Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
J Thorac Cardiovasc Surg. 2022 Feb;163(2):629-641.e7. doi: 10.1016/j.jtcvs.2020.04.100. Epub 2020 May 5.
Surgical ablation of atrial fibrillation (AF) is indicated both in patients with AF undergoing concomitant cardiac surgery and in those who have not responded to medical and/or catheter-based ablation therapy. This study examined our long-term outcomes following the Cox-Maze IV procedure (CMP-IV).
Between May 2003 and March 2018, 853 patients underwent either biatrial CMP-IV (n = 765) or a left-sided CMP-IV (n = 88) lesion set with complete isolation of the posterior left atrium. Freedom from atrial tachyarrhythmia (ATA) was assessed for up to 10 years. Rhythm outcomes were compared in multiple subgroups. Predictors of recurrence were determined using Fine-Gray regression, allowing for death as the competing risk.
The majority of patients (513/853, 60%) had nonparoxysmal AF. Twenty-four percent of patients (201/853) had not responded to at least 1 catheter-based ablation. Prolonged monitoring was used in 76% (647/853) of patients during their follow-up. Freedom from ATA was 92% (552/598), 84% (213/253), and 77% (67/87) at 1, 5, and 10 years, respectively. By competing risk analysis, incidence of first ATA recurrence was 11%, 23%, and 35% at 1, 5, and 10 years, respectively. On Fine-Gray regression, age, peripheral vascular disease, nonparoxysmal AF, left atrial size, early postoperative ATAs, and absence of sinus rhythm at discharge were the predictors of first ATA recurrence over 10 years of follow-up.
The CMP-IV had an excellent long-term efficacy at maintaining sinus rhythm. At late follow-up, the results of the CMP-IV remained superior to those reported for catheter ablation and other forms of surgical ablation for AF. Age, left atrial size, and nonparoxysmal AF were the most relevant predictors of late recurrence.
对于同时接受心脏手术和未对药物和/或导管消融治疗产生反应的房颤（AF）患者，外科消融术均适用。本研究对我们施行 Cox-Maze IV 手术（CMP-IV）后的长期结果进行了评估。
2003 年 5 月至 2018 年 3 月，853 例行双侧 CMP-IV（n=765）或左侧 CMP-IV（n=88）手术的患者接受了完全隔离左心房后壁的左房左后侧面标测消融术。10 年内评估无房性心动过速（ATA）的比例。对多个亚组的节律结果进行了比较。使用 Fine-Gray 回归确定复发的预测因子，允许死亡作为竞争风险。
大多数患者（513/853，60%）患有非阵发性 AF。24%（201/853）的患者至少对 1 次导管消融无反应。76%（647/853）的患者在随访期间进行了长时间监测。1、5 和 10 年时无 ATA 比例分别为 92%（552/598）、84%（213/253）和 77%（67/87）。通过竞争风险分析，1、5 和 10 年时首次 ATA 复发的发生率分别为 11%、23%和 35%。在 Fine-Gray 回归中，年龄、外周血管疾病、非阵发性 AF、左心房大小、术后早期 ATA 和出院时无窦性节律是 10 年随访期间首次 ATA 复发的预测因子。
CMP-IV 长期维持窦性节律的效果极佳。在随访晚期，CMP-IV 的结果仍然优于导管消融和其他形式的 AF 外科消融。年龄、左心房大小和非阵发性 AF 是晚期复发的最相关预测因子。
