Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Japan.
Ann Thorac Surg. 2021 Dec;112(6):1909-1920. doi: 10.1016/j.athoracsur.2020.11.069. Epub 2021 Feb 3.
Consensus regarding an optimal atrial fibrillation (AF) ablation lesion set concomitant with aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) has not been established.
We enrolled 125 consecutive patients (89 men; 70 ± 8 years old) with persistent AF who underwent radiofrequency-based pulmonary vein isolation (PVI) (PVI group, n = 53) or a Cox-Maze procedure (Maze group, n = 72) with AVR and/or CABG. To reduce the impact of treatment bias and potential confounding in the direct comparisons between patients who underwent Cox-Maze with and those who underwent PVI, we established weighted Cox proportional-hazards regression models with inverse probability of treatment weighting. Mean follow-up was 63 ± 34 months (maximum, 154 months).
There was 1 in-hospital death in each group. Patients who underwent Cox-Maze showed a higher freedom from AF at all follow-up examinations. After the operation, there were 32 deaths, 13 thromboembolisms, 8 hemorrhagic events, and 22 heart failure readmissions. The Maze group had higher rates for 5-year survival (88% vs 64%, P = .013) and freedom from composite events (74% vs 42%, P < .001). After adjustment with inverse probability of treatment weighting, the Cox-Maze procedure still showed a lower risk of overall mortality (adjusted hazard ratio, 0.38; 95% confidence interval, 0.21-0.66; P = .001) and composite adverse events (adjusted hazard ratio, 0.52; 95% confidence interval, 0.35-0.76; P = .001).
In patients with persistent AF indicated for nonmitral valve surgery, a concomitant Cox-Maze procedure resulted in superior AF- and event-free survival compared with PVI, without increased risk of early mortality. These findings may assist decision making for surgical management of persistent AF concomitant with AVR and/or CABG.
目前尚未就合并主动脉瓣置换术（AVR）和/或冠状动脉旁路移植术（CABG）的最佳心房颤动（AF）消融病灶集达成共识。
我们纳入了 125 例连续的持续性房颤患者（89 例男性；70±8 岁），他们接受了基于射频的肺静脉隔离（PVI）（PVI 组，n=53）或 Cox-Maze 手术（Maze 组，n=72），并同时进行 AVR 和/或 CABG。为了减少 Cox-Maze 组和 PVI 组患者之间直接比较的治疗偏倚和潜在混杂因素的影响，我们建立了基于逆概率治疗加权的加权 Cox 比例风险回归模型。平均随访时间为 63±34 个月（最长 154 个月）。
两组各有 1 例院内死亡。接受 Cox-Maze 手术的患者在所有随访检查中均有更高的 AF 无复发率。术后有 32 例死亡、13 例血栓栓塞、8 例出血事件和 22 例心力衰竭再入院。Maze 组的 5 年生存率（88% vs 64%，P=0.013）和无复合事件生存率（74% vs 42%，P<0.001）更高。经逆概率治疗加权调整后，Cox-Maze 手术的全因死亡率（调整后的危险比，0.38；95%置信区间，0.21-0.66；P=0.001）和复合不良事件（调整后的危险比，0.52；95%置信区间，0.35-0.76；P=0.001）的风险仍较低。
对于需要非二尖瓣手术的持续性房颤患者，与 PVI 相比，同期进行 Cox-Maze 手术可提高 AF 无复发和无事件生存率，且早期死亡率无增加。这些发现可能有助于决策合并 AVR 和/或 CABG 的持续性房颤的手术治疗。
