Department of Cardiovascular Surgery, Japan Labor Health and Welfare Organization Osaka Rosai Hospital, Sakai, Osaka, Japan.
Eur J Cardiothorac Surg. 2013 Dec;44(6):1013-22; discussion 1022. doi: 10.1093/ejcts/ezt117. Epub 2013 Mar 13.
We previously reported favourable short-term results of our 'trans-septal maze procedure', a novel technique for creating biatrial lesions through a septal-superior approach during mitral valve surgery. Here, we reviewed the mid-term results of this procedure and determined the impact of restored left atrial (LA) contraction on late outcomes.
We examined clinical data of 50 patients with persistent (n = 7) or long-standing persistent atrial fibrillation (AF) (n = 43) (mean period of rhythm disturbance 77 ± 78 months) who underwent a trans-septal maze procedure concomitant with mitral valve surgery and were followed postoperatively for at least 24 months. The mean preoperative LA dimension was 59 ± 9 mm (40-85 mm). The presence of an A wave in Doppler echocardiography was considered to indicate evidence of LA mechanical contraction. Serial echocardiography was performed to evaluate left ventricular and LA dimensions, degree of valvular regurgitation and estimated systolic pulmonary artery (PA) pressure. Follow-up was completed with a mean duration of 59 ± 17 months (27-92 months).
There were no ablation-related complications and 48 patients (96%) were free from AF immediately after the operation. At the latest follow-up, 39 patients (78%) were free from AF, while 28 (56%) presented LA mechanical contraction. Patients who restored LA mechanical contraction were less likely to experience postoperative thromboembolic events (4 vs 23%, P = 0.075), as compared with those who did not restore it. Serial echocardiography showed that patients with restored LA contraction showed improvement in Doppler-derived systolic PA pressure to a greater degree and less incidence of significant tricuspid regurgitation (7 vs 41%, P = 0.006). The Cox proportional hazards models with adjustments for all other covariates revealed LA dimension >60 mm at baseline as an independent risk factor for lack of LA mechanical contraction (adjusted hazards ratio 3.9, 95% confidence interval 1.1-14, P = 0.035).
Our trans-septal maze procedure may be an effective alternative surgical treatment for eliminating AF during mitral valve surgery. In patients with valvular AF, early surgery is warranted to restore sinus rhythm with LA mechanical contraction, before severe LA dilatation occurs. The impact of LA contraction recovery conferred by AF ablation on postoperative haemodynamic improvements and thromboembolic events remains to be determined.
我们之前报道了我们的“经间隔迷宫手术”的短期良好结果，这是一种通过二尖瓣手术期间的隔上途径来创建双心房病变的新方法。在此，我们回顾了该手术的中期结果，并确定了恢复左心房（LA）收缩对晚期结果的影响。
我们检查了 50 例持续性（n=7）或长期持续性心房颤动（AF）（n=43）患者的临床数据，这些患者在二尖瓣手术期间接受了经间隔迷宫手术，并在术后至少 24 个月进行了随访。术前 LA 尺寸的平均值为 59±9mm（40-85mm）。在多普勒超声心动图中存在 A 波被认为是 LA 机械收缩的证据。进行了一系列超声心动图检查，以评估左心室和 LA 尺寸、瓣膜反流程度和估计的收缩期肺动脉（PA）压力。随访完成时的平均时间为 59±17 个月（27-92 个月）。
无消融相关并发症，术后即刻 48 例（96%）患者无 AF。在最新随访时，39 例（78%）患者无 AF，而 28 例（56%）患者出现 LA 机械收缩。与未恢复 LA 机械收缩的患者相比，恢复 LA 机械收缩的患者术后血栓栓塞事件的发生率较低（4%对 23%，P=0.075）。系列超声心动图显示，恢复 LA 收缩的患者在多普勒衍生的收缩期 PA 压力方面有更大程度的改善，且显著三尖瓣反流的发生率较低（7%对 41%，P=0.006）。对所有其他协变量进行调整的 Cox 比例风险模型显示，基线时 LA 尺寸>60mm 是 LA 机械收缩缺乏的独立危险因素（调整后的风险比 3.9，95%置信区间 1.1-14，P=0.035）。
我们的经间隔迷宫手术可能是二尖瓣手术期间消除 AF 的有效替代手术治疗方法。在瓣膜性 AF 患者中，在 LA 严重扩张之前，需要早期手术以恢复窦性节律和 LA 机械收缩。AF 消融恢复 LA 收缩对术后血流动力学改善和血栓栓塞事件的影响仍有待确定。
