(Circulation. 2000;101:1559.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Results of Maze Surgery for Lone Paroxysmal Atrial Fibrillation
From the Departments of Cardiology (E.R.J, N.M.v.H., M.A.M.S., J.C.K., J.M.P.G.E.) and Cardiothoracic Surgery (J.A.M.T.D., A.B.d.l.R.), St Antonius Hospital, Nieuwegein, The Netherlands.
Correspondence to N.M. van Hemel, MD, Department of Cardiology, St Antonius Hospital, PO Box 2500, 3430 EM Nieuwegein, The Netherlands. E-mail rdcardio{at}worldonline.nl
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Abstract |
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Background—If drug refractoriness to paroxysmal atrial fibrillation (PAF) occurs, arrhythmia surgery that involves channelling and the exclusion of specific atrial areas can abolish atrial fibrillation. The purpose of this study was to establish the effectiveness and safety of maze III surgery to abolish PAF.
Methods and Results—Surgery was performed in 41 selected patients who had long-standing, symptomatic, drug-refractory, lone PAF. At discharge, 35 patients (85%) were arrhythmia free, and 6 patients (15%) showed PAF and paroxysmal atrial tachycardia. Death or stroke did not occur during a mean follow-up of 31±16 months. At the end of follow-up, 39 patients (95%) had no PAF; however, in 2 patients (5%), PAF persisted and eventually required His bundle ablation and pacing. Three months after surgery, nodal escape rhythm was observed in only 1 patient, whereas sick-sinus syndrome emerged late after surgery in 2 patients. Antiarrhythmic drugs were used in 20% of patients during follow-up. The quality of life improved markedly after surgery and remained unchanged afterward. Echocardiographic findings did not alter, but exercise capacity increased.
Conclusions—This pilot study demonstrates the effectiveness and safety of maze III surgery for lone PAF. In patients without sick-sinus syndrome, this intervention offers a sensible alternative to His bundle ablation and lifelong pacemaker dependency.
Key Words: atrial fibrillation • surgery • arrhythmia
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Introduction |
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Antiarrhythmic drugs remain the first-line therapy for the prevention and rate control of paroxysmal atrial fibrillation (PAF). If drug refractoriness emerges, however, catheter His bundle ablation followed by cardiac pacing is often applied; this therapy shows satisfying results.1 2 3 4 However, pacemaker dependency and the requested continuation of drug therapy after His bundle ablation to maintain sinus rhythm are often disliked by patients. Arrhythmia surgery is an alternative, nonpharmacological therapy that avoids the drawbacks of catheter His bundle ablation.
Atrial fibrillation (AF) is caused by random reentry, and a critical number of circulating reentrant wavelets is necessary to perpetuate the arrhythmia,5 6 although sometimes rapidly firing atrial foci may be responsible for the onset of PAF.7 A reduction of the atrial mass and surface limits the number of wavelets. Therefore, AF cannot be initiated by atrial premature beats or it terminates easily. Surgical exclusion, fractionation, and channeling of atrial areas8 are tools to suppress AF resulting from random reentry and to preserve atrial contraction and filling and sinus node function. Various surgical concepts, including the corridor procedure,9 left atrial isolation,10 11 maze surgery,12 13 pulmonary button isolation,14 and the atrial compartment operation15 16 have been performed in selected patients. However, the long-term results of surgery for PAF in patients without structural cardiac disease are few13 17 18 because this surgery is usually done in conjunction with mitral valve surgery. This study reports our long-term experience with maze III surgery as a treatment for lone PAF.
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Methods |
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Patient Selection
Patients younger than 70 years of age who were suffering from symptomatic, drug-refractory PAF were offered surgery as an alternative treatment. PAF was defined as AF with spontaneous termination,19 although electrical cardioversion was needed at least once in most cases. Drug refractoriness was defined as the failure of
4 different antiarrhythmic drugs or withdrawal from
use of the drugs because of side effects. Sick-sinus syndrome,
permanent ("accepted") AF, focal atrial tachycardias,
or serious ventricular arrhythmias ruled out
surgery. Patients with PAF who also showed structural cardiac disease
or who had suspected tachycardiomyopathy were also
excluded. Verbal consent for surgery was obtained after oral
information about the surgery was given to the patient.
Preoperative Studies
Preoperatively, the duration of PAF and the number of failed
antiarrhythmic drugs were noted. Standard ECG, 2-channel Holter
recordings, and bicycle stress testing with oxygen consumption
were used to document PAF and to exclude sinus node disease and
abnormal atrioventricular conduction. Two-dimensional
and pulsed-wave Doppler echocardiographic studies
were performed to measure cardiac chamber size and function and to
exclude structural cardiac disease. Left and right heart
catheterization and coronary angiography were
performed to rule out cardiac abnormalities and to obtain information
on the arterial supply of the sinus node area. Catheter
mapping of AF for detecting a focal origin or classifying the
arrhythmia was not done.
Surgical Procedure
The technique of maze surgery has been reported in detail
previously12 and can be summarized as follows. Initial
dissection consists of extensive mobilization of both caval veins and
the roof of the left atrium. After bicaval cannulation, total
cardiopulmonary bypass is instituted, and the heart is
arrested. The right and left atrium are incised (Figure 1
). After suturing all incisions, air is
evacuated from the heart, and the patient is weaned from
cardiopulmonary bypass. In addition to standard postoperative
care, anticoagulant therapy with Coumadin is administered from the
first postoperative day for up to 3 months after discharge. This is
followed by treatment with aspirin.
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2 cm, the other on the medial
aspect extending to the anteromedial tricuspid valve (TV) annulus (2);
a cryolesion (C) is placed at the annulus. A posterior, longitudinal
right atriotomy is made from deep in the inferior vena cava
and runs cranially high into the superior vena cava (3; SVC). Finally,
an incision perpendicular to this longitudinal incision is made,
Postoperative Studies
Pairs of temporary epicardial wires were attached to the left
and right atrium and the right ventricle for the diagnosis of
postoperative arrhythmias.18 Before discharge, we
attempted to induce AF using programmed electrical stimulation.
Follow-Up Studies
All patients were followed in our outpatient department,
initially at 3- to 6-month intervals, and then annually after the first
year. Patients were asked in particular about palpitations and symptoms
of cerebrovascular accidents; daily lifestyle and exercise capacity
were also questioned. Holter recordings and bicycle stress
tests were performed 6 months after discharge and annually thereafter
to detect AF, sinus node dysfunction, and abnormal
atrioventricular conduction.
Echocardiographic studies were done
simultaneously.
Quality of Life
Quality of life was assessed before surgery and at 3 and 12
months after surgery using a Dutch translation of the 36-item
Short-Form Health Survey questionnaire.20 This tool was
supplemented with a question about perceptions of changes in health and
a self-designed questionnaire that assessed cardiac symptoms, sleep,
cognitive functioning, mental health, and social functioning. Because
the range of scores varied for all subscales, scores were normalized to
a scale ranging from 0 to 100; lower scores represent a lower
quality of life.
Definitions
The primary end point of maze surgery was permanent absence of
AF. A second end point was preserved sinus node function. Chronotropic
incompetence of the sinus node was defined as symptomatic
sinus bradycardia at rest of <60 bpm, a requirement for pacemaker
therapy, or an insufficient increase of sinus rate at stress testing,
which was arbitrarily chosen as <80% of the predicted value according
to sex and age criteria.21
Statistical Analysis
All values are expressed as mean±SD. Hypothesis testing was
computed using paired tests. For proportions, the McNemar test was
used; for normally distributed data, the paired t test was
used; and for non-normally distributed data, the Wilcoxon test
was applied. P<0.05 was considered significant.
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Results |
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Patients
From June 1993 to July 1998, 41 patients with lone PAF underwent maze surgery. Table 1
shows the preoperative clinical characteristics of this consecutive
series. The common patient profile was a 50-year-old man who had PAF
for 5 years.
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In-Hospital Results
After surgery, neither major complications nor death
occurred in any patient. One patient had an immediate
recurrence of AF (Figure 2) and showed severe heart failure
1 week after surgery, which required high dosages of diuretics.
Before discharge, programmed electrical stimulation was performed in 32
of the 41 patients (78%). AF could not be induced in 29 of these
32 patients (92%); during follow-up, 1 of these 29 patients
temporarily showed PAF, and 1 patient showed paroxysmal atrial
tachycardia (Figure 3). In 3
of the 32 stimulated patients (8%), AF could be induced: only 1 of
these 3 patients suffered intractable PAF requiring His bundle ablation
afterward; the other 2 patients remained arrhythmia-free.
Postoperative stimulation was not done in 9 patients: 1 patient refused
the test, AF was present in 3 patients, and a loss of atrial
capture was present in 5 patients. At discharge (Figure 4), 35 of the 41 patients were free from
PAF (85%); 4 of these 35 patients showed nodal escape rhythm due to
incompetent sinus rhythm. Six of the 41 patients (15%) had PAF
(Figure 2), flutter, or atrial tachycardia, which
lasted from seconds to a maximum of 4 hours, with spontaneous
conversion to normal sinus rhythm. A total of 37 of the 41 patients
(90%) were discharged with no antiarrhythmic drug therapy.
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Follow-Up Results
Rhythm
All patients were alive after a mean follow-up of 31±16
months. Neither neurological nor cardiac complications were observed.
Only 1 patient complained of incessant sinus
tachycardia22 ; this patient required
ß-blockers some months after surgery. The proportion of patients with
sinus rhythm without atrial arrhythmias increased from 76%
immediately after discharge to 92% at the 12-month follow-up;
thereafter, this diminished to 85% (Figure 4
). After resumed
sinus rhythm, the number of patients with nodal escape rhythm without
AF diminished to 2 asymptomatic patients at 3 months and to
1 patient after 3 months. Exercise testing of this patient 34
months after surgery initiated sinus tachycardia with a
peak rate of 154 bpm (96%) at 89% of maximal exercise. In 2
other patients, infrequent asymptomatic sinus arrests of
>4 s were recorded 26 and 27 months after surgery,
respectively; 1 patient required atrial pacing. The number of patients
with atrial arrhythmias diminished 3 months
after surgery (Figure 4). Two patients with recurrent
drug-refractory PAF postoperatively underwent His bundle ablation and
pacemaker implantation 13 and 29 months after surgery, respectively
(Figure 2). The percentage of patients who did not take
antiarrhythmic drugs to prevent atrial arrhythmias remained
stable (80%).
Echocardiography
The mean values of
echocardiographic
parameters did not clearly change after surgery, except for
right atrial volume (Table 2).
The average preoperative left atrial volume was markedly larger
in the 6 patients with PAF at discharge compared with that of the
arrhythmia-free patients (62±17 and 49±11 mL, respectively,
[P=0.03]), but other atrial measurements did not differ.
Mitral and tricuspid valve damage was not detected after surgery. The
mean left ventricular end-diastolic diameter
remained unchanged.
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Exercise Tolerance
No patient showed PAF during exercise testing after surgery.
Exercise capacity, maximal workload, and peak oxygen consumption
(
O2) significantly increased
(Table 2) after surgery.
Quality of Life
This parameter was assessed in 18 of 41 patients
(34%). It significantly improved 3 months after surgery and stabilized
thereafter (Table 3).
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Discussion |
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This prospective study demonstrated very satisfying immediate and midterm results of maze surgery for lone PAF. Twelve months after surgery, PAF was abolished in >90% of patients, and sinus node function remained undisturbed in 97%. In addition, quality of life and exercise tolerance significantly improved, whereas atrial echocardiographic measurements did not show deleterious effects of surgery.
Atrial Arrhythmias After Surgery
It has been reported that PAF, atrial
tachycardia, and flutter frequently emerge soon after maze
surgery and continue for some months14 because of atrial
edema, pericarditis, surgical trauma, and elevated levels of
catecholamines, which inhibit the recovery of
preoperatively abnormal atrial
electrophysiological
properties.14 22 Recovery from the surgical trauma takes 2
to 3 months, as evidenced by a spontaneous reduction of atrial
arrhythmias, which was also observed in our study (Figure 4). Left atrial size seems more strongly associated with a cure
of AF in patients undergoing maze surgery in conjunction with other
cardiac surgery than other factors, such as age, sex, and duration of
AF.23 The left atrial volume was markedly larger in our
patients with early recurrent PAF than in those without postoperative
arrhythmias. Finally, scarring from the atrial incisions can
result in de novo atrial tachycardia (Figure 3),
although unexcluded atrial foci should be considered as well.
Sinus Node Function After Surgery
In 4 of our 41 patients, a nodal escape rhythm was
present at discharge; it persisted in only 1 patient. Temporary
denervation or degeneration of sinus node cells due to atrial surgery
is the supposed mechanism of this
dysfunction,24 although an impairment by PAF cannot be
excluded.25 The surgical trauma sometimes also causes a
temporary reduction of the circadian variations of autonomic nerve
activity24 26 or incessant sinus node
tachycardia24 ; only 1 of our 41 patients
transiently experienced incessant sinus tachycardia. The
heart rate response to exercise can be reduced soon after maze surgery,
but it usually normalizes within 1 year.24 27 An unchanged
average maximal heart rate at exercise 12 months after surgery was
observed in our patients (Table 2). Although sick-sinus syndrome
was ruled out before surgery, in 2 patients, longstanding sinus arrests
emerged >2 years later. Our findings confirm the previously reported
progression of atrial disease in AF as evidenced by sick-sinus
syndrome.28 29
Atrial Function After Surgery
Preoperative left and right atrial contraction could only be
observed in half of our patients (Table 2), probably because of
PAF.30 Twelve months after surgery, the number of patients
with atrial contraction had not clearly increased. This finding
suggests that surgery is detrimental to atrial contraction due to the
multiple atrial incisions and sutures and the subsequent scarring,
particularly of the left atrium,31 because contraction of
the right atrium was more frequently seen than contraction of the left
atrium.31 32 A second reason for this difference could be
a diminished synchronization between the left atrium and ventricle due
to the surgically created prolonged route of conduction from the right
to left atrium.31 Maze surgery did not markedly reduce
mean atrial volumes and diameters (Table 2) or adversely affect
mitral or tricuspid valve or ventricular function.
Longitudinal studies of atrial function are needed to establish the
risks of maze surgery on atrial
contractility.31
Patient Improvement
In view of the large physical impact of surgery for PAF, long-term
patient improvement is the crucial objective, but it was not an end
point of this study. Although long-term arrhythmia monitoring
was limited to regular Holter recordings and ECG at exercise,
clinical experience shows that these patients with longstanding
symptomatic PAF before surgery became very sensitive to
palpitations. Interruption of their normal heart rhythm after
surgery would be readily noticed, and they would ask for new
examinations. The arrhythmia history of these patients can,
therefore, provide reasonable insight into the long-term surgical
result. At the end of follow-up, 95% of the patients had no PAF and
80% were drug-free; thus, it is not surprising that the quality of
life, as documented in the patients who were operated on most recently
(40%), dramatically improved after surgery and remained unchanged
afterward. This was also true for the improvement in exercise
tolerance.
Because atrial function and dimensions did not change (Table 2),
one can conclude that suppression of atrial arrhythmias is the
crucial contribution to patient improvement.
Comparison With Other Surgical Methods
A technical obstacle of corridor surgery was the sometimes
irreducible conduction between the left atrium and corridor compartment
through the muscle tissue of the coronary sinus, which resulted
in postoperative recurrences of PAF.17 18
Sometimes, this technical failure is also observed when applying left
atrial isolation.10 11 In maze surgery, the isolation of
the coronary sinus is done more laterally to the
coronary os, where the amount of accompanying muscular tissue
to be destroyed diminishes strongly and where conduction is more easily
interrupted. Our maze surgery results with lone PAF clearly surpass our
previous results with corridor surgery in 36 comparable
patients.18
At 3.5 years of follow-up in the patients who had corridor surgery, the actuarial freedom of atrial arrhythmia without drugs was 72±9%, actuarial freedom of sinus node dysfunction was 81±7%, and chronic pacing was needed in 16%.17 18 Comparisons with the outcomes of surgery for left atrial isolation,10 11 the atrial compartment procedure,15 16 and pulmonary button isolation14 in patients with lone PAF cannot be made because these interventions were mostly done in conjunction with mitral valve surgery. In the accumulated maze surgery series (n=178) of Cox et al,13 32 58% of patients had lone AF and 66% underwent arrhythmia surgery only. The authors reported a combined recurrence of atrial flutter and AF of 2% in the 118 patients who had maze III surgery; they also reported blunted sinus node chronotropy in 6% of patients, and iatrogenic sinus node injury was absent in the 82 patients without preoperative sick-sinus node disease.
Limitations
As discussed earlier, the true incidence of PAF
recurrence could not be determined because Holter
recordings were done at intervals; symptoms during follow-up
were always a reason for further arrhythmia analysis.
Event recorders can undoubtedly provide better information, but the
devices must be activated by the patient and
asymptomatic arrhythmia will escape
recording. This study was designed to validate maze III surgery
for PAF; therefore, these results cannot provide a recommendation for
selection between focal catheter ablation, His bundle ablation, or
surgery in patients with problematic PAF. A larger patient
population with more variables (such as atrial
size)33 34 35 and a longer follow-up time are needed to
assess the contribution of this surgery to the suppression of AF and to
prove its superiority over other methods.28 Finally,
because PAF was only diagnosed by ECG, recommendations for surgery for
specific types of PAF cannot be given.
Conclusions
Successful surgery for lone PAF involves abolishment of the
arrhythmia, undisturbed sinus node function, no mortality, and
a low morbidity risk. In addition, the intervention must be widely
applicable, not cause a deterioration in hemodynamic
parameters and, finally, diminish the thromboembolic risk
of AF. The consequence is an improved quality of life after surgery.
This pilot study showed that these goals can be achieved with maze III
surgery provided that surgical experience with atrial
arrhythmia is available and sick-sinus syndrome can be ruled
out before surgery. Longitudinal evaluation of atrial contraction and
filling and of sinus node function is needed to define the position of
maze surgery in the management of lone PAF. Finally, more information
on the mechanism and pattern of PAF is needed to optimize the selection
of surgery for drug-refractory PAF.
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Acknowledgments |
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The authors thank Gerda J.L. van der Kuijl for manuscript editing.
Received August 6, 1999; revision received October 18, 1999; accepted November 5, 1999.
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S. Forlani, R. De Paulis, L. G. Wolf, R. Greco, P. Polisca, M. Moscarelli, and L. Chiariello Conversion to Sinus Rhythm by Ablation Improves Quality of Life in Patients Submitted to Mitral Valve Surgery. Ann. Thorac. Surg., March 1, 2006; 81(3): 863 - 867. [Abstract] [Full Text] [PDF]
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N. M. van Hemel and J. A.M.T. Defauw Maze procedure Ann. Thorac. Surg., January 1, 2004; 77(1): 381 - 381. [Full Text] [PDF]
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G. Bonanomi, D. Schwartzman, D. Francischelli, K. Hebsgaard, and M. A. Zenati A new device for beating heart bipolar radiofrequency atrial ablation J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 1859 - 1866. [Abstract] [Full Text] [PDF]
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J. Raman, S. Ishikawa, M. M. Storer, and J. M. Power Surgical radiofrequency ablation of both atria for atrial fibrillation: results of a multicenter trial J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1357 - 1365. [Abstract] [Full Text] [PDF]
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 H. T Sie, W. P Beukema, A. Elvan, and A. R Ramdat Misier New strategies in the surgical treatment of atrial fibrillation Cardiovasc Res, June 1, 2003; 58(3): 501 - 509. [Abstract] [Full Text] [PDF]
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E. R. Jessurun, N. M. van Hemel, J. C. Kelder, J. A.M.T. Defauw, A. Brutel de la Riviere, J. M.P.G. Ernst, and W. Jaarsma The effect of maze operations on atrial volume Ann. Thorac. Surg., January 1, 2003; 75(1): 51 - 56. [Abstract] [Full Text] [PDF]
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 E. R. Jessurun, J. M. T. de Bakker, N. M. van Hemel, T. Opthof, A. C. Linnenbank, P. F. H. M. van Dessel, J. J. A. M. T. Defauw, and A. B. de la Riviere Right atrial modification of maze surgery does not affect refractoriness and conduction patterns of human lone atrial fibrillation Europace, January 1, 2003; 5(1): 39 - 46. [Abstract] [PDF]
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S. Lonnerholm, P. Blomstrom, L. Nilsson, and C. Blomstrom-Lundqvist Atrial size and transport function after the Maze III procedure for paroxysmal atrial fibrillation Ann. Thorac. Surg., January 1, 2002; 73(1): 107 - 111. [Abstract] [Full Text] [PDF]
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M. M. Scheinman and F. Morady Nonpharmacological Approaches to Atrial Fibrillation Circulation, April 24, 2001; 103(16): 2120 - 2125. [Abstract] [Full Text] [PDF]
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