Evseev E P, Botashev A A, Aidamirov I A, Balakin E V, Fomin M A, Fazylov A O, Ivanov V A, Belov Yu V
B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia.
Sechenov First Moscow State Medical University, Moscow, Russia.
Khirurgiia (Mosk). 2024(12. Vyp. 2):25-34. doi: 10.17116/hirurgia202412225.
This study aimed to investigate the immediate and long-term outcomes of the Cox-Maze IV procedure in patients undergoing surgical treatment for multivalvular heart disease with atrial fibrillation. It also sought to identify predictors of atrial fibrillation recurrence in the long-term period.
We conducted an analysis of 92 patients who underwent multivalvular heart defect correction and simultaneous Cox-Maze IV procedure between 2017 and 2023. The mean age of the patients was 65.5 years (57.5; 69), 43 males (46.7%) and 49 females (53.3%). Sixty-six patients (71.7%) were classified as functional class III heart failure according to NYHA, while 3 (3.3%), 14 (15.2%), and 9 (9.8%) were classified as functional classes I, II, and IV, respectively. The types of atrial fibrillation were: paroxysmal in 15.2%, persistent in 22.8%, and long-standing persistent in 62%. The mean duration of atrial fibrillation prior to surgery was 15.5 months (10; 45.8) for those with paroxysmal form, 7 months (4; 9) for persistent form, and 60 months (22; 84) for long-standing persistent form. Mitral-aortic valve replacement was performed in 9 cases (9.8%), mitral-tricuspid correction in 69 cases (75%), and combined mitral-aortic-tricuspid correction in 14 cases (15.2%).
During the hospital stay, there were 3 fatalities. In the long-term follow-up, 8 deaths were recorded, with 3 attributed to cardiac causes. Permanent pacemaker implantation was required in just one case during the long-term postoperative period. The freedom from atrial fibrillation was 61.4% in patients with paroxysmal form at follow-up of up to 46 months, 58.1% in those with persistent form at up to 63 months, and 32.5% in those with long-standing persistent form at up to 82 months. Three predictors of arrhythmia recurrence were identified: early postoperative atrial fibrillation paroxysms, a duration of atrial fibrillation exceeding 60 months, and enlarged left atrial size.
The Cox-Maze IV rhythm-conversion procedure designed to restore sustained sinus rhythm is most effective in patients with paroxysmal and persistent forms of atrial fibrillation, achieving success rates of 61.4% and 58.1%, respectively. This procedure is not associated with a high rate of pacemaker implantation. An enlarged left atrium should not deter the use of the Cox-Maze IV procedure in patients with atrial fibrillation; however, atrioplasty is recommended if the left atrium is significantly enlarged. Episodes of rhythm disturbance during the early postoperative period and a history of atrial fibrillation lasting more than 60 months prior to surgery are associated with an increased risk of recurrence postoperatively. Therefore, careful monitoring of these patients after discharge is essential for early detection and management of recurrences.
本研究旨在调查接受多瓣膜性心脏病合并心房颤动手术治疗的患者行Cox-Maze IV手术的近期和长期结果。研究还试图确定长期心房颤动复发的预测因素。
我们对2017年至2023年间接受多瓣膜心脏缺陷矫正并同时行Cox-Maze IV手术的92例患者进行了分析。患者的平均年龄为65.5岁（57.5；69），男性43例（46.7%），女性49例（53.3%）。根据纽约心脏协会（NYHA）分级，66例（71.7%）患者被归类为III级心力衰竭，而3例（3.3%）、14例（15.2%）和9例（9.8%）分别被归类为I级、II级和IV级心力衰竭。心房颤动的类型为：阵发性占15.2%，持续性占22.8%，长期持续性占62%。阵发性心房颤动患者术前的平均持续时间为15.5个月（10；45.8），持续性心房颤动患者为7个月（4；9），长期持续性心房颤动患者为60个月（22；84）。9例（9.8%）患者行二尖瓣-主动脉瓣置换术，69例（75%）患者行二尖瓣-三尖瓣矫正术，14例（15.2%）患者行二尖瓣-主动脉瓣-三尖瓣联合矫正术。
住院期间有3例死亡。在长期随访中，记录到8例死亡，其中3例归因于心脏原因。术后长期仅1例需要植入永久性起搏器。随访至46个月时，阵发性心房颤动患者无房颤复发率为61.4%，随访至63个月时，持续性心房颤动患者为58.1%，随访至82个月时，长期持续性心房颤动患者为32.5%。确定了心律失常复发的三个预测因素：术后早期心房颤动发作、心房颤动持续时间超过60个月和左心房增大。
旨在恢复持续窦性心律的Cox-Maze IV节律转换手术在阵发性和持续性心房颤动患者中最为有效，成功率分别为61.4%和58.1%。该手术与起搏器植入率不高无关。左心房增大不应妨碍在心房颤动患者中使用Cox-Maze IV手术；然而，如果左心房明显增大，建议行心房成形术。术后早期的节律紊乱发作以及术前心房颤动病史超过60个月与术后复发风险增加相关。因此，出院后对这些患者进行仔细监测对于早期发现和处理复发至关重要。
