144例心脏瓣膜病合并心房颤动外科手术同期行单极冲洗射频消融改良迷宫术的疗效

目的分析本院心脏瓣膜病伴发心房颤动(简称房颤)的患者外科手术同期行单极冲洗射频消融改良迷宫术MazeⅢ型手术疗效。方法调查2007年11月至2010年8月收治的心脏瓣膜病合并房颤患者在心内直视手术下同期行单极冲洗射频消融改良迷宫术MazeⅢ型手术,观察随访6个月时的心律情况,根据节律分为窦性心律(简称窦律)组和非窦律组,分析影响术后转律的原因。结果 144例入选,2例安置永久起搏器,1例因瓣周漏而行二次手术。出院时窦律88例(61.11%),房颤39例(27.08%),随访6个月窦律88例(61.11%),房颤25例(17.36%)。窦律组左房小于非窦律组,房颤时间短于非窦律组。左房内径≥6.5 cm者,可达龙的转复率高于非可达龙组(53.8%vs 28.6%,P<0.05)。结论心脏病伴发房颤的病人,在心脏外科手术中同期行单极冲洗射频消融改良迷宫术,对窦律的恢复仍不失为一种安全有效的方法。术前左房内径大小及房颤持续时间是房颤转复的主要危险因素,可达龙在一定程度上可提高大左房(≥6.5 cm)的转复成功率。     

Preoperative atrial size predicts the success of radiofrequency maze procedure for permanent atrial fibrillation in patients undergoing concomitant valvular surgery

BACKGROUND: The radiofrequency (RF) maze procedure can effectively restore sinus rhythm and atrial transport function in the majority of patients with permanent atrial fibrillation (AF) and mitral valve disease. No previous study has described a cutoff value of preoperative atrial size determined by the discriminant analysis in predicting the success of sinus conversion by the RF maze procedure for permanent AF in patients with mitral valve disease. METHODS AND RESULTS: This study included 81 patients with permanent AF and mitral valve disease who underwent the RF maze IV procedure while undergoing concomitant valvular operations. There was one surgical death (1.2%). Another patient died of acute necrotizing pancreatitis 13 months later. Two patients (2.5%) developed sick sinus syndrome and received transvenous permanent pacemaker implantation. In the remaining 77 patients, there were 38 men and 39 women, with a mean (+/- SD) age of 51 +/- 11 years. At a mean follow-up time of 38 months, 65 patients (84.4%) had persistent sinus conversion that had been accomplished by the RF maze procedure (group 1), and 12 patients (15.6%) did not regain sinus rhythm (group 2). We evaluated the preoperative variables between the two groups. Univariate analysis demonstrated that the preoperative left atrial area and the left atrial diameter of group 1 patients were significantly smaller than those of group 2 patients. Group 1 had significantly fewer patients associated with tricuspid valve disease than did group 2. By multiple stepwise logistic regression analysis, only the preoperative left atrial area was an independent determinant of sinus conversion by the RF maze procedure (odds ratio, 0.961; 95% confidence interval, 0.935 to 0.988; p < 0.005). Linear discriminant analysis demonstrated that the sensitivity and specificity of the cutoff value of 56.25 cm(2) of the preoperative left atrial area in predicting the sinus conversion by the RF maze procedure were 50.0% and 86.2%, respectively, and the positive and negative predictive values were 40.0% and 90.3%, respectively. CONCLUSION: The preoperative left atrial area is an independent determinant of sinus conversion by the RF maze procedure for patients with permanent AF and mitral valve disease.     

瓣膜置换同期直视下射频消融治疗房颤

目的 探讨瓣膜置换手术同期行双极射频消融治疗心房纤颤(AF)的效果.方法 选择40例有瓣膜置换手术指征的患者,随机分成2组,瓣膜置换合并房颤同期行双极射频消融组20例(治疗组)和同期行经典迷宫组20例(对照组),比较两种手术方法的早期治疗效果.结果 治疗组16例术后恢复窦性心律,转复率为80%.对照组12例术后恢复窦性心律,转复率为60%,两组相比房颤转复率差异有统计学意义(P<0.01).结论 瓣膜置换手术期间使用双极射频消融治疗心房纤颤是安全有效的,能使绝大部分患者恢复窦性心律及心房正常收缩功能.     

Left Versus Bi-Atrial Intraoperative Saline-Irrigated Radiofrequency Modified Maze Procedure for Atrial Fibrillation

BACKGROUND: This study was conducted to evaluate the effectiveness of the saline-irrigated radiofrequency modified maze operation for the treatment of chronic atrial fibrillation (AF) and compare the results of the left and bi-atrial procedures. MATERIAL AND METHOD: During a period of two years, 105 patients with chronic AF having concomitant cardiac surgery underwent the procedure. Patients underwent either a bi-atrial ( n = 48) or left atrial ( n = 57) maze procedure. The first twenty patients underwent a bi-atrial maze procedure regardless of the pathology. In the following patients we adopted the bi-atrial approach in patients with a history of atrial flutter and where the right atrium has to be opened. Otherwise the procedure is restricted to the left atrial side. Mean age was 52 +/- 11 years in bi-atrial group and 54 +/- 9 years in left atrial group. RESULTS: Three patients died early postoperatively (2.9%). There were 4 revisions for bleeding (3.8%). Two patients in bi-atrial group received a permanent pacemaker (4.1%). Patients in both groups were free of AF at the end of the procedure. (Bi-atrial group: sinus: 79.2%, pacemaker: 20.8%), (Left atrial group: sinus: 82.5%, pacemaker: 17.5%) ( p > 0.05). During the last follow-up, sinus rhythm was maintained in 79.6% of cases in bi-atrial group, while this rate was 75.6% in left atrial group ( p > 0.05). CONCLUSION: Saline irrigated radiofrequency modified maze procedure was performed safely and efficiently. Both the left and bi-atrial procedures were successful in terms of restoring sinus rhythm. Our current policy is to adopt the bi-atrial approach in patients with a history of atrial flutter and where the right atrium has to be opened. Otherwise the procedure is restricted to the left atrial side.     

Atrial size reduction as a predictor of the success of radiofrequency maze procedure for chronic atrial fibrillation in patients undergoing concomitant valvular surgery

INTRODUCTION: Previous studies showed that the surgical maze procedure can restore sinus rhythm and atrial transport function in patients with chronic atrial fibrillation (AF). However, no previous studies discussed the association of atrial size reduction and the success of sinus conversion by the radiofrequency (RF) maze procedure for chronic AF. METHODS AND RESULTS: A total of 119 chronic AF patients undergoing valvular operations were included in this study. Sixty-one patients received RF and cryoablation to create lesions in both atria to simulate the surgical maze II or III procedure (RF maze II or RF maze III; 13 patients, group 1) or a modified maze pattern (RF maze "IV"; 48 patients, group 2). The other 58 patients who underwent valvular operations alone without the maze procedure served as control (group 3). At 3-month follow-up after operation, sinus rhythm was restored in 73%, 81%, and 11% of patients in groups 1, 2 and 3, respectively. Preoperative left and right atrial sizes were not statistically significant predictors of sinus conversion by the RF maze procedure. However, as a result of postoperative reduction of atrial sizes, postoperative left atrial diameter was significantly smaller in patients who had sinus conversion by the RF maze procedure than in patients who did not regain sinus rhythm (45.0+/-7.0 mm vs 51.0+/-8.0 mm; P = 0.03). Postoperative right atrial area of patients who had sinus conversion by the RF maze procedure also was significantly smaller than that of patients who did not regain sinus rhythm (18.1+/-4.4 cm2 vs 28.5+/-8.2 cm2; P = 0.008). CONCLUSION: Atrial size reduction appears to predict the success of sinus conversion with the RF maze procedure used in conjunction with valvular surgery.     

Outcomes and predictors of success of a radiofrequency- or cryothermy-simplified left-sided maze procedure in patients undergoing mitral valve surgery

BACKGROUND AND AIM OF THE STUDY: Restoration of sinus rhythm with a maze procedure after concomitant mitral valve (MV) surgery has been shown to reduce the rate of stroke and improve cardiac function and quality of life compared to MV surgery alone. Unlike the classical Cox-Maze III operation, a simplified left-sided maze procedure can be performed without any significant increase in operative complexity. METHODS: Outcomes were compared retrospectively between radiofrequency (RF) and cryothermy as an energy source and analyzed predictors of outcome in 73 consecutive patients undergoing MV surgery with a concomitant simplified left-sided maze procedure. Clinical characteristics as well as rhythm and complication rate at follow up were assessed by review of medical records and patient and physician interview. RESULTS: There were no complications associated directly with the maze procedure. At an average follow up of 342 days, 69% of patients were in normal sinus rhythm. Of the remainder, 30% had recurrent atrial fibrillation (AF) and 1% atrial flutter. In addition, 7% of patients required cardioversion and 14% required anti-arrhythmic therapy to maintain sinus rhythm. Patients with recurrent AF were more likely to have an enlarged right atrium or Carpentier Type IIIa mitral regurgitation on preoperative echocardiography, and more likely to have undergone concomitant aortic or tricuspid valve surgery. There was no difference in outcome between RF and cryothermy as an energy source in unadjusted or adjusted analyses. CONCLUSION: The results of the study helped to establish RF- or cryothermy-simplified left-sided maze procedure as being efficacious and without associated complications in patients having MV surgery and a history of AF. Further investigations are warranted to better define the clinical predictors of recurrent AF to improve patient selection and potentially to modify current maze techniques.     

Left atrial size reduction improves the sinus rhythm conversion rate after radiofrequency ablation for continuous atrial fibrillation in patients undergoing concomitant cardiac surgery

BACKGROUND: Radiofrequency (RF) ablation can effectively restore sinus rhythm in the majority of patients with continuous atrial fibrillation (AF). However, no previous randomized studies have discussed the association of left atrial size reduction and the improvement of sinus rhythm conversion rate after radiofrequency ablation for continuous AF. METHODS: This prospective randomized study included 46 patients with continuous AF and cardiac disease. Twenty patients underwent cardiac surgery and radiofrequency ablation (group I). The other 26 patients underwent cardiac surgery and RF ablation combined with left atrial size reduction (group II). The patients were followed for one year postoperatively. Rhythm, neurological complications, and left atrial size were evaluated. RESULTS: At the one-year follow-up sinus rhythm was restored in 61.1 % of patients in group I and 77.3 % of patients in group II. LA diameter, evaluated by echocardiography, was reduced from 60 +/- 15 mm to 55 +/- 8 mm in group I and from 69 +/- 19 mm to 51 +/- 8 mm in group II. One case of stroke was observed postoperatively in each group. In group I one patient suffered a transient ischemic attack. Two patients in each group received transvenous permanent pacemaker implantation. CONCLUSION: Left atrial size reduction improves sinus rhythm conversion rate after RF ablation for continuous atrial fibrillation in patients undergoing concomitant cardiac surgery.     

Factors related to sinus rhythm at discharge after radiofrequency ablation of permanent atrial fibrillation in patients undergoing mitral valve surgery

Late recovery of sinus rhythm is unusual in patients with permanent AF treated by (radiofrequency) RF maze procedure during mitral valve surgery. Identification of clinical and instrumental preoperative factors predictive of early success of RF ablation in patients with permanent AF undergoing mitral valve surgery may improve selection of subjects to obtain long-term results. Hundred and thirty consecutive patients with permanent AF and mitral valve disease underwent modified RF maze procedure during concomitant mitral valve surgery. Rheumatic valve disease (61 pts) and mitral valve prolapse (41 pts) were the more common aetiology of valve abnormalities. Mitral valve replacement was performed in 54 % of patients and mitral valve repair in the remaining 46 %. Four patients died after surgery. At discharge, 87 patients (69 %) were in sinus rhythm (group 1) and 43 patients in AF persisted (group 2). At an average 24-month follow-up, sinus rhythm was present in 67 % of patients, and 33 % were in atrial fibrillation. In this period, late recovery of sinus rhythm was observed only in five patients, while eight discharged in sinus rhythm developed again atrial fibrillation. Among preoperative parameters at univariate analysis female sex, atrial fibrillation >24 months, left atrial diameter >54 mm, left atrial area >24 cm², rheumatic valve disease and NYHA class were associated with persistence of AF. At Cox regression multivariate analysis, increased left atrial area (OR 1.07 per unit increase—95 % CI 1.01–1.131) and rheumatic aetiology of valve disease (OR 4.52, 95 % CI 1.65–12.4) were associated with persistence of AF at hospital discharge. Persistence of AF after RF ablation in patients undergoing mitral valve surgery is related to aetiology, e.g. rheumatic valve disease, and to increasing left atrial diameter. Due to low rate of late recovery of sinus rhythm, indication to RF ablation associated with MV surgery should be carefully considered in patients with large atria and rheumatic mitral valve disease.     

Antiarrhythmic Surgery to Cure Atrial Fibrillation—Subgroups and Postoperative Management

Antiarrhythmic surgical procedures to cure atrial fibrillation (AF) are widely used in cardiac surgery. Whereas the Cox maze procedure remains the highly effective gold-standard a variety of different antiarrhythmic procedures aim at reducing the extent and duration of the procedure. Antiarrhythmic procedures are especially effective in patients undergoing mitral valve surgery. In 110 patients with permanent AF undergoing various surgical procedures sinus rhythm was re-established in 75%. Subgroup analyses revealed no significant differences in rhythm or survival after antiarrhythmic intraoperative ablation indicating the usefulness and feasibility of this procedure in patients with a wide range of characteristics. Because conversion usually occurs spontaneously within the first 6 months and antiarrhythmic medication does not increase the incidence of conversion it seems reasonable to wait for spontaneous occurrence of sinus rhythm after antiarrhythmic intraoperative ablation. In patients with permanent AF undergoing open heart surgery additional antiarrhythmic procedures have been shown to be safe and effective.     

迷宫手术对二尖瓣病合并的慢性心房颤动电生理的影响

对21例二尖瓣疾患伴心房颤动（简称房颤）施行了迷宫手术和二尖辩手术的患者，采用12导联心电图、心内电生理、动态心电图、踏车运动试验方法进行检查，探讨迷宫手术对慢性房颤患者心脏围手术期和远期电生理的影响。平均随访17．9±7．9个月。结果如下：①术后3个月90％（18／20）恢复窦性心律，随访1年以上者（14例）房颤均未见复发。②术后除1例窦房结恢复时间延长外余均正常，无窦性起搏或房室给传导功能障碍。③术后都有正常的心房激动和房室同步激动顺序。④术后在各标测部位猝发刺激和程控刺激均不能诱发心房扑动和颤动，心房各部位有效不应期均显著长于高位右房有效不应期。⑤动态心电图和运动试验证明有良好的心率变时性反应和运动耐力。⑥1例术后4个半月死于急性坏死性肝炎。以上表明通过电生理检查手段证实了迷宫手术治疗房颤能达到：①消除房颤恢复窦性心律，②重建和（或）维持房室同步活动，③恢复心房传输功能。提出对二尖瓣疾患合并的慢性房颤病人在施行二尖瓣手术时应作迷宫手术。     

Impact of left atrial size reduction and endocardial radiofrequency ablation on continuous atrial fibrillation in patients undergoing concomitant cardiac surgery: three-year results

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the efficacy of left atrial (LA) size reduction combined with radiofrequency (RF) ablation in the treatment of continuous atrial fibrillation (AF), by comparative analysis of the outcomes of patients undergoing RF ablation with and without LA size reduction. METHODS: A total of 46 patients with continuous AF and cardiac disease underwent cardiac surgery and RF ablation alone (group I, n = 20) or combined with LA size reduction (group II, n = 26). Patients were followed for three years postoperatively, with evaluation of cardiac rhythm, neurological complications, LA size (by echocardiography) and atrial contractility. RESULTS: At three years after surgery, sinus rhythm (SR) was restored in 61.1% and 70% of patients in groups I and II, respectively. Mean LA diameter was reduced from 60 +/- 15 mm to 57 +/- 5 mm in group I, and from 69 +/- 19 mm to 55 +/- 6 mm in group II. The overall three-year survival was 90% in group I, and 88.5% in group II. Three-year freedom from stroke was 88.9% and 86.2% in groups I and II, respectively. Two patients in each group received transvenous permanent pacemaker implantation. Atrial contractility was recovered in all patients with stable SR. CONCLUSION: LA size reduction improves SR conversion rate after RF ablation for continuous AF in patients undergoing concomitant cardiac surgery.     

冲洗式射频消融迷宫手术治疗不同病因永久性心房颤动的疗效比较

目的分析和比较我院冲洗式射频消融迷宫手术治疗不同病因永久性心房颤动（房颤）的疗效。方法：收集我院201 1年1月1日-2012年12月31日外科冲洗式射频消融迷宫手术治疗永久性房颤502例病例资料进行分析。根据病因（手术方式）不同分为两组：瓣膜置换并发冲洗式射频消融迷宫手术（瓣膜病组）406例;非瓣膜置换并发冲洗式射频消融迷宫手术（非瓣膜病组）96例。分别于术中心脏复跳、术后1周、3个月和6个月行超声心动图及心电图检查,观察左房、左室大小及窦性心律维持情况。结果：两组术后各时点心脏转复率均无显著差异,两组左房内径均较术前显著缩小。就全部患者而言,术中心脏转为窦性心律者为358例,转复率为71．3％;术后1周为376例,转复率为74．9％;术后3个月为347例,转复率为69．1％。术后6个月为339例,转复率为67．5％。总体手术死亡3例,2例死于低心排,1例死于恶性心律失常（室颤）,手术死亡率为0．6％。结论：冲洗式射频消融迷宫手术治疗不同病因永久性房颤的疗效没有显著差异,疗效均较好。     

梅氏微创房颤消融术的手术配合及体会

目的 总结全胸腔镜下单纯左胸径路房颤超微创外科射频消融术（梅氏微创房颤消融术）的手术配合及体会。 方法 2010年9月至2013年12月,共201例房颤患者于我院接受梅氏微创房颤消融术,阵发性房颤98例,持续性及长程性房颤103例。其中,男106例,女95例;年龄29~81岁,平均年龄（58.7±15.4）岁。回顾性分析患者的临床资料,总结相关手术配合及护理经验,包括：术前访视;手术专用设备、器械及材料的准备;术中体位摆放,设备仪器的连接使用,手术台上操作配合以及对术中突发异常情况的配合。 结果 患者均顺利完成手术,无术中转为开胸手术,平均手术时间为104.9±37.2分钟,手术配合及护理达到预期目的。术中平均失血量小于50 ml,均无输血。73例（70.9%）持续性或长程性房颤接受术中电复律。所有患者离开手术室时均维持窦性心律,仅1例患者术中预放置心外膜临时起搏导线,无起搏器植入病例。8例患者术后住院期间行电复律治疗,出院时190（94.5%）例患者维持窦性心律。所有患者围术期均无脑卒中、大出血等严重并发症发生,无永久起搏器植入,无死亡病例。 结论 梅氏微创房颤消融术安全、有效。完善的术前护理准备,高质量的术中护理配合,对顺利的开展梅氏微创房颤消融术具有重要的临床意义。     

Different strategies for performing pulmonary vein isolation in patients with pulmonary vein rhythm

Pulmonary vein (PV) isolation was performed in atrial fibrillation (AF) patients whose cardiac rhythm was dominated by the ectopic beats originating from the PV. We herein report two cases with dominant PV ectopic rhythm that underwent catheter ablation for the treatment of paroxysmal AF. In one case, a permanent pacemaker implantation was required to treat a symptomatic long sinus pause after the isolation of all four PVs, while no AF was documented during the 5-year period after ablation. However, the isolation of all four PVs except for a PV with a dominant ectopic rhythm was performed in the other case. The latter case was free from both AF and symptomatic bradycardia following the procedure without the implantation of a pacemaker. Selective PV isolation therefore appears to be an effective therapy to both achieve the successful treatment of AF and to prevent the manifestation of sick sinus syndrome.     

Predictors of sinus rhythm after radiofrequency maze and mitral valve surgery

The prevalence and predictors of postoperative sinus rhythm in patients undergoing a radiofrequency ablation maze operation and mitral valve surgery were assessed in 63 patients of whom 54 (86%) were in permanent atrial fibrillation. Operative mortality was 3.17%. At a median follow-up of 18 months, 54 (88.5%) patients were in sinus rhythm and 7 (11.5%) were in atrial fibrillation. The probability of sinus rhythm at 30 months was 92%. Left atrial diameter was the most significant prognostic factor for sinus rhythm on multivariate proportional-hazard regression analysis. The cutoff value of preoperative left atrial diameter for predicting persistent atrial fibrillation at 6 months was 6 cm (100% sensitivity and 73.6% specificity). The radiofrequency ablation maze operation can be performed in addition to mitral surgery with a high rate of successful conversion to sinus rhythm. Preoperative left atrial diameter < 6 cm is an important prognostic factor for sinus rhythm conversion.     

Partial Maze Procedure Is Effective Treatment for Chronic Atrial Fibrillation Associated with Valve Disease

Abstract The maze procedure may be performed in combination with valve operations to treat chronic atrial fibrillation associated with valve dysfunction. Although we initially used the modified Cox maze III procedure, a more limited partial maze procedure is now preferred because the left atrium might be considered as the electrical impetues for atrial fibrillation. In this study we compared the results of 30 patients (group I) who underwent the full biatrial modified Cox maze III and 20 (group II) patients the partial maze procedure. While the rates of restored sinus rhythm were the same in both groups at 6-month follow-up (I: 83.3%, vs II: 80%), the following advantages were noted in the patients undergoing the partial maze procedure: shorter operative times, lesser elevations of creatine phosphokinase, lower rate of blood transfusion, lower rate of junc-tional rhythm soon after the operation, and a higher P wave in those patients with restored sinus rhythm. The effectiveness of the partial maze procedure seems equal to that of the biatrial modified Cox maze III procedure for atrial fibrillation associated with valve disease. The partial maze procedure is simple and less invasive, and thus might be applied more frequently as an additional procedure to valve operations without additional risk.     

Modified Maze Procedure for Atrial Fibrillation as an Adjunct to Elective Cardiac Surgery: Predictors of Mid-Term Recurrence and Echocardiographic Follow-Up

The radiofrequency maze procedure achieves sinus rhythm in 45%–95% of patients treated for atrial fibrillation. This retrospective study evaluates mid-term results of the radiofrequency maze—performed concomitant to elective cardiac surgery—to determine sinus-rhythm predictive factors, and describes the evolution of patients'' echocardiographic variables.From 2003 through 2011, 247 patients (mean age, 64 ± 9.5 yr) with structural heart disease (79.3% mitral disease) and atrial fibrillation underwent a concomitant radiofrequency modified maze procedure. Patients were monitored by 24-hour Holter at 3, 6, 12, and 24 months, then annually. Eighty-four mitral-valve patients underwent regular echocardiographic follow-up. Univariate and multivariate analysis for risk factors of maze failure were identified.The in-hospital mortality rate was 1.2%. During a median follow-up of 39.4 months, the late mortality rate was 3.6%, and pacemaker insertion was necessary in 26 patients (9.4%). Sinus rhythm was present in 63% of patients at the latest follow-up. Predictive factors for atrial fibrillation recurrence were arrhythmia duration (hazard ratio [HR]=1.296, P=0.045) and atrial fibrillation at hospital discharge (HR=2.03, P=0.019). The monopolar device favored maze success (HR=0.191, P <0.0001). Left atrial area and indexed left ventricular end-diastolic volume showed significant decrease both in sinus rhythm and atrial fibrillation patients. Early sinus rhythm conversion was associated with improved left ventricular ejection fraction.Concomitant radiofrequency maze procedure provided remarkable outcomes. Shorter preoperative atrial fibrillation duration, monopolar device use, and prompt treatment of arrhythmia recurrences increase the midterm success rate. Early sinus rhythm restoration seems to result in better left ventricular ejection fraction recovery.     

Sinus node function after cardiac surgery: is impairment specific for the maze procedure?

BACKGROUND: Maze surgery is a final solution for intractable atrial fibrillation (AF), but an adverse effect on postoperative sinus node function has been reported. Whether this also applies to other types of cardiac surgery is unclear. METHODS: We assessed postoperative rhythm by means of repeated exercise tolerance testing, ambulatory electrocardiography, and non-invasive testing of autonomic function between 1 and 12 months after four types of cardiac surgery. Fourteen patients without structural cardiac disease and medically refractory AF underwent the maze III procedure, 11 patients with mitral valve disease and preoperative AF underwent valvar surgery combined with a (simplified) maze III procedure, and 8 patients with mitral valve disease in sinus rhythm (SR) underwent isolated valvar surgery. The control group consisted of eight patients with sinus rhythm who underwent coronary artery bypass surgery (CABG). RESULTS: One month after surgery, the chronotropic response to exercise was depressed, mean heart rate was high, and heart rate variability (HRV) was low, especially after maze III, combined surgery, and isolated valvar surgery. Twelve months after surgery, moderate improvements were observed. After CABG, considerably fewer abnormalities were observed, and HRV parameters recovered to a large extent. Non-invasive testing of autonomic function indicated disturbed vagal modulation of heart rate in all three groups with atrial incision. CONCLUSION: Thus, attenuation of HRV and vagal modulation of sinus node function are not confined to maze surgery but also apply to isolated mitral valve surgery. Atrial incision therefore appears to be crucial and presumably produces autonomic nervous damage followed by partial reinnervation. Nevertheless, cardiac surgery in general seems initially to impair sinus node function with partial recovery in the consecutive 12 months.     

Intra-operative cooled-tip radiofrequency linear atrial ablation to treat permanent atrial fibrillation.

AIMS: To demonstrate the safety and efficacy of saline irrigated cooled-tip atrial linear endocardial radiofrequency ablation (SICTRA) concomitant to open-heart surgical procedures in the treatment of permanent atrial fibrillation (AF). METHODS AND RESULTS: Two hundred and twenty-two patients presenting with permanent AF and the need for cardiac surgery were included. In addition to the cardio-surgical procedure [mitral valve (MV) surgery (n = 94), aortic valve replacement (n = 29), bypass surgery (n = 76 including 24 patients with additional MV surgery), and combined procedures (n = 23)] concomitant SICTRA was performed. In 116 patients, the ablation pattern was restricted to the left atrium alone. During the mean follow-up of 29 months, 174 patients (78%) converted to sinusrhythm (SR). In patients with SICTRA restricted to the left atrium conversion rates were not different compared to a biatrial approach (83 vs. 74%, P = 0.47). Thirty-days mortality was found to be 4% (9/222). Post-mortem evaluation revealed 23% of all lesions to be histologically non-transmural. In the overall group, only 4% of patients developed sustained secondary regular atrial arrhythmia. CONCLUSIONS: SICTRA safely and effectively restores stable SR in 78% of patients with permanent AF undergoing open-heart surgery. Rhythm outcome is not influenced by treatment of the right atrium. Sustained regular atrial arrhythmia with the need for invasive treatment strategies occurs in 4% although intra-operative ablation lesions are often non-transmural.     

Mini-maze suffices as adjunct to mitral valve surgery in patients with preoperative atrial fibrillation

INTRODUCTION: After mitral valve (MV) surgery, preoperative atrial fibrillation (AF) often recurs while cardioversion therapy generally fails. Additional Cox maze surgery improves postoperative arrhythmia outcome, but the extensive nature of such an approach limits general appliance. We investigated the clinical outcome of a simplified, less extensive Cox maze procedure ("mini-maze") as adjunct to MV surgery. METHODS AND RESULTS: Thirteen patients with MV disease and preoperative AF were treated with combined surgery (group 1). Nine control patients without previous AF underwent isolated MV surgery (group 2). We retrospectively compared the results to findings in 23 patients with preoperative AF who had undergone isolated MV surgery (group 3). In group 1, mini-maze took an additional 46 minutes of perfusion time. One 75-year-old patient died of postoperative multiple organ failure. Seven patients showed spontaneously converting (within 2 months) postoperative AF. After 1 year, 82% were in sinus rhythm (SR). No sinus node dysfunction was observed. In group 2, all patients were in SR after 1 year. In group 3, only 53% were in SR after 1 year, despite serial cardioversion and antiarrhythmic drug therapy. Exercise tolerance and heart rate were comparable for groups 1 and 2. Left atrial function was present in all but one patient in group 1 and in all patients in group 2 (after MV reconstruction). CONCLUSION: Adding a relatively simple mini-maze to MV surgery improves arrhythmia outcome in patients with preoperative AF without introducing sinus node dysfunction or persistent absence of left atrial function. The results of this type of combined surgery are encouraging and deserve further attention.