Application of Cut-and-Sew Technique in Thoracoscopic Minimally Invasive Mitral Valve Surgery and Concomitant Maze Procedure.

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.

Long-Term Outcomes of the Maze Procedure Combined with Endoatriectomy for Patients with Calcified Left Atria.

PURPOSE: Left atrial calcification (LAC) is found in long-lasting rheumatic valvular disease and is almost always accompanied by atrial fibrillation (AF). In the presence of LAC, endoatriectomy is required when performing the maze procedure. However, the technical feasibility of endoatriectomy and the long-term outcomes of the maze procedure in patients with LAC are uncertain. METHODS: The medical records of 18 consecutive patients who underwent combined endoatriectomy and maze procedure were analyzed retrospectively. RESULTS: Accompanying operations were mitral valve replacement (n = 16) and commissurotomy (n = 2). There was 1 operative death from sepsis following mediastinitis. When patients were divided into "broad" (n = 11) and "limited" (n = 7) groups, with the extent of LAC either greater or less than half of the left atrium, respectively, there was no intergroup difference in postoperative complications. During follow-up (median, 11.4 years), AF recurred in 11 patients. At the last follow-up visits, electrocardiography revealed significantly fewer patients in the broad group maintaining sinus rhythm (1/11 vs 4/6, P = 0.03). The 10-year AF recurrence-free survival rates were 13.9% and 66.7% in the broad and limited groups, respectively (P = 0.01). CONCLUSIONS: The maze procedure combined with endoatriectomy seems technically feasible with acceptable long-term rhythm outcomes if the LAC extent is limited.

Impact of maze procedure in patients with severe tricuspid regurgitation and persistent atrial fibrillation.

OBJECTIVE: Patients with severe tricuspid regurgitation and persistent atrial fibrillation may not be good candidates for maze procedure due to preoperative atrial remodeling and various comorbidities. We attempted to evaluate the rhythm and clinical outcomes of maze procedure in these patients. METHODS: Patients with severe tricuspid regurgitation and persistent atrial fibrillation who underwent tricuspid valve surgery between January 1994 and December 2017 at a single tertiary center were analyzed. The primary end point was sinus rhythm restoration. The key secondary end point was major adverse cardiovascular and cerebrovascular event rate, which is the composite event of stroke, cardiac death, major bleeding, and readmission for heart failure. Propensity score matching analysis was used. RESULTS: A total of 388 patients underwent tricuspid valve surgery, and among them 172 patients (44%) underwent concomitant maze procedure. The maze group had sinus rhythm restoration rate of 56% in 9 years. Further, in the matched cohort, the maze group had higher freedom from major adverse cardiovascular and cerebrovascular event rate at 10 years than the nonmaze group (55.6% vs 36.2%; P = .047). Preoperative left atrial diameter (hazard ratio, 1.022; 95% CI, 1.012-1.033; P < .001) and right atrial diameter (hazard ratio, 1.012; 95% CI, 1.003-1.022; P = .013) were independent risk factors for failure of sinus rhythm. CONCLUSIONS: Maze procedure in severe tricuspid regurgitation and persistent atrial fibrillation had acceptable rates of sinus rhythm restoration and reduced major adverse cardiovascular and cerebrovascular events in the long-term. Careful patient selection considering preoperative atrial diameters is needed to enhance maze success rate and long-term clinical outcomes.

Mitral valve repair and concomitant maze procedure versus catheter ablation in the treatment of atrial functional mitral regurgitation.

BACKGROUND: To compare mitral valve (MV) repair and concomitant maze procedure with catheter ablation in treating patients with atrial functional mitral regurgitation (AFMR). METHODS: We retrospectively identified 126 patients with AFMR from January 2012 to December 2015. Of these patients, 60 patients underwent MV repair and concomitant maze procedure, and 66 patients received catheter ablation. Patients were followed up for 7.98 ± 2.01 years. The survival, readmission of heart failure (HF), persistent atrial fibrillation (AF), persistent moderate-severe mitral regurgitation (MR) and tricuspid Regurgitation (TR), and echocardiographic data were analyzed in the follow-up. Predictors of readmission of HF were analyzed. RESULTS: There was no significant difference in baseline and echocardiographic characteristics, in-hospital mortality, and other adverse events postoperatively between two groups. The surgical group was associated with lower rates of MR > 2 + grade either at discharge (P = 0.0023) or in the follow-up (P = 0.0001). There was no significant difference in the incidence of overall survival between the two groups. The surgical group was associated with a lower rate of readmission of HF and AF in the follow-up. Univariable and multivariable analysis confirmed AF at discharge, moderate-severe MR at discharge, no MV surgery, moderate-severe TR at discharge, and LA volume as predictors of readmission of HF. Both groups experienced significant reverse cardiac remodeling. CONCLUSIONS: Our results suggest that for the treatment of AFMR with persistent or long-standing persistent AF and moderate-severe MR, MV repair and concomitant maze procedure may achieve a better outcome than catheter ablation procedure.

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.

The systemic-immune-inflammation index predicts the recurrence of atrial fibrillation after cryomaze concomitant with mitral valve surgery.

BACKGROUND AND AIMS: Inflammation plays a key role in the initiation and progression of atrial fibrillation (AF). The systemic inflammation indexes are easily evaluated and predict AF development. However, it's role in prediction of recurrence of AF is unknown. We aim to explore the association between the systemic inflammation indexes and recurrence of AF in patients underwent cryoablation (CryoMaze) concomitant with mitral valve surgery. METHODS: We examined systemic inflammation indexes during perioperative period in 122 patients between 2015 and 2018. Systemic inflammation indexes were developed by systemic immune-inflammation index (SII), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and lymphocytes to monocytes ratio. Univariate and multivariate analyses were performed to examine the association of each markers with recurrence of AF. RESULTS: Of the 122 patients included in this study, 22 patients (18%) experienced AF recurrence after CryoMaze concomitant with mitral valve surgery. There is no significant difference between each systemic inflammation indexes before surgery and recurrence of AF. In univariate analysis, MLR after surgery 3 days, PLR, MPLR, NLR, SII after surgery 7 days were able to predict recurrence of AF. In multivariate analyses, SII ≥ 1696 independently predicted recurrence (OR, 3.719; 95% CI, 1.417-9.760). Interestingly, baseline SII showed no significant in prediction of recurrence. It was sharply elevated after surgery and dropped slowly. In patients of recurrence, SII after 7 days of surgery increased again. CONCLUSIONS: The raised SII again was associated with an increased risk of the postoperative recurrence of AF and independently predicted the late recurrence of AF after CryoMaze concomitant with mitral valve surgery.

The long-term outcomes and durability of the Cox-Maze IV procedure for atrial fibrillation.

OBJECTIVE: Surgical ablation of atrial fibrillation (AF) is indicated both in patients with AF undergoing concomitant cardiac surgery and in those who have not responded to medical and/or catheter-based ablation therapy. This study examined our long-term outcomes following the Cox-Maze IV procedure (CMP-IV). METHODS: Between May 2003 and March 2018, 853 patients underwent either biatrial CMP-IV (n = 765) or a left-sided CMP-IV (n = 88) lesion set with complete isolation of the posterior left atrium. Freedom from atrial tachyarrhythmia (ATA) was assessed for up to 10 years. Rhythm outcomes were compared in multiple subgroups. Predictors of recurrence were determined using Fine-Gray regression, allowing for death as the competing risk. RESULTS: The majority of patients (513/853, 60%) had nonparoxysmal AF. Twenty-four percent of patients (201/853) had not responded to at least 1 catheter-based ablation. Prolonged monitoring was used in 76% (647/853) of patients during their follow-up. Freedom from ATA was 92% (552/598), 84% (213/253), and 77% (67/87) at 1, 5, and 10 years, respectively. By competing risk analysis, incidence of first ATA recurrence was 11%, 23%, and 35% at 1, 5, and 10 years, respectively. On Fine-Gray regression, age, peripheral vascular disease, nonparoxysmal AF, left atrial size, early postoperative ATAs, and absence of sinus rhythm at discharge were the predictors of first ATA recurrence over 10 years of follow-up. CONCLUSIONS: The CMP-IV had an excellent long-term efficacy at maintaining sinus rhythm. At late follow-up, the results of the CMP-IV remained superior to those reported for catheter ablation and other forms of surgical ablation for AF. Age, left atrial size, and nonparoxysmal AF were the most relevant predictors of late recurrence.

Postoperative Coronary Artery Spasm After Mitral Valve Replacement and Cox-Maze IV Procedure: A Case Report.

BACKGROUND: Few cases have been reported about coronary artery spasm after a mitral valve replacement and concomitant Cox-Maze IV procedure. We report the case of an adult male who developed right coronary artery (RCA) spasm after a mitral valve replacement with tricuspid valve repair and Cox-Maze IV procedure. CASE REPORT: A 66-year-old male, complaining of progressive exertional shortness of breath, was diagnosed with severe mitral stenosis, moderate tricuspid regurgitation, complete right bundle branch block, and persistent atrial fibrillation (AF) in our clinic. The patient underwent elective mitral valve replacement, tricuspid valve repair, and Cox-Maze IV procedure. Four hours after surgery, a 12-lead electrocardiogram (ECG) showed progressive elevation of ST-segment in the avF and III leads and Troponin-T was over 7000 pg/mL. After one hour, Troponin-T increased to over 10000 pg/mL, and ECG still showed persisted ST-segment elevation in inferior leads. Emergent angiography was performed, and intra-coronary administration of nitroglycerin completely relieved the spasm. CONCLUSION: Potential risks of coronary injury after valvular surgery and Cox-Maze IV procedure need further aggressive investigation and postoperative ischemia should prompt an emergent coronary angiography to identify the cause and apply immediate therapy.

Does ablation of atrial fibrillation at the time of septal myectomy improve survival of patients with obstructive hypertrophic cardiomyopathy?

OBJECTIVE: To evaluate the outcomes after septal myectomy in patients with obstructive hypertrophic cardiomyopathy according to atrial fibrillation and surgical ablation of atrial fibrillation. METHODS: We reviewed patients with obstructive hypertrophic cardiomyopathy who underwent septal myectomy at the Mayo Clinic from 2001 to 2016. History of atrial fibrillation was obtained from patient histories and electrocardiograms. All-cause mortality was the primary end point. RESULTS: A total of 2023 patients underwent septal myectomy, of whom 394 (19.5%) had at least 1 episode of atrial fibrillation preoperatively. Among patients with atrial fibrillation, 76 (19.3%) had only 1 known episode, 278 (70.6%) had recurrent paroxysmal atrial fibrillation, and 40 (10.2%) had persistent atrial fibrillation. Surgical ablation was performed in 190 patients at the time of septal myectomy, including 148 with pulmonary vein isolation and 42 with the classic maze procedure. Among all patients, operative mortality was 0.4%, and there were no early deaths in patients undergoing surgical ablation. Over a median follow-up of 5.6 years, patients with preoperative atrial fibrillation had increased mortality (hazard ratio, 1.36; 95% confidence interval, 0.97-1.91; P = .070) after multivariable adjustment for comorbidities. When considering the impact of atrial fibrillation with or without surgical treatment, the adjusted hazard ratio for mortality in patients undergoing ablation compared with no ablation was 0.93 (95% confidence interval, 0.52-1.69; P = .824). CONCLUSIONS: Atrial fibrillation is present preoperatively in one-fifth of patients with obstructive hypertrophic cardiomyopathy undergoing myectomy and showed a trend toward higher all-cause mortality. Survival of patients undergoing septal myectomy with preoperative atrial fibrillation was similar between those who did and did not receive concomitant surgical ablation.

Impact of age on atrial fibrillation recurrence following surgical ablation.

OBJECTIVES: The incidence of atrial fibrillation (AF) in patients older than 75 years of age is expected to increase, and its treatment remains challenging. This study evaluated the impact of age on the outcomes of surgical ablation of AF. METHODS: A retrospective review was performed of patients who underwent the Cox-maze IV procedure at a single institution between 2005 and 2017. The patients were divided into a younger (age <75 years, n = 548) and an elderly cohort (age ≥75 years, n = 148). Rhythm outcomes were assessed at 1 year and annually thereafter. Predictors of first atrial tachyarrhythmia (ATA) recurrence were determined using Fine-Gray regression, allowing for death as the competing risk. RESULTS: The mean age of the elderly group was 78.5 ± 2.8 years. The majority of patients (423/696, 61%) had nonparoxysmal AF. The elderly patients had a lower body mass index (P < .001) and greater rates of hypertension (P = .011), previous myocardial infarction (P = .017), heart failure (P < .001), and preoperative pacemaker (P = .008). Postoperatively, the elderly group had a greater rate of overall major complications (23% vs 14%, P = .017) and 30-day mortality (6% vs 2%, P = .026). The percent freedom from ATAs and antiarrhythmic drugs was lower in the elderly patients at 3 (69% vs 82%, P = .030) and 4 years (65% vs 79%, P = .043). By competing risk analysis, the incidence of first ATA recurrence was greater in elderly patients (33% vs 20% at 5 years; Gray test, P = .005). On Fine-Gray regression adjusted for clinically relevant covariates, increasing age was identified as a predictor of ATAs recurrence (subdistribution hazard ratio, 1.03; 95% confidence interval, 1.02-1.05, P < .001). CONCLUSIONS: The efficacy of the Cox-maze IV procedure was worse in elderly patients; however, the majority of patients remained free of ATAs at 5 years. The lower success rate in these greater-risk patients should be considered when deciding to perform surgical ablation.

A safe and secure approach for creating a box lesion in the left atrium.

A bipolar radiofrequency clamp is an attractive alternative to the cut-and-sew technique for surgical ablation of atrial fibrillation. We have been using this device for isolating the posterior left atrium. However, there is a risk of disconnection of the ablation lines as well as perforation of the left atrium by the tip of the radiofrequency clamp. Here, we report our simple contrivance to make the procedure more secure and safe.

Partial upper sternotomy for concomitant left atrial ablation and aortic valve replacement.

BACKGROUND: Minimally invasive access via partial sternotomy has been established for aortic valve surgery in the past years. But concomitant procedures like atrial ablation and aortic valve replacement via partial upper sternotomy have not been investigated so far. We therefore present our operative technique and results in terms of safety and efficacy, including follow-up and quality of life. METHODS: Between February 2007 and March 2014 a total of 67 patients undergoing isolated minimally invasive aortic valve replacement received concomitant left atrial ablation at our centre. Operative technique and short- and midterm results are described, including quality of life assessment using the SF-36 questionnaire. RESULTS: Operative techniqual success rate was 98.5%. We observed only one (1.5%) ablation-related conversion to full sternotomy. Operative times, reexploration and stroke rates as well as 30-day mortality are comparable to open procedures. Efficacy: The proportions of patients in sinus rhythm at discharge was 54.5% for paroxysmal AF patients and 27.7% overall. After a mean follow-up time of 38.0±22.6 months the cardiac related mortality rate was 4.5%, the rate of sinus rhythm was 72.7% for paroxysmal AF patients and 36.8% overall. Of survivors, overall mean quality of life was 7.3±2.1 as measured by SF-36. CONCLUSIONS: Concomitant left atrial ablation and aortic valve replacement can safely be performed via partial sternotomy and results are non-inferior to open surgery.

Inter/Intra-Atrial Dissociation in Patients With Maze Procedure and Its Clinical Implications: Pseudo-Block and Pseudo-Ventricular Tachycardia.

Background Severe conduction delay and inter/intra-atrial dissociation may occur in patients who undergo an extensive catheter ablation or a maze procedure for atrial tachyarrhythmia. We report a series of patients with inter/intra-atrial dissociation that mimicked complete atrioventricular block or ventricular tachycardia. Methods and Results We retrospectively reviewed the medical records of 7 patients who were referred for the evaluation of atrioventricular block (patients 1-6) or ventricular tachycardia (patient 7) that occurred after biatrial maze procedure and valvular surgery. During the electrophysiologic study, slow atrial or junctional escape rhythm dissociated from isolated atrial activity mimicked complete atrioventricular blocks. Intra-atrial dissociation of the right atrium or left atrium was observed. Atrioventricular nodal conduction from the nondissociated atrium to the ventricle was preserved in all patients, while the conduction from the dissociated atrium was blocked. In patient 7, the pacing of the ventricle by tracking of atrial tachycardia from the nondissociated left atrium/coronary sinus mimicked ventricular tachycardia during pacemaker interrogation. A total of 5 patients received new permanent pacemaker implantations during the index hospitalization for the surgery (n=2) or as a deferred procedure (n=3) according to the treatment for sick sinus syndrome. Conclusions Pseudo-atrioventricular block or pseudo-ventricular tachycardia may occur because of inter/intra-atrial dissociation after a maze procedure. The selection of patients for permanent pacemaker implantation should be determined based on the patient's symptoms and the status of the escape pacemaker and not on the apparent atrioventricular block. Proper diagnosis is important to avoid unnecessary implantation of a pacemaker or a defibrillator.

Repeat pulmonary vein isolation with or without FIRM-guided ablation for recurrent atrial fibrillation with pulmonary vein reconnection.

INTRODUCTION: Focal impulse and rotor modulation (FIRM) ablation can be used to target nonpulmonary vein (PV) sources of atrial fibrillation (AF). No published studies have compared freedom from atrial fibrillation (FFAF) after pulmonary vein reisolation (PVRI) plus FIRM to PVRI alone in patients with reconnected PVs undergoing repeat ablation. METHODS: A 3:1 matched retrospective cohort study was performed on 21 patients with recurrent AF and PV reconnection who underwent PVRI plus FIRM-guided ablation and 63 patients with recurrent AF treated with PVRI alone at a single institution. All patients in the PVRI-alone cohort had cryoballoon PVRI at the time of repeat ablation without additional lesion sets for AF. Cases were matched based on the type of AF (paroxysmal vs nonparoxysmal), left atrial diameter (±4 mm), left ventricular ejection fraction (±10%), duration of AF (±18 months), and age (±5 years). The primary endpoint was FFAF after a 3-month blanking period. RESULTS: Out of 53 total FIRM cases performed at Northwestern Memorial Hospital between 2015 and 2017, 21 patients had PVRI plus FIRM for recurrent AF with PV reconnection. These patients had an average of 3.3 ± 2.1 rotors (60% left atrial) ablated. Over a median follow-up time of 24.7 months (interquartile range, 13-36 months), patients in the PVRI-alone cohort demonstrated a higher rate of FFAF (n = 35; 55.6%) than patients in the PVRI plus FIRM-guided ablation cohort (n = 7; 33.3%) (logrank P = .049). CONCLUSION: In patients undergoing repeat ablation for AF with PV reconnection, PVRI plus FIRM did not increase FFAF compared to PVRI alone.

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.

Strangulated Intrapericardial Diaphragmatic Hernia after Hybrid Maze Procedure.

Convergent hybrid maze procedure is very safe and effective surgical modality for the treatment of refractory atrial fibrillation. It carries very little risk of complications and an intrapericardial diaphragmatic hernia is amongst the rarest of complications. Only three cases of intrapericardial hernia have been reported in literature till date. This case report describes a middle aged gentleman admitted in emergency department with life-threatening condition of small bowel obstruction secondary to strangulated intrapericardial diaphragmatic hernia. He was resuscitated in Surgical Assessment Unit and underwent emergency laparotomy involving bowel resection and repair of diaphragmatic hernia.