Modified Mini-Maze for Atrial Fibrillation with Interruption of Inferior Vena Cava

A 57-year-old female with paroxysmal atrial fibrillation and an interrupted inferior vena cava (IVC) was referred to our hospital for radiofrequency ablation. Transseptal puncture and left atrium ablation failed through a standard IVC approach via the femoral vein due to intrahepatic interruption of IVC. We performed a modified mini-maze procedure in this patient through the left thoracic cavity under video-assisted thoracoscopic surgery (VATS). We can successfully complete pulmonary vein (PV) isolation, left atrium box isolation, cardiac ganglia ablation, Marshall ligament ablation, and coronary sinus epicardium ablation using this technique.

Himalayan Fibrillatory Waves in Juvenile Rheumatic Mitral Stenosis

An 18-year-old girl, a known case of rheumatic mitral stenosis, presented with dyspnea and palpitations. Electrocardiogram was done, which revealed atrial fibrillation and a large amplitude atrial fibrillatory wave, which was more than the voltage of R wave V1, a finding which is quite uncommon. Echocardiography revealed a large left atrium which was 80 mm in diameter. The patient was started on oral anticoagulation and referred for mitral valve replacement with maze procedure.

Abstract 16851: Simultaneous Mitral Valve Replacement, Aortic Valve Replacement, Tricuspid Valve Repair, Left Atrial Appendage Ligation, Maze Procedure And Cabg In A 57-year Old Female With History Of Tavr And Severe Mitral Annular Calcification

Background: Open heart surgery is preferred for patients with multiple valvular issues with conflicting physiology. Case: A 57-year-old female with a past medical history of Type I Diabetes Mellitus complicated by kidney & pancreatic transplant in 1999 s/p failed kidney transplant in 2016 subsequently back on dialysis, aortic stenosis leading to Transcatheter Aortic Valve Replacement (TAVR) in 2016 who presented to the hospital for profound cardiogenic shock and was found to have severe tricuspid regurgitation, severe mitral stenosis secondary to mitral annular calcification with severe concentric hypertrophy of left ventricle. Decision Making: Her conflicting right and left heart physiology due to Tricuspid Regurgitation and Mitral Stenosis was very difficult to manage medically. She was not deemed a candidate for a heart transplant due to a history of a failed kidney transplant. She underwent surgery which included Mitral Valve Replacement, explant TAVR and repeat aortic valve replacement, Tricuspid repair, Left atrial appendage ligation and maze procedure, and CABG x1 with saphenous vein graft to PDA. She stayed on V-V extracorporeal membrane oxygenation (ECMO) post-operatively and was discharged on post-operative Day # 14. Conclusion: Severe tricuspid Regurgitation & coexisting mitral stenosis pose a dilemma for medical management and only feasible option is surgery which could be extremely challenging.

An off-pump biatrial mini-maze procedure for treatment of long-standing persistent atrial fibrillation

Background Surgical treatment has assumed a more prominent role in the therapy of atrial fibrillation (AF) with favorable efficiency and acceptable safety during the last decades. The traditional Cox-Maze procedure and Wolf Mini-Maze procedure focused on left atrial ablation. However, it is ubiquitous that patients with long-standing persistent atrial fibrillation (LSPAF) typically suffer from biatrial electrical and structural remodeling. The left atrial procedures are still not enough in patients with LSPAF. Purpose Herein, we aimed to introduce a modified biatrial off-pump ablation procedure based on the Wolf Mini-Maze procedure and to detect the safety and efficacy of the surgery for patients with LSPAF. Methods Between January 2016 and September 2020, 102 patients of LSPAF underwent our modified Mini-Maze procedure using bipolar radiofrequency ablation. Those patients firstly underwent a Mini-Maze procedure using Dallas lesion set, including video-assisted bilateral mini-thoracotomy, left atrial appendage excision, bilateral pulmonary vein isolation, ganglionic plexi evaluation and destruction, left atrial roof connecting lesion, and a linear lesion connecting this roofline to the root of the aorta at the junction of the left coronary and the non-coronary cusp. Secondly, a purse-string suture was performed on the right atrium, and then four ablation lesions were made to the superior vena cava, to the inferior vena cava, to the appendix of the right atrium, and to the tricuspid valve annulus from the purse-string suture point by the bipolar radiofrequency clamp. After the operation, the patients were followed up at an interval of 3, 6, 12 months, and every 1 year after that. Results No mortality No surgical re-exploration for bleeding. No permanent pacemaker implantation. 99 patients were free from LSPAF upon discharge. A follow-up at interval of 3, 6, 12, 24, 36, and 48 months showed a success rate free from LSPAF was 95.1% (97/102), 94.4% (85/90), 94.8% (73/77), 91.5% (54/59), 90.3% (28/31) and 100% (9/9), respectively Conclusions The modified biatrial Mini-Maze suggested a safe and feasible procedure. Early follow-up demonstrated an acceptable success rate free from AF. It might have the potential to become another option for clinical treatment of LSPAF. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): General Program of the National Natural Science Foundation of China Schematic of the procedure

The occurrence and risk factors of bradycardia after the Maze procedure in patients with atrial fibrillation and tricuspid regurgitation

Objective To evaluate the occurrence and risk factors of bradycardia after the Maze procedure in patients with atrial fibrillation and tricuspid regurgitation. Methods All patients underwent mitral valve (MV) replacement and concomitant bi-atrial cut-and-sew Maze procedure along with other cardiac surgical procedures were recruited from the Department of Cardiovascular Surgery at the First Affiliated Hospital of Medical College of Xi'an Jiaotong University. According to the severity of tricuspid regurgitation, all patients were divided into mild tricuspid regurgitation group and moderate-to-severe tricuspid regurgitation group. The general clinical data, biochemical indexes, intraoperative and postoperative data were collected. The relationship between tricuspid regurgitation and sinus bradycardia after the Maze procedure was analyzed by multivariate logistic regression model. Results We enrolled 82 patients, including 24 males and 58 females. The patients had an average age of 56 ± 10 years old. There were 50 cases in mild tricuspid regurgitation group and 32 cases in moderate-to-severe tricuspid regurgitation group. Compared with the mild tricuspid regurgitation group, postoperative bradyarrhythmia (41% vs. 14%), pre-discharge bradyarrhythmia (63% vs. 14%), postoperative sinus bradycardia (34% vs. 10%) and pre-discharge sinus bradycardia (63% vs. 10%) in moderate-to-severe tricuspid regurgitation group were significantly increased (P < 0.01). In moderate-to-severe tricuspid regurgitation, the risk of sinus bradycardia increased after the Maze procedure (OR = 1.453, 95% CI 1.127–1.874), area under ROC curve was 0.81, the Jordan index was 0.665. Conclusion The severity of tricuspid regurgitation may be an important factor affecting sinus bradycardia after the Maze procedure. It can be considered as a factor to predict sinus bradycardia after the Maze procedure.