Nitta Takashi, Iwasaki Yuki, Sakamoto Shun-Ichiro, Fujii Masahiro, Otsuka Toshiaki, Ishii Yosuke
Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan.
Department of Cardiology, Nippon Medical School, Tokyo, Japan.
JTCVS Open. 2024 Nov 14;23:110-119. doi: 10.1016/j.xjon.2024.10.031. eCollection 2025 Feb.
Atrial tachyarrhythmias are the most frequent complication after the maze procedure. We examined the mechanism of atrial tachyarrhythmias in association with the ablation energy and technique used at each lesion and by the findings of postoperative electrophysiological study.
Four-hundred fifty-three patients who underwent the maze procedure with biatrial incisions and bilateral pulmonary vein (PV) isolation were examined for the incidence and mechanism of recurrence of atrial fibrillation (AF) and development of atrial tachycardia (AT). PV isolation was performed by radiofrequency (RF) ablation, cryothermia, or cut-and-sew technique. The atrioventricular isthmi and the coronary sinus (CS) were ablated by RF, cryothermia, or a combination of these.
Of 443 patients who survived surgery (98%), 54 patients (12.2%) had recurrent AF and 36 patients (8.1%) developed AT during the median of 28 months (interquartile range, 3-75) postoperatively. Multivariate logistic regression analysis showed preoperative left atrial dimension and nonperformance of intraoperative PV pacing were the independent predictors for AF recurrence. Electrophysiologic study in patients with AT demonstrated incomplete ablation in 24 patients (67%), most frequently at the CS in 16 patients (67%), and non-PV focal activations in 16 patients (44%). Preoperative New York Heart Association functional class of 1 and nonperformance of additional epicardial ablation of the CS were the independent predictors for postoperative AT development.
Incomplete ablation is a cause of AF recurrence and AT development after the maze procedure. Intraoperative PV pacing prevents AF recurrence and additional epicardial CS ablation prevents AT development.
房性快速心律失常是迷宫手术后最常见的并发症。我们结合每个消融部位所使用的消融能量和技术以及术后电生理研究结果，对房性快速心律失常的机制进行了研究。
对453例行双心房切口及双侧肺静脉隔离迷宫手术的患者，检查房颤（AF）复发率、房性心动过速（AT）发生率及其机制。肺静脉隔离采用射频（RF）消融、冷冻消融或切割缝合技术。房室峡部和冠状静脉窦（CS）采用射频、冷冻消融或两者联合消融。
443例术后存活患者（98%）中，54例（12.2%）出现房颤复发，36例（8.1%）在术后28个月（四分位间距3 - 75个月）发生AT。多因素logistic回归分析显示，术前左心房大小及术中未进行肺静脉起搏是房颤复发的独立预测因素。AT患者的电生理研究显示，24例（67%）存在消融不完全，其中16例（67%）最常见于冠状静脉窦，16例（44%）存在非肺静脉局灶激动。术前纽约心脏协会心功能分级为1级及未对冠状静脉窦进行额外的心外膜消融是术后发生AT的独立预测因素。
消融不完全是迷宫手术后房颤复发和AT发生的原因。术中肺静脉起搏可预防房颤复发，额外的心外膜冠状静脉窦消融可预防AT发生。
