Radiofrequency Maze Operation for Permanent Atrial Fibrillation 高高高高高高 高高高高 高高高高高 Mien-Cheng Chen, MD
Background AF is the most common sustained cardiac
arrhythmia Unpleasant palpitation, aggravation of CHF
and ischemic syndromes, sudden death (eg, WPW syndrome)
Compromised cardiac function: impaired LV function as a result of AF with rapid ventricular rate
Increase the risk of thromboembolism
Mechanisms of AF The wavelength for circus defined as: the
distance traveled by the depolarization wave during the period of the refractory period
wavelength = conduction velocity X refractory period Short wavelength of a premature beat, either
by depressed conduction or shortened refractoriness, may lead to induction of AF
Atrial flutter
AFL was defined as a rapid atrial rhythm (rate > 240 beats/min) characterized by a constant beat-to-beat cycle length, polarity, morphology, and amplitude of the recorded bipolar electrograms and the presence of a constant, stable, and a single reentrant circuit)
Cir Res
1994;74:882-894
Atrial fibrillation AF was defined as a rapid atrial rhythm (rate >
260 beats/min) characterized by variability of the beat-to-beat cycle length, polarity, morphology, and/or amplitude of recorded bipolar atrial electrograms and the presence of an unstable reentrant circuit (ie, one changing in both location and cycle length), more than one reentrant circuit, and/or multiple activation fronts (wavelets)
Cir Res 1994;74:882-894
Surgery for AF 1980, Cox et al. described the left atrial
isolation procedure 1985, Guiraudon et al. described
Corridor procedure 1987, Cox et al. introduced maze
procedure 1994, Lin et al. described atrial
compartment operation
Left Atrial Isolation 1980, Cox et al. performed the procedure in 10
dogs, all remained in normal sinus rhythm
Left Atrial Isolation Graffigna et al. described the procedure in 100
patients with valvular heart disease
Operative mortality 3%
Early postoperative, 81.4% in sinus rhythm
3.1% late death
Long-term results with persistence of sinus rhythm in more than 60%
Ann Thorac Surg 1992;54:1093-8
Left Atrial Isolation Electrically isolated the left atrium from
the remainder of the heart Loss of synchronous left atrial kick
Corridor Operation (Sinus Node-Atrioventricular Node isolation)
Electrically isolating the sinus node, a band of atrial tissue and AV node from the remaining atrial tissue
Corridor Operation 7/9 patients free of AF, 2 recurrent AF,
permanent pacemaker in 4 patients for sinus node dysfunction
JACC 1991;17:970-5
32 patients lone AF, 68% free of any atrial arrhythmias at 4 years
Pace 1993;16:880
Corridor Operation Compromise in hemodynamics
secondary to the absence of synchronous atrioventricular contraction
Same physiological state as His bundle ablation
Vulnerability to systemic embolization
Atrial Compartment Operation 22 patients underwent mitral valve surgery Immediately after operation 91% in sinus rhythm 68% maintained in sinus rhythm for > 1 week 64% maintained in sinus rhythm > 6 months No surgical mortality complication Left atrial paralysis: 11/15 at 1 week, 6/14 at 2
months Right atrial paralysis: 9/15 at 1 week, 1/14 at 2
months
Maze Procedure 1987, Cox et al introduced the maze
procedure Cure AF (by separating and blocking all
the potential macroreentrant pathways and narrowing the atrial tissue to block propagation of the microreentrant wavelets)
Restore AV synchrony Preserved atrial transport function
Maze Procedure 46 patients, Doppler echocardiography, 8 ± 7
months after maze procedure Right atrial (RA) contraction: 83% Left atrial (LA) contraction: 61% RA filling fraction: 32 ± 7% (control: 33 ± 8%) LA filling fraction: 20 ± 5% (control: 36 ± 7%) Decreased LA compliance Cox et al. Circulation 1994;90[Part 2]: II 285-II 292
RF maze II and III operation Between December 1995 and August 1996 12 patients with mitral valve disease and chronic AF
(9M/3F; mean age 50 ± 14 yrs), underwent RF-maze II or III and concomitant valvular operation
10 patients in NYHA class III, 2 in class IV Mean duration of documented AF: 31.3 ± 30.7
months (1-84 months) Preoperative LA dimension 55.0 ± 6.3 mm (48-70) MVD+AVD in 5 patients, MVD+TVD in 3,
MVD+CAD in 1 and isolated MVD in 3
Characteristics of PatientsCase No. Age/Sex NYHA AF
duration
(months)
Heart disease Procedures Type of Maze
1 56/M 3 1 MSR, AR MVR, AVR III
2 32/M 3 48 MSR MVP III
3 47/F 3 72 MR, AR MVR, AVR II
4 35/F 3 24 MSR, TR MVR, TAP II
5 63/M 4 72 MR, TR MVP, TAP II
6 54/F 3 36 MSR MVR II
7 34/M 3 2 MSR, AR MVR, AVR II
8 38/M 3 2 MSR, AR MVR, AVR II
9 44/M 3 12 MR, TR MVR, TAP III
10 57/M 3 18 MSR, AR MVR, AVR II
11 76/M 4 4 MR, CAD MVP, CABG
II
12 61/M 3 84 MSR MVP IIAnn Thorac Surg 1998;65:1666-72
RF maze II and III operation 2 surgical deaths (1 died of massive
cerebral infarction 17th days after operation while in atrial rhythm; the other died of acute renal failure and refractory heart failure while in sinus rhythm)
RF maze II and III operation
Post-operative cardiac rhythm at 6 months: 6 patients in sinus rhythm, 2 in atrial rhythm, 1 in paroxysmal atrial tachycardia and 1 in AF
RF maze II and III operation Doppler echocardiographic study at 6
months:
Right atrial contraction: 80%
Left atrial contraction: 30%
Efficacy of RF-Maze IV Procedure Group 1: 13 patients with mitral valve disease
and chronic AF underwent the RF-maze II (n=9) or III (n=4) procedure
Group 2: Between March 1997 and September 1999, 48 chronic AF patients with mitral valve disease received modified RF-maze IV procedure and concomitant valvular operation
Group 3: 58 chronic AF patients who had mitral valve disease underwent valvular operations only without maze procedure served as control
Mortality and Morbidity Surgical death:
2 patients in Group 2 developed sick sinus syndrome and received VVIR pacemaker implantation
Group 1 Group 2 Group 3
2/13 (15.4%)
1/48 (2.1%), 4/58 (6.9%)
Restoration of Sinus Rhythm Group 1: at a mean follow-up of 43 months,
sinus rhythm: 73% (8/11) AF: 1 patient; paroxysmal AF: 1 patientAFL: 1 patient
Group 2: at a mean follow-up of 16 months,sinus rhythm: 87% (41/47)AF: 3 patientsjunctional rhythm: 1 patientparoxysmal AT and sick sinus syndrome: 1 patientAFL: 1 patient
Group 3: at a mean follow-up of 61 months,sinus rhythm: 11% (6/54)
AF: 48 patients
Postoperative Doppler Echocardiographic Study
Group 1: at a mean follow-up of 43 months, Transmitral A wave (+) in 55% (6/11)
Transtricuspid A wave (+) in 73% (8/11) Group 2: at a mean follow-up of 16 months,
Transmitral A wave (+) in 74% (35/47) Transtricuspid A wave (+) in 81% (38/47) Group 3: at a mean follow-up of 61 months,
Transmitral A wave (+) in 11% (6/54) Transtricuspid A wave (+) in 11% (6/54)
Atrial Size Reduction as a Predictor of the Success of RF-Maze Procedure
01020304050607080
Preop 3M 6M 12M 18M
Time
Lef
t A
tria
l Dia
met
er (
mm
) Success
Failure † †*
A
JCE 2001;12:867-874
Atrial Size Reduction as a Predictor of the Success of RF-Maze Procedure
0
10
20
30
40
50
60
Preop 3M 6M 12M 18M
Time
Rig
ht A
tria
l Are
a (c
m2 ) Success
Failure
† ‡ ‡ ‡
*
B
JCE 2001;12:867-874
Preoperative Left Atrial Size Predicts the Success of Radiofrequency Maze Procedure for Permanent Atrial Fibrillation in Patients Undergoing Concomitant Valvular Surgery
陳勉成醫師 , 張仁平醫師高雄長庚醫院
心臟內科 , 心臟外科
Aims
To test whether preoperative atrial size could determine the rhythm status after RF maze IV operation
Aims
To determine the best cutoff value of preoperative atrial size in predicting the sinus conversion by the RF maze IV procedure using linear discriminant analysis
Methods (Patient Population) Between March 1997 and March 2002, 81
permanent AF patients with mitral valve disease received RF-maze IV procedure while undergoing valvular operation
Results One surgical mortality (1.2%) due to
pneumonia and sepsis; 1 died 13 months later as a result of acute necrotizing pancreatitis
Results Two patients received transvenous VVIR
permanent pacemaker due to sick sinus syndrome developed postoperatively
Results At a mean follow-up of 38 months in the
remaining 77 patients
Sinus rhythm: 65 patients (84.4%)
AF in 9 patients; PAF in 2; persistent AFL in 1
ResultsSuccess (n=65) Failure (n=12) P value
Age 51.7 48.9 NS
Sex (M/F) 32/33 6/6 NS
Duration of AF (months)
36.2 62.1 NS
LA pre (mm) 53.0 62.7 0.02
LAA pre (cm2) 45.0 67.5 0.03
RAA pre (cm2) 25.4 29.1 NS
LVEDD pre (mm) 54.6 51.8 NS
LVESD pre (mm) 35.6 34.9 NS
EF pre (%) 61.6 60.2 NS
RF time (mins) 59.2 68.9 0.02
LA RF time (mins) 35.5 43.4 0.01
Results
By multivariate stepwise logistic regression analysis, only preoperative LA area was significant independent predictor of sinus conversion (P < 0.005)
Results Preoperative LA area: cutoff value 56.25
cm2
Sensitivity: 50%
Specificity: 86.2%
Positive predictive value: 40%
Negative predictive value: 90.3%
Follow-up Months
36 24 12 6 0
50
10
0 Inci
denc
e of
atr
ial
fibr
illa
tion
LA area < 56.25 cm2
LA area > 56.25 cm2
%
40
30
20
P < 0.003
Chen et al. Chest 2004;125:2129-2134
ResultsSuccess (n=65)
Failure (n=12) P value
LA post (mm) 44.1 55.6 < 0.006
LAA post (cm2)
28.5 46.5 < 0.02
RAA post (cm2)
17.9 24.7 < 0.004
LVEDD post (mm)
48.0 51.0 NS
LVESD post (mm)
31.7 33.8 NS
EF post (%) 62.3 62.3 NS
Conclusions (I) RF-maze IV procedure is effective in
terms of restoration of sinus rhythm in permanent AF patients with mitral valve disease undergoing valvular operations
Conclusions (III) Patients who restore their sinus rhythm
have significantly more atrial size reduction after operation than those who fail to restore their sinus rhythm
Predictor of Sinus Conversion by RF-Maze IV Procedure Between March 1997 and March 2002, 81 chronic AF
patients with mitral valve disease received RF-maze IV procedure while undergoing valvular operation
One surgical mortality (1.2%) due to pneumonia and sepsis; 1 died 13 months later as a result of acute necrotizing pancreatitis
Two patients received transvenous VVIR permanent pacemaker due to sick sinus syndrome developed postoperatively
At a mean follow-up of 38 months in the remaining 77 patientsSinus rhythm: 65 patients (84.4%)AF in 9 patients; PAF in 2; persistent AFL in 1
Chest 2004 in press
Predictor of Sinus Conversion by RF-Maze IV Procedure
Success (n=65) Failure (n=12)
P value
Age 51.7 ±11.4 48.9 ±11.9 NS
Sex (M/F) 32/33 6/6 NS
Duration of AF (months)
36.2 ± 44.6 62.1 ± 51.3 NS
LA pre (mm) 53.0 ±8.2 62.7 ±12.2 0.02
LAA pre (cm2) 45.0 ±16.8 67.5 ±30.6 0.03
RAA pre (cm2) 25.4 ± 8.5 29.1 ± 11.2 NS
LVEDD pre (mm) 54.6 ± 9.7 51.8 ± 7.9 NS
LVESD pre (mm) 35.6 ± 9.3 34.9 ± 6.9 NS
EF pre (%) 61.6 ± 13.3 60.2 ± 8.9 NS
RF time (mins) 59.2 ± 13.0 68.9 ± 15.3 0.02
LA RF time (mins) 35.5 ± 9.6 43.4 ± 11.7 0.01
Hospital days 18.5 ± 17.2 16 ± 5.3 NS
ICU days 6.4 ± 11.9 4.8 ±4.6 NS
Predictor of Sinus Conversion by RF-Maze IV Procedure
By multivariate stepwise logistic regression analysis, only preoperative LA area was significant independent predictor of sinus conversion (P < 0.005)
Preoperative LA area < 56.2 cm2
Sensitivity: 86.2%
Specificity: 50%
Positive predictive value: 90.3%
Negative predictive value: 40%
Follow-up Months
36 24 12 6 0
50
10
0 Inci
denc
e of
atr
ial
fibr
illa
tion
LA area < 56.25 cm2
LA area > 56.25 cm2
%
40
30
20
P < 0.003
Chest 2004 in press
Predictor of Sinus Conversion by RF-Maze IV Procedure
Success (n=65)
Failure (n=12) P value
LA post (mm) 44.1 ± 7.6 55.6 ± 11.5 < 0.006
LAA post (cm2)
28.5 ± 9.8 46.5 ± 21.9 < 0.02
RAA post (cm2)
17.9 ± 3.9 24.7 ± 6.5 < 0.004
LVEDD post (mm)
48.0 ± 6.5 51.0 ± 5.7 NS
LVESD post (mm)
31.7 ± 6.7 33.8 ± 5.1 NS
EF post (%) 62.3 ± 10.8 62.3 ± 5.2 NS
Conclusion RF-maze IV procedure is effective in terms of
restoration of sinus rhythm in chronic AF patients with mitral valve disease undergoing valvular operations
Preoperative left atrial size could predict the postoperative rhythm status
Patients who restore their sinus rhythm have significantly more atrial size reduction after operation than those who fail to restore their sinus rhythm