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ABSTRACT Introduction: Atrial fibrillation is one of the common complications of mitral valve disease. Currently, in the absence of freezing equipment, it's still impossible to fully conduct a minimally invasive Cox-maze IV procedure to treat atrial fibrillation. Methods: We analyzed the clinical data of 28 patients who underwent thoracoscopic minimally invasive mitral valve full maze surgery in our hospital from October 2021 to September 2022; 13 patients were male and 15 were female, three suffered from paroxysmal atrial fibrillation, and 25 suffered from permanent atrial fibrillation; average age was 61.88±8.30 years, and mean preoperative left atrial diameter was 47.12±8.34 mm. Isolation of left atrial posterior wall (box lesion) was completed in all patients by cut-and-sew technique and bipolar clamp ablation. Results: For these subjects, the median cardiopulmonary bypass time was 169 (109.75-202.75) minutes, aortic cross-clamping time was 106 (77.75-125.50) minutes, and ventilator assistance time was 6.5 (0-10) hours. Among them, eight subjects had the endotracheal tubes removed immediately after surgical operation. Three subjects were in the blanking period; two subjects still had atrial fibrillation at three months after operation, one of whom resumed sinus rhythm after electrical cardioversion therapy; and all the remaining 23 subjects had sinus rhythm. Conclusion: The minimally invasive cut-and-sew technique for electrical isolation of left pulmonary veins can improve sinus conversion rate of patients suffering from both mitral valve disease and atrial fibrillation. In selected subjects, it is safe and has good results in the short-term postoperative period.
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@#Objective To detect the expression of PITX2 and KCNQ1 in the left atrial appendage of patients with atrial fibrillation after modified mini-maze procedure, and to detect the clinical risk factors of different types of atrial fibrillation. Methods We collected left atrial appendage tissue of 59 atrial fibrillation patients who received modified mini-maze procedure and left atrial appendectomy from February 2017 to August 2018. The expression levels of PITX2 and KCNQ1 of left atrial appendage tissue were quantitatively analyzed by western blotting assay between paroxysmal attial fibrillation and persistent atrial fibrillation groups. The correlation between protein expression and prognosis after surgery was also analyzed based on clinical data. Results Binary-logistic regression analysis showed that KCNQ1 expression level was an independent risk factor for the progression from paroxysmal atrial fibrillation to persistent atrial fibrillation. Receiver operating characteristic (ROC) curve confirmed that KCNQ1 expression level (the ratio of KCNQ1 to actin in the analysis) was 0.60, which was the best cut-off point for the progression of paroxysmal atrial fibrillation to persistent atrial fibrillation. Conclusion High expression of KCNQ1 in left atrial appendage is a risk factor for progression from paroxysmal atrial fibrillation to persistent atrial fibrillation.
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BACKGROUND: Patients with mitral valve disease have a higher incidence of atrial fibrillation after mitral valve replacement and mitral annuloplasty. Maze surgery is the gold standard for surgical treatment of atrial fibrillation. The effect of artificial valve and valve ring on maze surgery is not clear. OBJECTIVE: To evaluate the changes of sinus rhythm-left atrial contractive function after surgical maze ablation of valvular atrial fibrillation and whether valve replacement or valve ring implantation affects the recovery of sinus rhythm-left atrial contractive function. METHODS: From October 2013 to October 2017, 324 patients who underwent surgical maze ablation due to mitral valve lesions associated with persistent or long-term persistent atrial fibrillation in the General Hospital of Northern Theater Command were enrolled. All patients were treated with artificial valve replacement or artificial valve ring implantation after maze operation. The patients were followed up by electrocardiogram and echocardiography at discharge and 1, 3, 6, 12 and 24 months after procedure. A multivariate Cox analysis of predictive factors for left atrial contractive function recuperation was applied. This study was approved by the Medical Ethics Committee of General Hospital of Northern Theater Command (original General Hospital of Shenyang Military Region of Chinese PLA). RESULTS AND CONCLUSION: (1) Two patients (0.6%) died during the perioperative period, and the remaining 322 patients were followed up for 2 years. There were no adverse events related to artificial materials during the follow-up. (2) The recovery rate of left atrial contractive function increased gradually after procedure. The coexistence consistency of left atrial contractive function and sinus rhythm was good until 1 year after surgery (Kappa coefficient = 0.75, P 3 months) after surgical maze ablation (all P values 0.05). (4) ROC curve analysis showed that the optimal critical value of preoperative atrial fibrillation time and preoperative left atrial diameter for prediction of left arterial contractive function recovery was 36.5 months (sensitivity 90.5%, specificity 93.7%) and 60.5 mm (sensitivity 93.8%, specificity 85.0%) respectively. (5) These results suggest that the recovery of left atrial contractive function after surgical maze ablation is a dynamic improvement process. Early recovery of left atrial contractive function is beneficial to maintaining stable sinus rhythm in the future. Prolonged duration of atrial fibrillation, enlarged left atrial diameter, and cryoablation mode may have adverse effects on surgical maze ablation. Valve ring implantation or valvular replacement does not affect the efficacy of surgical maze ablation.
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A 74-year-old female underwent an uneventful bilateral thoracoscopic maze procedure for persistent atrial fibrillation with continuous transesophageal echocardiographic (TEE) guidance. She presented six weeks later with persistent fever and focal neurological signs. Computed tomography of the thorax revealed air in the posterior LA, raising suspicion for an abscess versus an atrioesophageal fistula (AEF). Before undergoing an exploratory median sternotomy, an esophagogastroduodenoscopy (EGD) was performed by the surgeon to check for any esophageal pathology. This however, resulted in sudden hemodynamic compromise that required intensive treatment with vasopressors and inotropes. In this case-report, we review the various intraoperative risk factors associated with the development of AEF during cardiac ablation procedures as well as the potential hazards of esophageal instrumentation with TEE, naso- or oro- gastric devices, and/or an EGD when an AEF is suspected.
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BACKGROUND: Limited comparative data are available on the efficacy of cryoablation versus radiofrequency ablation in patients with atrial fibrillation. This study aimed to compare radiofrequency ablation and cryoablation with regard to clinical outcomes and the restoration of sinus rhythm or atrial contractility. METHODS: A total of 239 patients who underwent surgical ablation between August 2003 and December 2016 at our institution were included. The patients were divided into 2 groups according to the energy device that was used (group A: n=140, radiofrequency ablator; group B: n=99, cryoablator). Echocardiographic data, overall survival, and major cardiovascular and cerebrovascular event (MACCE)-free survival were compared between the 2 groups. RESULTS: At 1 year of follow-up, the atrial contractility recovery rate was 32.2% (19 of 59) in group A and 48.8% (21 of 44) in group B. In addition, cryoablation was found to be a predictive factor for the recovery of atrial contractility (cryoablation vs. radiofrequency ablation: odds ratio, 2.540; 95% confidence interval, 1.063–6.071; p=0.036). The left ventricular ejection fraction was significantly higher in group B (53.1%±11.5% vs. 59.1%±6.3%, p=0.001). The median follow-up duration was 36 months. The 5-year overall survival rate was 80.1%±3.6% in group A and 92.1%±2.9% in group B (p=0.400). The 5-year MACCE-free survival rate was 70.3%±4.0% in group A and 70.9%±5.6% in group B (p=0.818). CONCLUSION: Cryoablation was associated with a higher atrial contractility restoration rate and better left ventricular function than radiofrequency ablation. However, no significant relationship was observed between the energy source and overall or MACCE-free survival.
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Humans , Atrial Fibrillation , Catheter Ablation , Cryosurgery , Echocardiography , Follow-Up Studies , Odds Ratio , Stroke Volume , Survival Rate , Ventricular Function, LeftABSTRACT
Objective: To explore the clinical efficacy of surgical radiofrequency ablation-modified Maze procedure in treating atrial fibrillation (AF) patients with large left atrial heart valve disease. Methods: A total of 267 patients received cardiac valve replacement and radiofrequency ablation-modified Maze procedure at the same time in our hospital from 2014-01 to 2015-15 were retrospectively studied. Based on the size of left atril, patients were divided into 2 groups: Group A, patients with left atrial size<60 mm, n=182 and Group B, patients with left atrial size≥60 mm, n=85. All patients were followed-up for 6 months after operation, clinical efficacy of surgical radiofrequency ablation-modified Maze procedure in treating AF was compared between 2 groups. Results: ①All patients were successfully completed the operation, radiofrequency ablation time was similar between Group A and Group B [18-32 (24±4) min] vs [22-38 (25±6)min], P>0.05. ②The ratios for recovering to sinus rhythm at the end of operation and discharge in Group A were 156/182 (86%) and 152 (84%), in Group B were 56/85 (66%) and 54 (64%); at 3 and 6 months post-operation in Group A were 149/182 (81.6%) and 146 (80.2%), in Group B were 48/85 (56.4%) and 46 (54.1%), all P<0.05. ③No patients needed installing permanent pacemaker, no operative mortality and no ablation related complications.Conclusion: Radiofrequency ablation-modified Maze procedure was safe, simple and effective in treating heart valve disease complicated AF, the effect in patients with left atrial ≥60 mm was inferior than left atrial<60mm; it could be used in clinical practice.
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@#Objective To investigate the preliminary experience, the evolution of surgical approach of multidisciplinary therapy for atrial fibrillation and the advantages and disadvantages of each procedure. Methods We retrospectively analyzed the clinical data of 69 patients with stand-alone surgical ablation with or without transcatheter radiofrequency ablation for atrial fibrillation in our center from January 2015 to May 2017. There were 50 males and 19 females at average age of 57.2 years. The patients were divided into three groups according to the surgical approach including a median sternotomy group (n=9), a left unilateral thoracoscopy group (n=7) and a bilateral thoracoscopy group (n=53). One (11.1%) patient, 3 (42.9%) patients and 26 (49.1%) patients received transcatheter mapping and radiofrequency ablation after surgical ablation in each group, respectively. Results The mean follow-up time in the median sternotomy group was 10.2 months. All 9 patients maintained sinus rhythm. The mean follow-up time of the left unilateral thoracoscopy group was 7.4 months. Five (71.4%) patients maintained sinus rhythm. While the mean follow-up time of the bilateral thoracoscopy group was 5.0 months. Forty-seven (88.7%) patients maintained sinus rhythm. There was no perioperative death, or death, stroke, major bleeding nor pulmonary vein stenosis during follow-up. Conclusion The classic Cox-Maze Ⅳ procedure with high success rate is still the basic operation for the surgical treatment of atrial fibrillation, while the thoracoscopic mini maze procedure has the advantages of minimally invasiveness, repeatibility, and can achieve similar results as Cox-Maze Ⅳ procedure when combined with transcatheter radiofrequency ablation. Multidisciplinary therapy could be the best solution for non-paroxysmal atrial fibrillation.
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Objective To investigate the clinical efficacy and prognosis of bipolar radiofrequency ablation for atrial fibrillation in patients with cardiac valve disease.Methods Sixty patients with atrial fibrillation and valvular heart diseases who merely underwent cardiac valve surgery were selected as the control group,and seventy-five patients who underwent bipolar radiofrequency ablation modified Maze procedure along with concomitant cardiac valve surgery were selected as the observation group.The perioperative technological characteristics and postoperative restoration of sinus rhythm in different time-points of the two groups were retrospectively analyzed.Results There was no significant differences in terms of the surgical pathway and types of replaced cardiac valves (P ＞ 0.05),but the cardiopulmonary bypass time and aortic-cross clamping time of the observation group were significantly longer than those in the control group(P ＞ 0.05).Successful restoration of sinus rhythm in the observation group was significantly higher than that of the control group 3 months,6 months,and 1 year after operation respectively.Conclusion Bipolar radiofrequency ablation modified Maze procedure along with concomitant cardiac valve surgery is clinically effective during the short term for the patients with atrial fibrillation and valvular heart diseases.
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BACKGROUND: The absence of atrial contraction (AC) after the maze procedure has been reported to cause subsequent annular dilatation and to increase the risk of embolic stroke. We hypothesized that the lack of AC could increase the risk of permanent pacemaker (PPM) implantation in patients undergoing the maze procedure. METHODS: In 376 consecutive patients who had undergone a cryo-maze procedure and combined valve operation, recovery of AC was assessed at baseline and at immediate (≤2 weeks), early (≤1 year, 4.6±3.8 months), and late (>1 year, 3.5±1.1 years) postoperative stages. RESULTS: With a median follow-up of 53 months, 10 patients underwent PPM implantation. Seven PPM implants were for sinus node dysfunction (pauses of 9.6±2.4 seconds), one was for marked sinus bradycardia, and two were for advanced/complete atrioventricular block. The median (interquartile range) time to PPM implantation was 13.8 (0.5–68.2) months. Our time-varying covariate Cox models showed that the absence of AC was a risk factor for PPM implantation (hazard ratio, 11.92; 95% confidence interval, 2.52 to 56.45; p=0.002). CONCLUSION: The absence of AC may be associated with a subsequent risk of PPM implantation.
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Humans , Atrial Fibrillation , Atrioventricular Block , Bradycardia , Cryosurgery , Dilatation , Follow-Up Studies , Proportional Hazards Models , Risk Factors , Sick Sinus Syndrome , StrokeABSTRACT
Purpose: Atrial fibrillation (AF) is the most common arrhythmia treated in the world. While medical treatment with antiarrhythmic drugs remains the primary treatment modality, symptomatic refractory AF often requires treatment with a catheter or surgical ablation. One minimally invasive therapy is the Mini‑Maze procedure, which utilizes epicardial radiofrequency ablation via a subxiphoid approach to rid the heart of arrhythmogenic atrial foci without a median sternotomy or cardiopulmonary bypass. The goal of this retrospective cohort study was to identify clinical factors associated with metabolic acidosis following the Mini‑Maze procedure. Materials and Methods: After Institutional Review Board approval, we studied patients undergoing the Mini‑Maze procedure, off‑pump coronary artery bypass grafting or patients conventional Cox‑Maze on cardiopulmonary bypass. The first base deficit value obtained in the Intensive Care Unit was used as a measure of metabolic acidosis. Using logistic regression with Akaike information criteria, we analyzed preoperative, intraoperative, and postoperative data to determine the factors associated with changes in base deficit. Results: A multivariable model using stepwise selection demonstrated that diabetes mellitus and weight were associated with a decrease in the base deficit by 2.87 mEq/L (95% CI: −5.55–−0.19) and 0.04 mEq/L (95%CI: −0.08, 0.004), respectively. Furthermore, creatinine was associated with a 1.57 mEq/L (95% CI: 0.14, 2.99) increase in the base deficit. Conclusion: The Mini‑Maze procedure was not associated with postoperative metabolic acidosis. Instead, nondiabetic patients and patients with higher creatinine were associated with greater base deficits after undergoing cardiac surgery.
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<p>Cor triatriatum is a rare congenital cardiac anomaly in which the accessory chamber is separated from the left atrium by an anomalous septum. We report a rare case of cor triatriatum with severe mitral regurgitation and atrial fibrillation in an adult. The patient was a 65-year old woman who developed congestive heart failure 3 years previously, and received medical follow-up with mitral regurgitation, atrial fibrillation and cor triatriatum since then. She developed congestive heart failure again and was referred to our hospital for operation for progressed mitral regurgitation, tricuspid regurgitation and atrial fibrillation. Mitral valve plasty (Physio ring II 28 mm, cleft closure, edge to edge repair for PMC), tricuspid annuloplasty (Physio tricuspid ring 28 mm), resection of the anomalous septum and maze procedure was performed. All of the pulmonary veins were connected to the accessory chamber. There was only one hole on the anomalous septum, and the hole was large, about 3.0 cm in diameter. The patient regained sinus rhythm without mitral and tricuspid regurgitation after the operation. Even though the duration of atrial fibrillation was long and left atrium diameter was large, complete excision of the anomalous septum and maze procedure were effective for the patient diagnosed cor triatriatum.</p>
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Despite its proven efficacy in the treatment of atrial fibrillation (AF), the Cox-Maze III procedure has not been widely accepted owing to its complexity and technical difficulty. New ablation technologies have led to the development of various simplified lesion sets, including minimally invasive techniques. Given recent improvements in the percutaneous catheter ablation technique, it seems to have replaced surgical treatment of AF, especially for lone AF. However, suboptimal results of catheter ablation have been reported, and it has been well established that the Cox-Maze III procedure is still the gold standard for surgical AF ablation. Nevertheless, many physicians and patients are reluctant to undergo surgery for lone AF because of its invasiveness. In this regard, improvements in minimally invasive technology should be directed toward replicating the original Cox-Maze III technique and ultimately on performing it on the beating heart without cardiopulmonary bypass. This review provides an overview of the current state of the art and future directions in the surgical treatment of AF. Based on a better understanding of the mechanisms of AF and various treatment techniques, and improvements in diagnostic techniques, the appropriate option among various surgical techniques should be selected tailored to individual patients, making the surgical treatment of AF available to a larger population of patients.
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Humans , Atrial Fibrillation , Cardiopulmonary Bypass , Catheter Ablation , HeartABSTRACT
Objective To observe the bipolar radiofrequency ablation maze procedure (BRAMP) combined with heart valve replacement for rheumatic heart disease (RHD) complicated with atrial fibrillation (AF), and discuss the curative effect of the new operation method. Methods Fifteen patients with RHD complicated with AF were treated with heart valve replacement and BRAMP (treatment group). At the same time, 15 patients with RHD complicated with AF were only heart valve replacement without BR AMP(control group). Results Treatment group were all cured, and they had the sinoatrial rhythm after operation.Followed up 6 months, 14 patients maintained sinus rhythm,one had AF occasionally. In control group, 13 patients had AF after operation,2 patients had the sinoatrial rhythm after operation, but they tumed to AF one or two days later,and amiodarone hydrochloride had no effect to them. The two groups had obvious differences in the length of left atria, the length of left ventricle, the size of the heart, the function of the heart and LVEF before and after operation (P ＜ 0.01 or ＜ 0.05). But in treatment group, the length of left atria and the size of the heart had obvious difference after operation compared with control group [ (31.06 ± 2.28 ) mm vs. (36.16 ±2.23) mm,t = 11.645,P =0.002; (50 ±9)% vs. (56 ± 10)% ,t =8.052,P =0.008].Conclusion Compared with the operation that heart valve replacement without BRAMP,BRAMP is simple and little, should be promising.
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BACKGROUND: We analyzed our experience of arrhythmia surgery in patients with congenital heart disease. MATERIAL AND METHOD: A retrospective review was performed on 43 consecutive patients with congenital heart disease, who underwent arrhythmia surgery between June 1998 and June 2006. RESULT: The median age at surgery was 52 years (4~75 years). The most frequent cardiac anomaly was an atrial septal defect (23/43, 53.5%). The types of arrhythmias were atrial flutter-fibrillation, intermittent non-sustainable ventricular tachycardia and others in 37, 2 and 4, respectively. Arrhythmia surgery consisted of a bi-atrial maze operation in 18 patients (modified cox maze III procedure in 5 patients, and a right side maze plus pulmonary vein cryo-isolation in 13), right side maze operation in 18 patients, cavo-tricuspid isthmus cryoablation for benign atrial flutter in 4 patients, right ventricular endocardial cryoablation in 2 patients and extranodal cryoablation for atrioventricular node re-entry tachycardia in 1 patient. The median follow-up was 23.8 months (1~95.2 months). There was no early mortality, and one late non-cardiac related death. The overall rates of restored sinus rhythm before discharge and 3~6 months after surgery were 79% and 81%, respectively (bi-atrial maze group: 72% and 83%, right-side maze group: 77%, 77%). CONCLUSION: Arrhythmias associated with congenital heart disease can be safely treated surgically with an excellent intermediate-term outcome.
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Humans , Arrhythmias, Cardiac , Atrial Fibrillation , Atrial Flutter , Atrioventricular Node , Cryosurgery , Follow-Up Studies , Heart Defects, Congenital , Heart Septal Defects, Atrial , Mortality , Pulmonary Veins , Retrospective Studies , Tachycardia , Tachycardia, VentricularABSTRACT
55 mm or course of AF over 2 years [54.5%(24/44) and 68.7%(46/67),?2=29.265,P=0.000 and ?2=13.814,P=0.000].Conclusion RFA Maze Ⅲ procedure during open-heart surgery is safe and effective for patients with AF.
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A 53-year-old woman with atrial septal defect (ASD) and atrial fibrillation (AF) with idiopathic thrombocytopenic purpura (ITP), was scheduled to undergo ASD closure and the maze procedure. Because steroid therapy was not effective, high-dose γ-globulin administration (400mg/kg/day) was performed for 5 days before surgery. The platelet count increased from 5.4×10<sup>4</sup>/mm<sup>3</sup> to 14.0×1<sup>4</sup>/mm<sup>3</sup>. ASD patch closure and modified bilateral appendage preserving (BAP) maze procedure were performed. No hemorrhagic tendency was recognized. The postoperative course was uneventful, and the sinus rhythm was recovered. The maze procedure become possible in this ITP patient with preoperative administration of high-dose γ-globulin.
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Atrial fibrillation is one of the most common cardiac arrhythmias requiring treatment. About 60% of patients with mitral valvular disease have atrial fibrillation and one third of the patients with atrial fibrillation may have the past history of thromboembolic events. Between April 1994 and June 1995, 20 patients with organic heart diseases combined with atrial fibrillation underwent open heart surgery including Cox-maze III procedure. There were 6 men and 14 women with an average age of 48 years (range, 31 to 66 years). Nineteen patients had valvular heart diseases and 1 ventricular septal defect (VSD). Mean duration of atrial fibrillation was 36 months (+/-42 months) (range, 1 to 132 months). The past medical history of thromboembolic events was positive in 7 patients (35%) and left atrial thrombi was detected in 9 patients (45%). The concomitant procedures were mitral valve replacement (MVR) and aortic valve replacement (AVR) in 5 patients, MVR in 4, MVR and tricuspid annuloplasty (TAP) in 4, mitral valvuloplasty (MVP) in 3, MVP and TVP in 1, MVP and coronary artery bypass surgery in 1, AVR in 1, and patch closure of VSD in 1. Mean aortic cross-clamping time was 175 minutes (range, 116 to 270 minutes). Atrial fibrillation recurred in 16 patients (80%) during the early postoperative period, however, the recurrent atrial fibrillation converted to regular rhythm at postoperative forty-first day in average. There was no early or late death in this series of 20 patients and postoperative complications were inappropriate tachycardia in 5 patients (25%), low cardiac output syndrome in 3 (15%), aggravated hemiplegia in 1, and acute renal failure in 1. Mean follow-up interval of the patients was 16.5 months (range, 10.5 to 24 months) and all the patients are currently in regular rhythm. Seventeen patients (85%) are in sinus rhythm and 3 (15%) in junctional rhythm. Right atrial contraction was detected in 95% of patients and left atrial contraction in 63% on postoperative transthoracic echocardiogram. The surgical treatment of atrial fibrillation concomitant with open heart surgery is warranted in the recent clinical setting of improved myocardial protection technique, considering the untoward side-effects of atrial fibrillation.
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Female , Humans , Male , Acute Kidney Injury , Aortic Valve , Arrhythmias, Cardiac , Atrial Fibrillation , Cardiac Output, Low , Coronary Artery Bypass , Follow-Up Studies , Heart Diseases , Heart Septal Defects, Ventricular , Heart Valve Diseases , Heart , Hemiplegia , Mitral Valve , Postoperative Complications , Postoperative Period , Tachycardia , Thoracic SurgeryABSTRACT
This paper presents successful surgical treatment of a-trial fibrillation by a simplified maze procedure (SMP) in 3 patients. All of them suffered from rheumatic heart valvular diseases complicated with atrial fibrillation (AF) for 3 to 10 years. Their heart function were in class III-IV(NYHA). The diameter of the left atrium varied from 52-58 mm and the cardiothoracic ratio 0. 64-0.70. The open heart operation was performed under conventional cardiopulmonary bypass combined with systemic hypothermia and using cardio-plegia for myocardial protection. After finishing the modified maze operation,mitral valve replacement was performed in 2 cases and mitral and aortic valve replacement together with tricuspid annuloplasty in one. Sinus rhythm recovered after cardiac ressuscitation and was maintained in the early postoperative period in all 3 cases. However, with in 3 months after the operation, one patient died of cerebrovascular accident, probably a complication of anticoagulant therapy. The other 2 patients remained well with normal sinus rhythm and their heart function was in class I 3 years after the operation. The clinical results indicate that mitral valve or mitral and aortic valve replacements plus simplified maze procedure to abolish atrial fibrillation may improve the postoperative hemodynamics by recovery of the sinus rhythm.