Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa; Cardiovascular Surgery, Washington Adventist Hospital, Takoma Park, Md; Inova Fairfax Hospital, Falls Church, Va.
Heart and Vascular Institute, West Virginia University Medicine, Morgantown, WVa.
J Thorac Cardiovasc Surg. 2019 Apr;157(4):1505-1514. doi: 10.1016/j.jtcvs.2018.09.131. Epub 2018 Nov 22.
Newly published guidelines made the highest level recommendation for surgical treatment for atrial fibrillation. However, the number of patients without a mitral valve procedure with atrial fibrillation who are treated with concomitant surgical ablation is still low (15%-25%), because surgeons are reluctant to perform procedures in patients who would not otherwise require left atriotomy. The purpose of this study was to compare the outcomes of concomitant Cox maze with and without mitral valve procedures.
Patients who underwent concomitant Cox maze procedures were prospectively followed since September 2005. Of the 711 patients, 238 did not receive mitral valve surgery. Propensity score matching was conducted to balance preoperative characteristics between patients with and without mitral valve procedures (164/group after matching).
Before matching, patients in the mitral valve group were younger (65 vs 67 years, P = .047) and had higher euroSCORE II (European System for Cardiac Operative Risk Evaluation; 3.2% vs 2.6%, P = .002), larger mean left atrial size (5.3 vs 4.8 cm, P < .001), and shorter median atrial fibrillation duration (19 vs 25 months, P = .064). Early outcomes were similar for the matched groups. Cumulative 5-year freedom from stroke did not differ between matched mitral valve and non-mitral valve groups (96.1% vs 96.6%, P = .667). At each time point, the proportion in sinus rhythm off antiarrhythmic medications was similar for the matched groups, including 5 years after surgery (68% vs 63%, P = .492).
The Cox maze procedure is safe and effective with comparable outcomes when performed concomitant to mitral valve or non-mitral valve surgery. Surgeons should base the decision to perform surgical ablation procedures on atrial fibrillation pathophysiology and the benefit to patients, not on the type of concomitant procedure.
新发表的指南对房颤的手术治疗提出了最高级别的推荐。然而，对于那些不需要进行左心房切开术的房颤患者，同时进行外科消融术的患者数量仍然较低（15%-25%），因为外科医生不愿意对这些患者进行手术。本研究旨在比较同时行 Cox 迷宫术和不伴二尖瓣手术的结果。
自 2005 年 9 月以来，前瞻性随访了同时行 Cox 迷宫术的患者。在 711 例患者中，238 例未接受二尖瓣手术。采用倾向评分匹配法平衡了伴或不伴二尖瓣手术患者的术前特征（匹配后每组 164 例）。
在匹配前，二尖瓣组患者年龄较小（65 岁 vs 67 岁，P=0.047），欧洲心脏手术风险评估系统评分 II 较高（3.2% vs 2.6%，P=0.002），左心房平均大小较大（5.3 cm vs 4.8 cm，P<0.001），房颤持续时间中位数较短（19 个月 vs 25 个月，P=0.064）。两组患者的早期结果相似。匹配组的 5 年无卒中生存率无差异（96.1% vs 96.6%，P=0.667）。在每个时间点，两组患者在停用心律失常药物后窦性心律的比例相似，包括手术后 5 年（68% vs 63%，P=0.492）。
当同时行二尖瓣或非二尖瓣手术时，Cox 迷宫术是安全有效的，且结果相似。外科医生应根据房颤病理生理学和对患者的获益来决定是否进行手术消融术，而不是根据伴随手术的类型。
