There was no operative mortality and no significant difference in cardiopulmonary bypass and aortic cross-clamp times. The sinus conversion rate at 7 days postoperatively was 86% in both groups, and at 6 months it was 95.3% in group R and 97.7% in group D (p > 0.05). The transmitral A wave detection rates in groups R and D at 7 days and 6 months postoperatively were, respectively, 63.1% versus 67.4% and 90.4% versus 91.9% (p > 0.05). The transmitral A wave velocity (cm/second) at the same times (7 days and 6 months postoperatively) was 41.9 +/- 41.6 versus 45.5 +/- 37.7 and 67.8 +/- 38.2 versus 69.8 +/- 35.8 in groups R and D, respectively (p > 0.05).

CONCLUSIONS

The maze procedure is equally effective in treating chronic atrial fibrillation in patients with either rheumatic or nonrheumatic mitral valve disease in terms of sinus conversion rate and left atrial transport function.

Atrial fibrillation: current surgical options and their assessment

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with morbidity and mortality. Traditional surgical treatment of AF is the Cox-Maze III procedure, a complicated operation. New surgical approaches include alternate energy sources (radiofrequency, microwave, cryothermy) and simplified left atrial lesion sets. These operations cure AF in 70% to 80% of patients. This review describes contemporary and emerging surgical approaches to AF, synthesizes results of these operations, and proposes new standards for reporting results of AF treatment.

The significance of atrial fibrillation ablation in patients undergoing mitral valve surgery

Atrial fibrillation is present in close to 50% of all patients undergoing surgery for mitral valve disease.(1-3) However, surgical correction of atrial fibrillation in patients with other cardiac pathology that requires surgical intervention such as mitral valve disease was never considered as a standard approach. The Maze procedure for the treatment of atrial fibrillation was introduced in 1987 and was performed safely in hundreds of patients with excellent outcomes.(4-7) As a result, several centers have begun to combine the Maze procedure with other cardiac procedures, especially mitral valve surgery, without adding undue operative risk to patients.(8) When properly performed, the results with this combined approach have been excellent.(9,10)

Combined atrial fibrillation and mitral valve surgery using radiofrequency technology

Recently, intraoperative radiofrequency ablation of the left atrium combined with mitral valve surgery has become widely used. In our center, 30 patients underwent this combined procedure; median sternotomy was used in 16 patients, and port access was used in 14 patients. At hospital discharge, 18 patients (60%) were no longer in atrial fibrillation, and at 6 months, 19 patients (65%) remained in sinus rhythm. All sinus rhythm patients had a well-defined transmitral A wave detectable by echocardiography. One patient sustained a major stroke. Two patients required pacemaker implantation. Such encouraging preliminary results have triggered worldwide interest in the percutaneous and surgical treatment of atrial fibrillation. However, the excellent long-term results with the classic Cox-Maze III operation have not yet been achieved with these newer approaches. Further basic and clinical research is required before a predictable simple and safe technique can be introduced as a new standard for the surgical treatment of atrial fibrillation in patients with or without structural heart disease.