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(Circulation. 1995;92:359-364.)
© 1995 American Heart Association, Inc.

Articles

Modified Maze Procedure for Patients With Atrial Fibrillation Undergoing Simultaneous Open Heart Surgery

Yoshio Kosakai, MD; Akira T. Kawaguchi, MD; Fumitaka Isobe, MD; Yoshikado Sasako, MD; Kiyoharu Nakano, MD; Kiyoyuki Eishi, MD; Yoshitsugu Kito, MD; Yasunaru Kawashima, MD

From the National Cardiovascular Center, Osaka, Japan.

Correspondence to Yoshio Kosakai, MD; National Cardiovascular Center, Fujishirodai 5-7-1, Suita 565, Osaka, Japan.

	Abstract

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Background Persistent atrial fibrillation (AF) leaves patients symptomatic and at increased risk of thromboembolism even after otherwise successful cardiac surgery.

Methods and Results To treat AF secondary to cardiac lesions requiring surgery, we combined a modified maze procedure in 101 patients simultaneously undergoing valvular procedures (87), repair of congenital anomalies (12), and other procedures (2), including 24 repeat operations. Duration of AF varied from 0.1 to 30 years (average±SD, 8.8±7.0 years); the f-wave voltage ranged from 0 to 0.45 mV (0.15±0.09 mV); and cardiothoracic ratio varied from 40% to 99% (63±9%). Aortic cross-clamp time varied from 75 to 229 minutes (138±31 minutes), with bypass time ranging from 119 to 326 minutes (217±42 minutes). There were two early deaths (2%), no late deaths, and one episode of transient neurological ischemic attack in follow-up ranging from 1.0 to 3.1 years, for a total of 190 patient-years. Postoperative rhythms were sinus in 83 patients (82%), junctional in 4 (4%), and persistent AF in 14 (14%), each of whom had mitral valve disease. Patients with other underlying pathology had complete recovery of atrial rhythm. A normal-sized A wave was detected in 88% for transtricuspid flow and in 73% for transmitral flow, suggesting concomitant recovery of atrial contraction. Among 36 patients without mechanical valves, 30 (83%) with atrial rhythm and contraction have been taken off anticoagulation therapy, including 10 who are free of all medication.

Conclusions The results suggest that the combined approach is safe, effective, and indicated in patients who are judged capable of tolerating the procedure and likely to regain atrial rhythm.

Key Words: surgery • fibrillation • embolism • survival

	Introduction

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Atrial fibrillation (AF) became surgically correctable when Cox and colleagues developed the maze procedure¹ and treated patients with lone AF.² Because the majority of the patients who present to us have organic cardiac disorders predisposing to AF, surgery for the underlying lesions alone usually fails to abolish AF,³ leaving patients symptomatic and at an increased risk of thromboembolism.⁴ Although adding the maze procedure is desirable, the combined surgery may not be as safe or effective as in the patients with lone AF.² Because of these concerns, for safety and efficacy we initially selected patients undergoing a simple operation to include the maze procedure.⁵ After we modified the original procedure¹ to simplify it and to preserve the sinus node artery,⁶ we extended the application of the combined approach. The present study presents a review of our experience with the initial 101 patients undergoing the maze procedure simultaneous with open heart surgery for underlying organic lesions.

	Methods

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Between February 1992 and April 1994, a total of 101 patients underwent a modified maze procedure and simultaneous open heart surgery for a variety of cardiac lesions, as listed in Table 1. Four other patients underwent isolated maze procedure for lone AF during the same period. Women (58) outnumbered men (43), with age varying from 32 to 76 years (average±SD, 57.7±9.0 years). The majority of patients had significant mitral valve lesions (Table 1): rheumatic disease (67), degenerative lesion (19), and congenital etiology (3). Thirty-two patients had aortic valve disease (isolated lesion [1] associated with mitral valve disease [21] and the mitral and tricuspid valve lesions [10]) (Table 1). Forty-six patients had significant tricuspid valve pathology, secondary to mitral valve disease (41) or associated with atrial septal defect (4) or Ebstein's anomaly (1). Twenty-four patients (24%) had had previous cardiac surgery, and 17 (17%) had a giant left atrium.⁷ The sinus node artery variation⁸ was right in 43, left in 23, posterior in 10, and unidentified in 25. Eight patients had paroxysmal AF or atrial flutter, and the other 93 had chronic sustained AF. Duration of documented arrhythmia ranged from 0.1 to 30 years (8.8±7.0 years): 1 (1%) for less than 3 months, 6 (6%) for 3 to 12 months, 32 (32%) for 1 to 5 years, 18 (18%) for 5 to 10 years, 34 (34%) for 10 to 20 years, and 10 (10%) for 20 or more years. Preoperative maximum f-wave voltage in lead V₁ varied from undetectable, or 0, to 0.45 mV (0.15±0.09 mV). Functional class ranged from I (1) to IV (4) (2.2±0.6), and cardiothoracic ratio varied from 40% to 99% (63±9%).

View this table: [in this window] [in a new window]   Table 1. Underlying Cardiac Lesions and Results of 101 Patients Undergoing the Combined Maze Procedure

As for the maze procedure (Table 2), we modified Cox's maze 2 procedure (first modification⁹ ) for the first 14 patients selected on the basis of high f-wave voltage and a simpler concomitant procedure. We further modified the maze atriotomies (Fig 1) so as not to disrupt the sinus node artery⁸ and used cryoablation to simplify the combined procedure; the current procedure⁶ was performed for the last 70 patients referred for surgery on an unselected basis except for those patients who were judged unable to tolerate the procedure. Other modifications included transection of the superior vena cava¹⁰ and detachment of the left ventricle at the circumferential left atriotomy around the pulmonary veins to improve exposure and manipulation of the mitral valve. Parallel to the current modification, an additional 17 patients underwent Cox's maze 3 procedure (Fig 1, second modification⁹ ). All patients had antegrade infusion of St Thomas' solution (10 mL/kg) every 30 minutes with topical cooling for myocardial protection.

View this table: [in this window] [in a new window]   Table 2. Comparison Among Modified Maze 2, Current Modification (I), and Cox's Maze 3 (II)

View larger version (44K): [in this window] [in a new window]   Figure 1. Surgical techniques. Atriotomies (solid line with cross bars) and cryoablation (dotted area) with variations of sinus node artery for the current modification (left)6 and for Cox's maze 3 (right).9 Top, Posterior views of the cardiac base. Bottom, Endocardial views of the atria. Areas of cryoablation at valvular annuli were close to the circumflex artery (closed asterisk) and the right coronary artery (open asterisk). LAA indicates left atrial appendage; RAA, right atrial appendage; SN, sinus node; LSA, left sinus node artery; RSA, right sinus node artery; PSA, posterior sinus node artery; SVC, superior vena cava; IVC, inferior vena cava; MV, mitral valve; TV, tricuspid valve; and FO, fossa ovalis.

Cardiac rhythm was continuously monitored after surgery until stable rhythm returned. Temporary wires were used to pace the patient, to monitor the rhythm, or to overdrive the atrium. Postoperative atrial arrhythmias were treated with DC cardioversion if they were hemodynamically deleterious or not responding to overdrive pacing or antiarrhythmics, usually class I-A. Patients who had such arrhythmias were maintained on antiarrhythmics to suppress triggering effects and to stabilize atrial rhythm before discontinuation of warfarin.

After discharge, patients were followed monthly for adjustment of medication, rhythm, signs of myocardial ischemia, and control of anticoagulation. Doppler echocardiography and chest radiography were scheduled for 1, 3, 6, and 12 months after surgery. Anticoagulation was discontinued only in patients with atrial rhythm and documented contraction 3 to 6 months after reparative surgery. Antiarrhythmics were tapered after anticoagulation was discontinued or after cardiac rhythm was considered stable.

Continuous variables were compared with the use of Student's t test, and discrete variables were analyzed with the use of ² test. Differences were considered statistically significant at a value of P<.05.

	Results

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Procedures performed simultaneously with the maze operation were relevant to the diagnoses listed in Table 1. Patients (8) with atrial septal defect underwent defect closure, additional four tricuspid annuloplasties, and three mitral valve repairs. The patient with Ebstein's anomaly received a tricuspid bioprosthesis, and another patient with hypertrophic obstructive cardiomyopathy had a mechanical mitral valve placed. As a result, 65 received mechanical valve(s): 1 had a bioprosthesis, and the remainder underwent reparative surgery (35). Aortic cross-clamp times ranged from 75 to 229 minutes (138±31 minutes), and cardiopulmonary bypass runs varied from 119 to 326 minutes (217±42 minutes). Immediately after surgery, AF disappeared in 99 patients (98%): 42 showed junctional rhythm, and 57 showed sinus rhythm, with 2 patients (2%) who had never been defibrillated. During hospitalization, 37 (37%) had AF or atrial flutter, usually within the first month after surgery; 23 of the 37 eventually regained atrial rhythm after pharmacological therapy or electrocardioversion, leaving 14 patients with persistent AF. Rhythms after the combined procedures were sinus in 83 (82%), persistent AF or atrial flutter in 14 (14%), and junctional in 4 (4%) who eventually required atrial pacemaker implantation.

Four initial patients required intra-aortic balloon pumping, and 8 underwent reexploration for hemostasis (7) or for relief of late cardiac tamponade (1). Two patients died in the hospital (2%). One of the patients, a 67-year-old woman with hypertrophic obstructive cardiomyopathy, was extubated 11 days after mitral valve replacement and moved to the general ward, where she developed ventricular tachycardia. After the episode, she deteriorated and died 71 days after surgery. The other patient was a 76-year-old woman who had a long history of congestive failure due to rheumatic heart disease. Although she was extubated 4 days after mitral valve replacement with tricuspid annuloplasty, she was reintubated 1 week later, followed by tracheostomy. She developed AF, pneumonia, and multiple-organ failure and died 93 days after surgery. One transient neurological ischemic attack occurred in a patient who regained sinus rhythm after mechanical mitral valve replacement. Another patient had cerebral bleeding 1 month after mechanical mitral valve replacement. There was no other morbidity or late mortality in the follow-up (range, 1.0 to 3.1 years; mean, 1.92±0.54 years; total, 190 patient-years).

Results were stratified according to the underlying lesions (Table 1) and surgical modifications of the maze procedure (Table 2). The 4 patients with lone AF regained sinus rhythm after isolated maze procedure. The combined approach was highly successful in restoring sinus rhythm in congenital anomalies and acquired lesions other than mitral valve disease, which included the 14 patients with persistent AF after surgery. Excluding the initial 14 selected patients, underlying disorders and results were basically comparable between the current modification and Cox's maze 3 procedure except for shorter bypass runs, shorter cardiac arrest, and earlier appearance of atrial electromechanical activity after the current modification. Comparison between patients who did and those who did not regain atrial rhythm (Table 3) showed significant differences in duration of AF, incidence of giant left atrium, preoperative and postoperative left atrial dimensions, and cardiothoracic ratio.

View this table: [in this window] [in a new window]   Table 3. Comparison Between Patients With AF (+) and Without AF (-) After Surgery

Among 88 patients who had a transthoracic Doppler study, an atrial A wave was detected in 77 (88%) for transtricuspid flow and in 64 (73%) for transmitral flow. An A wave was not detected in 5 patients who regained atrial rhythm. The height of transmitral A and E waves and their ratio (A/E) were plotted as a function of age with normal references (Fig 2).¹¹ Although the height of the A wave remained within the normal range after the combined approach, patients with mitral valve disease had a higher-than-normal E wave, rendering the A/E ratio significantly smaller than in age-matched control subjects.

View larger version (16K): [in this window] [in a new window]   Figure 2. Scatterplot of diastolic left ventricular filling showing peak velocity of transmitral A wave (top), E wave (middle), and their ratio (A/E ratio, bottom) as detected by Doppler echocardiography for patients undergoing combined surgery with (closed circles) and without mitral valve involvement (closed asterisks) as a function of age. Open circles, Normal control subjects without known cardiac abnormalities.11

Among 36 patients without mechanical valves, anticoagulation with warfarin was discontinued in 30 (83%) who regained both atrial rhythm and contraction; 10 of them became totally free from medication after repair of congenital defects (8) and valvular lesions (2). Warfarin was continued in the remaining 6 (17%) because of persistent AF (5) or no atrial contraction (1). One year after surgery, 29 (29%) were receiving antiarrhythmics, disopyramide (19), quinidine (6), or other medications (6) to suppress premature atrial contraction and paroxysmal atrial flutter.

Selective coronary angiography 1 month after surgery in 21 patients showed no abnormalities around the mitral and tricuspid annuli where cryoablation was performed (Fig 1). Postoperatively, variation of the sinus node artery changed to the right sinus node artery in 3 patients: 2 from the posterior and 1 from the left sinus node artery. In later follow-up, no patients developed signs of myocardial ischemia.

	Discussion

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Most of the patients with AF referred to us for surgery have underlying organic disorders with cardiomegaly,¹² increased atrial size,¹³ and a long history of AF.^{12 13} Because these factors are known to predispose patients to AF, it is necessary to combine the maze procedure to abolish established AF. To reduce the risk of the combined procedure, we used cryoablation and modified the atriotomies.⁶ As a result, cardiac arrest and cardiopulmonary bypass runs were significantly shortened in comparison with those required for Cox's maze 3 procedure in treating a comparable patient population. Nevertheless, an additional 40 minutes was required for cardiac arrest and an additional 70 minutes for cardiopulmonary bypass compared with surgery other than the maze procedure alone.¹⁴ Although the complexity of the combined approach carries potential risks, it did not appear to be reflected in our series. The mortality rate (2%) was comparable to that of our experience with a similar patient group. Although deaths were related to nonischemic myocardial failure, all patients had recovered before developing complications, which were unrelated to the additional maze procedure per se.

Postoperative persistent AF occurred only in patients with mitral valve disease, whereas the other etiological groups had complete recovery of sinus rhythm, including 4 patients with lone AF during the same period. These results suggest that the differences in recovery and maintenance of atrial rhythm and contraction among reports^{2 6} derive mainly from underlying cardiac pathology rather than from modification in atriotomies or use of cryoablation. As for the sinus node dysfunction requiring pacemaker implantation, the initial two patients had this requirement after a modified Cox's maze 2 procedure; 14% (2 of 14) required pacemakers, necessitating modification of the atriotomies to the current procedure with the incidence reduced to 2.9% (2 of 70), comparable to that after Cox's maze 3 procedure. Atrial electromechanical activity appeared in the operating room in 69% of patients after the current modification, which was more frequent and earlier than after modified Cox's maze 2 or 3 procedure. This may be due to better preservation of arterial blood supply for the sinus node, although recovery of sinus rhythm eventually became comparable among the three different maze procedures. Although postoperative changes in variation of the sinus node artery (14%, 3 of 21) may indicate disruption of the artery, postoperative surveys for myocardial ischemia have been negative for the complications of cryoablation applied close to the nonperfused coronary arteries.¹⁵

Transthoracic Doppler echocardiography failed to detect left atrial contraction in approximately one fourth of the patients who regained electric atrioventricular synchrony. This may be due to fibrotic and calcific degeneration of the atrial myocardium as 85% of our patients had rheumatic or degenerative mitral valve disease. A significantly higher transmitral E wave in these patients suggests relative stenosis or increased impedance across the mitral valve as the result of repair or replacement. Lack of concomitant increase in A-wave,¹¹ or a reduced A/E ratio, may suggest attenuation or absence of physiological compensation¹¹ in patients after combined surgery, presumably due to extensive atriotomies or cardiac denervation.¹⁶

As patients had improved hemodynamics¹⁴ and exercise capacity after combined approach,¹⁶ a reduced incidence of thromboembolism and bleeding complications may become significant in extended long-term follow-up; 30 patients (83% of 36 without mechanical valves) no longer need anticoagulation therapy. These are the objectives¹ and advantages² of the maze procedure over the electric isolation of the left atrium. Although a similar incidence of atrial rhythm (81%) was reported by Graffigna and colleagues¹⁷ in patients with AF and organic diseases undergoing combined left atrial isolation, detrimental hemodynamics and risk of thromboembolism inherent to AF may remain unchanged. Chua and colleagues¹⁸ contended that surgical ablation for established AF should be associated with little or no additional mortality or morbidity because there were no differences in survival and neurological events between patients with or without AF after repair of mitral regurgitation. The results of our review are compatible with theirs in that neurological events could be minimized with anticoagulation and that postoperative survival depends mainly on the severity of the underlying diseases regardless of the presence or absence of AF. As the maze-associated risks have been reduced, simultaneous abrogation of rhythm and organic diseases should be considered not only on the basis of mortality or morbidity but also for improved hemodynamics and quality of life, which are the benefits of the maze procedure.

Unselected application of the combined approach for the last 87 patients allowed meaningful retrospective analyses, which identified a longer history and larger preoperative and postoperative atrial dimension as predisposing factors of persisting AF, similar to those without the maze procedure.^{3 4 12 13} Although exclusion of patients who are less likely to regain atrial rhythm may seem prudent, simultaneous reduction in atrial size may also prove effective. Chua and colleagues¹⁸ recommended early performance of isolated mitral valve repair for recent-onset AF since spontaneous ablation of AF occurred in all 11 of their patients with AF lasting for less than 3 months. On the other hand, Bonchek and colleagues¹⁹ suggested combining the procedure prophylactically in elderly patients with atrial septal defect who are still in sinus rhythm because they are likely to develop AF. Considering the progressive nature of the underlying diseases, adding the maze procedure may be justified in patients with organic disease and AF regardless of its duration because such patients have underlying pathology, or substrate, that predisposes them to the development and maintenance of AF. We believe that patients with combined diseases who are likely to regain atrial rhythm should be considered for the combined approach provided the patients are judged capable of tolerating and benefiting from the procedure.

	Acknowledgments

 
This work was supported in part by Research Grant 6C 4 from the Ministry of Health and Welfare and by special Coordination Funds for Promoting Science and Technology (Encouragement System of COE) from the Science and Technology Agency. We appreciate the editorial help of Dr Leonard M. Linde, Professor of Pediatrics (Cardiology), University of Southern California (Los Angeles).

	References

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