Itoh Akinobu, Kobayashi Junjiro, Bando Ko, Niwaya Kazuo, Tagusari Osamu, Nakajima Hiroyuki, Komori Shigeru, Kitamura Soichiro
Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan.
Eur J Cardiothorac Surg. 2006 Jun;29(6):1030-5. doi: 10.1016/j.ejcts.2006.03.028. Epub 2006 May 3.
Recent studies indicated that successful maze procedure for atrial fibrillation (AF) adjunct to mitral valve surgery provided a lower incidence of stroke and recurrence of AF. The purpose of this study is to review the 13-year experience of these combined procedures and to identify the risk factors and late outcomes of successful maze procedures compared to failed maze procedures.
At a single institution, 521 consecutive patients underwent combined maze procedures with mitral valve replacements or valvuloplasties. Three kinds of maze techniques were primarily used: Cox-maze III, Kosakai maze, and cryo-maze procedure. Three months after the operation, 394 patients were in sinus rhythm (Group S) while the remaining 116 patients were in continuous or intermittent AF (Group F), excluding 11 early death patients. Risk factors for Group F were determined by the analysis of all patient demographics. Survival, freedom from stroke, cardiac events, and AF recurrence were analyzed.
The proportion of the patients without any other simultaneous procedures was greater in Group S (41% vs 29%, P = 0.02). The distributions of mitral valve surgery and maze procedure techniques were similar in these two groups. A left atrium larger than 70 mm [hazard ratio (HR) = 2.6; 95% confidence interval range 1.04-6.3, P = 0.043], preoperative AF history longer than 10 years (HR = 8.2; 4.5-15.1, P < 0.001) and f-wave voltage in V1 smaller than 0.1 mV (HR = 6.2; 5.0-15.2, P < 0.001) were determined to be risk factors for unsuccessful maze procedures. All the results of Cox proportional hazards models showed superiority in Group S; actuarial survival rates (HR = 2.7; 1.04-7.0, P = 0.035), freedoms from stroke (HR = 3.0; 1.1-8.1, P = 0.003) and cardiac events (HR = 4.3; 2.9-6.1, P < 0.001). Freedom from AF recurrence rate was 98.4% at 5 years and 81.0% at 12 years in Group S, and 73.0% and 60.1% in overall patients.
Patients with successful maze procedures resulted in higher survival rate, greater freedom from stroke and cardiac events. The large left atrium, small f-wave, and long AF duration were significant risk factors for failed maze procedures, suggesting that earlier surgical interventions would result in superior results in mitral valve surgery combined with maze procedure.
近期研究表明，二尖瓣手术联合迷宫手术治疗心房颤动（AF）可降低中风发生率及房颤复发率。本研究旨在回顾13年的联合手术经验，确定成功迷宫手术与失败迷宫手术相比的危险因素及远期结局。
在单一机构中，521例连续患者接受了迷宫手术联合二尖瓣置换或瓣膜成形术。主要采用了三种迷宫技术：Cox迷宫III、Kosakai迷宫和冷冻迷宫手术。术后3个月，394例患者处于窦性心律（S组），其余116例患者持续或间歇性房颤（F组），排除11例早期死亡患者。通过分析所有患者的人口统计学特征确定F组的危险因素。分析生存率、无中风、心脏事件及房颤复发情况。
S组未进行任何其他同期手术的患者比例更高（41%对29%，P = 0.02）。两组二尖瓣手术和迷宫手术技术的分布相似。左心房大于70 mm[风险比（HR）= 2.6；95%置信区间1.04 - 6.3，P = 0.043]、术前房颤病史超过10年（HR = 8.2；4.5 - 15.1，P < 0.001）以及V1导联f波电压小于0.1 mV（HR = 6.2；5.0 - 15.2，P < 0.001）被确定为迷宫手术失败的危险因素。Cox比例风险模型的所有结果在S组均显示出优势；精算生存率（HR = 2.7；1.04 - 7.0，P = 0.035）、无中风率（HR = 3.0；1.1 - 8.1，P = 0.003）和无心脏事件率（HR = 4.3；2.9 - 6.1，P < 0.001）。S组5年时房颤复发率为98.4%，12年时为81.0%；总体患者分别为73.0%和60.1%。
迷宫手术成功的患者生存率更高，中风和心脏事件发生率更低。左心房大、f波小和房颤持续时间长是迷宫手术失败的重要危险因素，提示早期手术干预在二尖瓣手术联合迷宫手术中会取得更好的效果。
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