Five-year experience with the maze procedure for atrial fibrillation

doi:10.1016/0003-4975(93)90338-I

The Annals of Thoracic Surgery

Volume 56, Issue 4, October 1993, Pages 814-824

https://doi.org/10.1016/0003-4975(93)90338-I Get rights and content

Abstract

Between September 25, 1987, and December 31, 1992, 75 patients (53 men, 22 women; average age, 52 years) underwent the maze procedure for the treatment of atrial fibrillation. Six patients had undergone a previous cardiac operation and 28% underwent concomitant cardiac procedures in addition to the maze procedure. One patient (1.3%) died 10 days after undergoing a combined maze procedure and Morrow procedure for the management of chronic atrial fibrillation and hypertrophic obstructive cardiomyopathy. Postoperative atrial pacemakers were required in 40%:26% for preoperative sick sinus syndrome and 6% for iatrogenic injury of the sinus node, and 8% had pacemakers in place preoperatively. As of December 31, 1992, 65 patients had been followed up for at least 3 months after operation (range, 3 to 63 months). The maze procedure cured atrial fibrillation, restored atrioventricular synchrony, and preserved atrial transport function in 64 of 65 patients (98%). The procedure has been curative without the need for medications in 58 of 65 patients (89%) and with the need for medications in 6 of 65 (9%), with medications failing in only 1 of the 65 patients (2%). The results support the maze procedure as the treatment of choice in patients with medically refractory symptomatic atrial fibrillation.

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Concomitant atrial fibrillation often goes untreated because of surgeon concerns regarding lesion set complexity and pump times. We describe a new cryoablation procedure to address this.
From June 2013 to March 2021, a modified CryoMaze III procedure was used using 3 left atrial ± 3 right atrial cryo-applications creating the key lesions of the Cox Maze III procedure. Since 2018, 3-minute cryo-lesions were used for the left atrial box lesion for total cryoablation times of 8 minutes for the left atrium ± 6 minutes for the right atrium. By using propensity matching, patients undergoing mitral valve surgery with no atrial fibrillation history were compared with CryoMaze III–treated patients.
A total of 100% of the 277 patients with atrial fibrillation requiring mitral valve surgery ± other procedures received the modified CryoMaze III procedure. After propensity score matching (n = 161 each group), the modified CryoMaze III group had mean crossclamp and bypass times 10.5 and 13.4 minutes longer than the control group, respectively. There were no significant differences in 30-day mortality, morbidity, pacemaker use, renal dysfunction, or late survival between groups, but there were less postoperative strokes in the CryoMaze III group. Freedom from atrial fibrillation off antiarrhythmics was 77% (mean follow-up of 3.0 ± 2.1 years). At 12 months, freedom from atrial fibrillation off antiarrhythmics was 90% for the 3-minute ablation group. Late survival was similar to age- and sex-matched Centers for Disease Control and Prevention controls.
The modified CryoMaze III technique is efficient, safe, and effective. Education of the surgical community regarding the late benefits of ablation and the simplicity of this new technique should improve adoption of the Class I Guidelines to treat concomitant atrial fibrillation.
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Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice and its prevalence increases with age. AF causes palpitations, heart failure, and cardiogenic embolism. Of them, the most critical and fatal complication is a cardio-embolic event. Oral anticoagulation plays a central role in reducing stroke risk in AF patients. Recently, when oral anticoagulation is considered in patients with non-valvular AF who are eligible for direct oral coagulations, they are preferred to vitamin K antagonist based on accumulating evidence. Although many patients can tolerate oral anticoagulation, there is a subset of patients who cannot tolerate long-term oral anticoagulation. Such a subset has a higher bleeding risk as indicated by the HAS-BLED score under oral anticoagulation. This subset of patients requires effective and safe non-pharmacological alternative therapies for stroke prevention. One of the promising non-pharmacological therapies is left atrial appendage closure. Three randomized controlled trials demonstrated non-inferiority of percutaneous left atrial appendage closure using WATCHMAN family to oral anticoagulation (Boston Scientific, Marlborough, MA, USA). WATCHMAN FLX, which was innovated following WATCHMAN 2.5, was associated with fewer safety events and a higher success rate of effective appendage closure. Nevertheless, several unsolved issues remain, including device-related thrombosis, post-treatment antithrombotic therapy, and peri-device leakage. Left atrial appendage closure for patients with non-valvular AF may be an alternative therapy to avoid cardiac embolism for high bleeding risk patients with contraindications to long-term oral anticoagulation therapy.
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Atrial appendages were collected from 11 nonfailing donor hearts and 111 patients undergoing heart surgery for the correction of valvular heart disease, resistant atrial fibrillation, or ischemic heart disease. Chymase mRNA was analyzed by real-time polymerase chain reaction and enzymatic activity by high-performance liquid chromatography using Ang-(1-12) as the substrate. Ang-(1-12) levels were determined by immunohistochemical staining.
Chymase gene transcripts, chymase activity, and immunoreactive Ang-(1-12) expression levels were higher in left atrial tissue compared with right atrial tissue, irrespective of cardiac disease. In addition, left atrial chymase mRNA expression was significantly higher in stroke versus nonstroke patients and in cardiac surgery patients who had a history of postoperative atrial fibrillation versus nonatrial fibrillation. Correlation analysis showed that left atrial chymase mRNA was positively related to left atrial enlargement, as determined by echocardiography.
As Ang-(1-12) expression and chymase gene transcripts and enzymatic activity levels were positively linked to left atrial size in patients with left ventricular heart disease, an important alternate Ang II forming pathway, via Ang-(1-12) and chymase, in maladaptive atrial and ventricular remodeling in humans is uncovered.
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Randomized Trial of Concomitant Maze Procedure Using Nitrous Oxide- Versus Argon-Based Cryoablation
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Currently, two types of cryoprobes are available: nitrous oxide (N₂O)-based and argon gas-based. However, few studies have compared the outcomes obtained with these two cryoprobe types. The aim of this study was to compare the early outcomes of a concomitant maze procedure using N₂O-based cryoablation (the N₂O group) versus argon gas-based cryoablation (the argon group) in patients with persistent atrial fibrillation (AF).
This study was a single-center, prospective, randomized controlled clinical trial. Sixty patients were randomly assigned to receive a concomitant maze procedure using N₂O-based cryoablation (n = 30) or argon gas-based cryoablation (n = 30) for persistent AF. Patients were followed up at 3, 6, and 12 months by electrocardiography, 24-hour Holter monitoring, and transthoracic echocardiography.
No important intergroup differences were observed in terms of preoperative variables, morbidity, or mortality. During 1 year of follow-up, normal sinus rhythm was maintained in 26 patients in the N₂O group and 26 patients in the argon group (86.7% versus 86.7%, p = 1.000). Freedom from atrial arrhythmia events at 12 months was observed in 84.5% ± 4.7% without intergroup differences. Early AF episode before discharge was correlated with atrial arrhythmia events during follow-up (hazard ratio 7.89, 95% confidence interval: 1.75 to 35, p = 0.007). The N₂O group showed earlier recovery of left atrial activity compared with the argon group (p = 0.043); however, this difference disappeared after 6 months.
Both procedures have similar 1-year sinus rhythm maintenance rates. Left atrial contractile activity tends to return earlier in the N₂O group.

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^☆: Presented at the Twenty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1993.

^☆☆: Supported by NIH grants RO1 HL32257 and RO1 HL33722.

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Original articleFive-year experience with the maze procedure for atrial fibrillation☆,☆☆

Abstract

J Thorac Cardiovasc Surg

Surg Clin North Am

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Lancet

Left atrial isolation: new technique for the treatment of supraventricular arrhythmias

J Thorac Cardiovasc Surg

Catheter-induced ablation of the atrioventricular junction to control refractory supraventricular arrhythmias

JAMA

Original article
Five-year experience with the maze procedure for atrial fibrillation☆,☆☆