Predictor of atrial fibrillation recurrence in patients who underwent a tricuspid valve operation with modified Cox maze procedure.

BACKGROUND: Recurrence of any atrial arrhythmia after surgical ablation is known as a negative predictor of cardiovascular events and total mortality. However, there have been no focused studies for atrial fibrillation (AF) recurrence prediction in patients with significant tricuspid regurgitation (TR), and the risk-benefit estimation of surgical ablation in tricuspid valve (TV) surgery is not fully established. METHOD: We screened 385 patients who underwent a TV operation between 2001 and 2017. After excluding patients who did not undergo a maze operation, 158 patients were enrolled. Enrolled patients were divided by recurrence of AF. We analyzed the difference between the AF recurrence group and no AF recurrence group, and AF recurrence factors in terms of clinical risk factors and echocardiographic risk factors. The hazard ratio (HR) and 95% confidence intervals (CIs) were presented using a Cox proportional hazard model. RESULTS: Among 158 patients, AF recurred in 65 patients within 10 years. For AF prediction, age was most the important clinical factor and right atrium (RA) diameter was the most important echocardiographic parameters. In patients with a larger RA diameter over 49.2 mm, the prevalence of AF recurrence was higher (HR 4.322, 95% CI [2.185-8.549], log rank p value < .001). In clinical outcome, there was no significant difference between the AF recurrence group and the no recurrence group in terms of death, TR recurrence, heart failure, and stroke. However, the risk of permanent pacemaker (PPM) insertion was higher in the AF recurrence group (HR 10.240, 95% CI [1.257-83.480], log rank p value .007) compared to the no recurrence group. CONCLUSION: Age and RA enlargement are key predictors of AF recurrence after TV operation with the CM procedure in patients with significant TR.

Cox-maze III procedure for atrial fibrillation during valve surgery: a single institution experience.

OBJECTIVES: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in patients with heart valve disease. Our aim was to summarize our experience and evaluate the efficacy and safety of the Cox maze III procedure combined with valve surgery in patients with AF. METHODS: A retrospective, observational analysis was performed for all consecutive patients underwent maze III procedure combined with valve surgery between October 2015 and June 2019. In this trial, we used a monopolar radiofrequency (RF) ablation in addition to cut and sew technique to treat AF. RESULTS: 66 patients (37 female, 56.1%) with persistent or long-lasting persistent AF associated with valve disease were identified. The mean age was 54.2 ± 8.4 years (range, 30 to 73 years). Overall hospital mortality was 3.0%. The duration of cardiopulmonary bypass and aortic cross clamping was 175.4 ± 32.9 and 115.6 ± 22.8 min respectively. The first 24 h drainage was 488.6 ± 293.3 ml. The postoperative hospital stay was 14.8 ± 8.3 days. The postoperative incidence of permanent pacemaker implantation, reoperation for bleeding, renal failure required hemodialysis, and stroke was 4.5, 1.5, 4.5% and 0 respectively. The frequency of sinus rhythm was 91.7, 93.1, 94.7, 93.3 and 89.5% at 1, 3, 6, 12, and 24 months respectively. CONCLUSIONS: The Cox-Maze III procedure is safe in the surgical treatment of AF associated with valve disease, and efficacious for sinus rhythm maintenance, with low morbidity and mortality.

The Belgian experience with concomitant surgical ablation of atrial fibrillation: a multi-centre prospective registry.

Background: The Belgian 'National Institute for Health and Disability Insurance (RIZIV-INAMI)' requested prospective collection of data on all ablations in Belgium to determine the outcomes of surgical ablation of atrial fibrillation (AF) during concomitant cardiac surgery.Methods: 890 patients undergoing concomitant ablation for AF between 2011 and 2016 were prospectively followed. Freedom from AF with and without anti-arrhythmic drugs was calculated for 817 patients with follow-up beyond the 3-month blanking period and for 574 patients with sufficient rhythm-related follow-up consisting of at least one Holter registration or a skipped Holter due to AF being evident on ECG. Besides preoperative AF type, concomitant procedure and ablation, potential covariates were entered into uni- and multivariable regression models to determine predictors of outcome.Results: The overall freedom from AF beyond 3 months was 69.9% (571/817) and without anti-arrhythmic drugs at last follow-up 51.0% (417/817), respectively, 61.3% (352/574) and 44.4% (255/574) for patients with sufficient rhythm-related follow-up. Using a Kaplan-Meier estimate, freedom from AF was 89.3%, 74.9% and 59%, without antiarrhythmic drugs 74.4%, 47.8% and 32.3% at 6, 12 and 24 months, respectively. In-hospital mortality was 1.7% (15/890) and the overall survival was 95.0% at 1 year and 92.3% at 2 years. Preoperative left atrial diameter and AF type were significant predictive factors of freedom from AF in a multivariable analysis.Conclusion: Analysis of the Belgian national registry shows that concomitant surgical ablation of atrial fibrillation is safe, achieves favourable freedom from AF and, therefore, deserves to be performed in accordance to the guidelines.

Long-term results of atrial maze surgery in patients with congenital heart disease.

AIMS: Recurrent atrial tachycardia is common after repair of many types of congenital heart disease, and surgical ablation with a maze procedure represents a potential treatment strategy. The objective of this study is to report a single-centre 19 years' experience with maze surgery in congenital heart patients. METHODS AND RESULTS: Patients undergoing maze procedure concomitantly with cardiac surgical procedures were retrospectively analysed. The maze procedure was classified as therapeutic if the patient demonstrated preoperative atrial arrhythmias, or as prophylactic if done because the patient was considered high risk for post-operative arrhythmias. Acute outcomes and longer-term freedom from atrial arrhythmias were analysed. Maze surgery was performed in 166 patients: 137 in the therapeutic group, and 29 in the prophylactic group. The most common congenital heart lesion was single ventricle for the therapeutic group (27%) and Ebstein's anomaly for the prophylactic group (76%). Surgery consisted of a right atrial maze in 63%, left atrial maze in 4%, and bilateral maze in 33%. There were no direct complications or mortality related to the maze procedure itself. For the therapeutic group, freedom from arrhythmias was 82% and 67% at 1 and 5 years post-maze. Younger age at the time of surgery correlated with a lower long-term recurrence risk. CONCLUSION: Maze procedure at the time of an elective anatomic surgery is reasonably effective to prevent and treat atrial arrhythmias in patients with congenital heart disease at short- and mid-term, with low morbidity and mortality.

Contemporary outcomes of the concomitant CryoMaze procedure.

OBJECTIVES: As an institutional strategy, the CryoMaze procedure has been established for treating atrial fibrillation (AF) since 2001. In this study, we aimed to analyse the contemporary outcomes of the CryoMaze procedure and to examine the predictive factors of successful sinus rhythm conversion. METHODS: Between January 2009 and March 2018, we performed 352 CryoMaze procedures. The contemporary outcomes of the CryoMaze procedure concomitant with other cardiac procedures were analysed by the Kaplan-Meier method. The logistic regression model was used to predict risk factors for recurrent AF. RESULTS: There were no 30-day or in-hospital deaths and all of the patients were discharged. The 1- and 5-year survival rates were 99.0% and 94.6%, respectively. The rates of freedom from permanent pacemaker implantation and cerebrovascular accidents were 92.6% at 1 year and 86.9% at 5 years, and 99.1% at 1 year and 97.9% at 5 years, respectively. The rates of freedom from recurrent permanent AF were 91.9% at 1 year and 86.1% at 5 years. The multivariable analysis showed that the independent predictive factors for recurrent permanent AF included an F-wave grade in lead V1 (P < 0.001), the preoperative duration of persistent AF (P = 0.031), a non-mitral procedure (P = 0.019) and a preoperative tricuspid regurgitation grade (P = 0.034). CONCLUSIONS: Preoperative voltage of the F wave in V1 lead is strongly associated with the sinus rhythm restoration after the CryoMaze procedure.

How does the Cox maze procedure compare? Cost-effectiveness analysis of alternative treatments of atrial fibrillation.

OBJECTIVES: Data related to the cost effectiveness of surgical interventions and catheter ablation is sparse. This model-based analysis assessed the clinical and economic trade-offs involved in using catheter ablation or the Cox maze procedure in treating patients with atrial fibrillation. METHODS: A deterministic model was developed to project 1 year and lifetime health-related outcomes, costs, quality-adjusted life years (QALYs) and cost effectiveness of each treatment in patients with atrial fibrillation. Using previously unpublished Inova Heart and Vascular Institute (IHVI) data for patients undergoing either procedure, 1 year cost and clinical efficacy inputs were estimated. This data was supplemented with published literature and used to estimate costs, utilities, mortality and likelihood of patient improvement. Results were reported as cost-effectiveness ratios in $/QALY. Sensitivity analyses were conducted to assess the robustness of results. RESULTS: Patients initially treated with a Cox maze procedure were estimated to have higher costs than those treated with catheter ablation, both after 1 year and over the lifetime. However, patients undergoing the Cox maze procedure also had lower rates of 1 year mortality than catheter ablation patients (3.5% vs. 8.5%) and the highest rate of improvement following treatment, resulting in higher QALYs (12.4 vs. 10.2). Compared to catheter ablation, the lifetime incremental cost-effectiveness ratio for the Cox maze surgical procedure was $12,794 per QALY gained. Without quality adjustment, the ratio was $11,315. Results were most sensitive to the likelihood of improvement following each intervention and the cost of the initial procedure. CONCLUSIONS: At a societal willingness to pay of $100,000/QALY, Cox maze procedure was found to both increase overall and quality-adjusted survival and constitute an effective use of resources in patients with atrial fibrillation.