Outcome of a modified left atrial maze procedure for atrial fibrillation concomitant to cardiac surgery

Objective The Cox-Maze IV procedure has been shown to be an effective treatment for atrial fibrillation when performed concomitantly with other operations either via median sternotomy or right minithoracotomy. Few studies have compared these approaches in patients with lone atrial fibrillation. This study examined outcomes with sternotomy versus minithoracotomy in stand-alone Cox-Maze IV procedures at our institution. Methods Between 2002 and 2015, 195 patients underwent stand-alone biatrial Cox-Maze IV. Minithoracotomy was used in 75 patients, sternotomy in 120. Freedom from atrial tachyarrhythmias was ascertained using electrocardiography, Holter, or pacemaker interrogation at 3 to 60 months. Predictors of recurrence were determined using logistic regression. Results Of 23 preoperative variables, the only differences between groups were that minithoracotomy patients had a higher rate of New York Heart Association 3/4 symptoms and a lower rate of previous stroke. Minithoracotomy and sternotomy patients had similar atrial fibrillation duration and type. Minithoracotomy patients had a smaller left atrial diameter (4.5 vs 4.8 cm, P = 0.03). More minithoracotomy patients received a box lesion (73/75 vs 100/120, P = 0.002). Minithoracotomy patients had a shorter hospital stay (7 vs 8 days, P = 0.009) and a similar rate of major complications (3/75 (4%) vs 7/120 (6%), P = 0.74). There were no differences in mortality or freedom from atrial tachyarrhythmias. Predictors of atrial fibrillation recurrence included a preoperative pacemaker, omission of the left atrial roof line, and New York Heart Association 3/4 symptoms. Conclusions Stand-alone Cox-Maze IV via minithoracotomy was as effective as via sternotomy with a shorter hospital stay. A minimally invasive approach is our procedure of choice.

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Multiple peripheral embolisation following left atrial MAZE procedure for atrial fibrillation (AF) ablation

European Journal of Internal Medicine ◽

10.1016/j.ejim.2007.05.004 ◽

2008 ◽

Vol 19 (1) ◽

pp. 71-72

Author(s):

Sagar Saha ◽

Martin Lowe ◽

Clare Dollery

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Maze Procedure ◽

Af Ablation

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Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery

JAMA ◽

10.1001/jama.2017.20125 ◽

2018 ◽

Vol 319 (4) ◽

pp. 365 ◽

Cited By ~ 61

Author(s):

Daniel J. Friedman ◽

Jonathan P. Piccini ◽

Tongrong Wang ◽

Jiayin Zheng ◽

S. Chris Malaisrie ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Left Atrial Appendage Occlusion

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Abstract 3175: Plasma Tansforming Growth Factor Beta as a Biochemical Marker to Predict the Recurrence of Atrial Fibrillation After Surgical Maze

Circulation ◽

10.1161/circ.116.suppl_16.ii_713-a ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Young Keun On ◽

Dae-Hee Shin ◽

Jin-Oh Choi ◽

Yong Hwan Park ◽

Sang Yeub Lee ◽

...

Keyword(s):

Atrial Fibrillation ◽

Messenger Rna ◽

Left Atrial ◽

Multiple Logistic Regression Analysis ◽

Internal Standard ◽

Maze Procedure ◽

Atrial Remodeling ◽

Rt Pcr ◽

Heart Operation

BACKGROUND Atrial remodeling leads to perpetuation of atrial fibrillation (AF). Structural remodeling in the form of fibrosis alters the substrate. The surgical Maze procedure was developed as a surgical treatment of AF. Our purpose was to evaluate the role of plasma NT-proBNP, hsCRP, TIMP-1(Tissue inhibitors of MetalloProteinase-1), TGF-β, MMP-3(Matrix MetalloProteinase-3), and pro-MMP-1in predicting the recurrence of AF after surgical Maze procedure. And we also evaluated the association of expression of CTGF, TGF-β, BNP, ANP, collagen-1α, and collagen-3α in LA with the recurrence of AF after surgical Maze procedure. METHODS Preoperative plasma NT-proBNP, hsCRP, TIMP, TGF-β, MMP-3, and pro-MMP-1 levels were measured in consecutive 86 patients (age 54±12 yrs) who underwent the open heart operation for valvular heart disease and surgical Maze procedure for AF. Moreover, we performed molecular examinations of CTGF, TGF-β, BNP, ANP, Collagen-1α, Collagen-3α in the resected left atrial tissues. Symptomatic AF documented by ECG or an episode of AF revealed at follow-up holter monitoring were considered atrial fibrillation recurrences. RESULTS At 1-year follow-up, 10 among 86 patients had persistence of AF. Patients with AF persistence had higher plasma TGF-β levels than the patients with sinus rhythm (0.44 ± 0.29 vs 0.32 ± 0.15 ng/ml) . Patients with AF persistence had higher messenger RNA expressions of Collagen-3α (0.21 ± 0.20 vs 0.12 ± 0.12, compared with internal standard GAPDH by RT-PCR) and lower messenger RNA expressions of ANP (0.31 ± 0.16 vs 0.60 ± 0.76, compared with internal standard GAPDH by RT-PCR ) in left atrial tissues. Multiple logistic regression analysis revealed that plasma TGF-β was independently associated with postoperative persistence of atrial fibrillation at 1 year follow-up after surgical Maze procedure. CONCLUSIONS Advanced atrial degenerative change might result in a decrease of atrial ANP secretion. Cardiac fibrosis might be a determinant of myocardial heterogeneity and the persistence of AF. Plasma TGF-β could predict the persistence of AF at 1 year follow-up after surgical Maze procedure.

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Abstract 14990: Pulmonary Vein Stenosis After Epicardial Atrial Fibrillation Ablation and Epicardial Left Atrial Appendage Occlusion: A Diagnostic Dilemma and Challenges in Management

Circulation ◽

10.1161/circ.142.suppl_3.14990 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Moghniuddin Mohammed ◽

Nachiket Apte ◽

Mohammed Ansari ◽

Amit Noheria ◽

Seth Sheldon ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Maze Procedure ◽

Pulmonary Vein Stenosis ◽

Epicardial Ablation ◽

Left Atrial Appendage Occlusion ◽

Vein Stenosis

Background: Pulmonary vein stenosis is a dreaded complication of endocardial atrial fibrillation (AF) ablation but rare after epicardial ablation and has not been reported after epicardial left atrial appendage occlusion (LAAO). Case: A 55-year-old male was referred to our tertiary hospital for management of left superior pulmonary vein (LSPV) stenosis causing dyspnea on exertion. About 2 years prior to presentation, he underwent quadruple coronary artery bypass grafting for non-ST elevation myocardial infarction along with modified Cox-Maze procedure with pulmonary vein and posterior wall isolation as well as epicardial LAAO with AtriClip for history of paroxysmal AF. At our institute, V/Q scan showed ventilation-perfusion mismatch and absent perfusion of the left upper lobe (Figure 1A). Cardiac CT showed persistent LSPV occlusion (Figure 1B). TEE showed atrial appendage occluded with a clip and no flow was observed from LSPV (Figure 1C). After multidisciplinary discussion between cardiology and cardiothoracic surgery teams, surgical approach to remove the AtriClip was deemed futile as it was placed 2 years ago and less likely to result in resolution of stenosis. Thus, an endovascular approach was attempted with left atrial and pulmonary vein angiography showing LSPV to be 100% occluded (Figure 1D). Pulmonary vein recanalization was attempted but was not successful. Conclusion: Our case highlights the importance of recognition of PVS as a possible complication after epicardial LAAO as early intervention can improve patient outcomes. PVS has been previously described with Maze procedure but that patient was successfully treated with catheter-balloon angioplasty. Given 100% occlusion and difficulty with recanalization makes epicardial ablation a less likely cause of occlusion in our case. More careful application of Atriclip protocols might be necessary to prevent this potential complication.

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