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Ann Thorac Surg 1998;66:800-804
© 1998 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Operative results after the Cox/maze procedure combined with a mitral valve operation

^a Department of Cardiovascular Surgery, Iwate Medical University Memorial Heart Center, Iwate Medical University, Morioka, Iwate, Japan

Accepted for publication April 15, 1998.

Address reprint requests to Dr Izumoto, Department of Cardiac Surgery, Iwate Medical University Memorial Heart Center, Iwate Medical University, 1-2-1 Chuodori, Morioka 020-8505, Iwate, Japan

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. There have been few reports on postoperative morbidity and mortality analyses after concomitant mitral valve operation and the Cox/maze procedure.

Methods. Between April 1993 and August 1995, 87 consecutive patients with chronic atrial fibrillation underwent a mitral valve operation and concomitant Cox/maze procedure at Iwate Medical University. The patients were divided into the replacement group (n = 31) and repair group (n = 56) according to the method of mitral valve replacement. Our initial experience with the combined operative procedures is presented along with the operative mortality and morbidity rates. Univariate analysis on preoperative and intraoperative variables affecting early mortality and morbidity is carried out retrospectively.

Results. Total cardiopulmonary bypass time in all patients was 177.2 ± 70.1 minutes. Total aortic cross-clamp time was 121.7 ± 30.8 minutes. Total intensive care unit stay was 5.3 ± 7.9 days. The average intubation period was 55.5 ± 187.6 hours. The intensive care unit stay and the intubation period of the replacement group were longer than those of the repair group. There were four operative deaths among the 87 patients (4.6%). All repair group patients survived operation, whereas 4 replacement group patients died after operation. In all patients, the New York Heart Association functional class was higher (p = 0.028) in those who died than in those who survived. The overall restoration rate from atrial fibrillation was 79.5% (66 of 83 survivors). Seventeen patients (20.5%) had persistent atrial fibrillation postoperatively. Sick sinus syndrome occurred in 7 patients (8.4%). In the repair group, the restoration rate was 76.8%, whereas in the replacement group it was 85.2% for the survivors.

Conclusions. The Cox/maze procedure can be combined with a mitral valve operation with acceptably low operative risk. Analysis of risk factors of early mortality revealed that the type of mitral valve operation (replacement versus repair) and higher preoperative New York Heart Association functional class were associated with mortality. Long-term results from this combined procedure should be clearly demonstrated before its universal acceptance.

	Introduction

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Atrial fibrillation (AF) is a common form of arrhythmia, and is present in about 1% of the general population and in about 40% to 60% of patients undergoing mitral valve replacement in Western countries [1–4]. Chua and associates [5] at the Mayo Clinic reported that 80% of patients with preoperative chronic AF remained in AF after successful mitral valve repair. Studies have revealed that the persistence of AF not only impairs cardiac function by the loss of "atrial kick" but also poses a substantial risk of thromboembolic complications [6–9]. Patients with chronic AF and mitral valve disease are at increased risk of thromboembolic complications. In 1990, Stein and colleagues [10] reported the relative risk of thromboembolism in patients with various types of underlying heart disease and stated that patients with either mitral valve stenosis or regurgitation are at risk for thromboembolism and recommended anticoagulation with warfarin.

Originally developed by Cox and associates [11], the maze procedure (Cox/maze) is one type of surgical treatment for symptomatic patients with drug-resistant chronic AF. Because a significant number of patients undergoing mitral valve operations are associated with chronic drug-resistant AF in Japan, the Cox/maze procedure has been concomitantly performed with a mitral valve operation in an effort to improve the quality of life after operation by eliminating the morbidity associated with chronic AF. There have been some reports describing experience with the combined procedures [12–14]. Little is known, however, about the operative outcome and operative risk after the combined procedure. This study was undertaken to update experience with the Cox/maze procedure combined with a mitral valve operation at Iwate Medical University and evaluate the operative results and early mortality and morbidity.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Patients
Between April 1993 and August 1995, 87 consecutive patients with chronic AF underwent a mitral valve operation and concomitant Cox/maze procedure at Iwate Medical University. The duration of AF was 119 ± 83 months (mean ± standard deviation), with a range of 5 to 360 months. These 87 patients constitute the study population. There were 35 men (40.2%) and 52 women (59.8%) whose mean age was 59.3 ± 10.2 years, with a range of 21 to 77 years. The mean preoperative New York Heart Association (NYHA) class was 2.7 ± 0.75. All patients had organic mitral valve disease. The mitral valve was repaired in 56 patients (repair group) and replaced in 31 patients (replacement group). Additional surgical procedures were performed in 63 patients (72.4%) (Table 1 ). During the study period, all patients undergoing mitral valve operation with chronic AF were informed of the possible benefits and risks after the combined procedure.

Surgical procedure
All procedures were performed using cardiopulmonary bypass under moderate hypothermia. Atriotomies made in the Cox/maze procedure were basically similar to the second modification (Cox/maze III) [15]. However, we used cryoablation in several parts of Cox’s second modification instead of surgical atriotomy. Details of the operative procedure have been presented elsewhere [14].

Mortality and morbidity
Hospital mortality is defined as death occurring during the initial period of hospitalization or within 30 days after operation. Significant perioperative morbidity was defined as the necessity for reexploration, re-repair, or re-replacement of the mitral valve, gastrointestinal complications, evidence of wound infection or pneumonia, acute renal failure, central nervous system complications (infarction or bleeding), low cardiac output, or multiple organ failure, alone or in combination.

Statistical analysis
The operation reports, discharge summaries, cardiac catheterization data, echocardiographic data, and full hospital records were reviewed and collected data were entered into a database. Continuous variables were expressed as mean ± standard deviation. Means were compared using Student’s t test. In the case of non-normal distribution, the nonparametric Wilcoxon test was used. Proportions were compared using Fisher’s exact test. A p value less than 0.05 was considered statistically significant.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Patient characteristics
The mean cardiothoracic ratio in all patients was 63.3% ± 9.7%. The mean left atrial diameter was 59.5 ± 12.5 mm on echocardiography. Mean left ventricular ejection fraction was 0.63 ± 0.12. Preoperative patient characteristics are presented in Table 2. Nine of 87 patients (10.3%) had undergone a previous cardiac procedure. The cause of mitral valve disease was rheumatic in 49 patients (56.3%). Thirteen patients (14.9%) were hypertensive, 4 (4.6%) were diabetic, 3 (3.4%) had hyperlipidemia. Fifty-nine patients (67.8%) had history of congestive heart failure and 62 (71.3%) underwent another concomitant cardiac procedure.

In the replacement group, wound infection occurred in 3 patients, and 2 patients required reexploration for bleeding or tamponade. Low cardiac output occurred in 1 patient. Redo mitral valve replacement was necessary in 1 patient, 2 patients had cerebral infarction, and 2 patients required long-term intubation (more than 48 hours) or reintubation because of respiratory failure. Multiple organ failure occurred in 3 patients, acute renal failure in 1, and left ventricular rupture in 2 patients.

In the repair group, 1 patient had gastrointestinal bleeding and 5 patients required reexploration for bleeding or tamponade. Three patients experienced respiratory failure, and 1 patient developed postoperative cholecystitis. Redo mitral valve repair was performed in 2 patients. Low cardiac output occurred in 1 patient, and 1 patient had a cerebral infarction.

Restoration of sinus rhythm and frequency of sick sinus syndrome
The overall restoration rate from AF was 79.5% (66 of 83 survivors). Seventeen patients had persistent AF postoperatively (20.5%). Sick sinus syndrome occurred in 7 patients (8.4%), and in 5 of them (6.0%) it was necessary to implant a pacemaker. In the repair group, the restoration rate was 76.8%, whereas in the replacement group it was 85.2% for the survivors.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
At first, the Cox/maze procedure was applied to patients with chronic AF as an isolated cardiac procedure [13]. However, as experience has expanded, it has been performed concomitantly with other cardiac procedures [12, 13, 16]. In combining the Cox/maze procedure with mitral valve operation, it is urgently needed to clarify the operative mortality and morbidity rates and to define the indications for this combination [17]. The present study was performed to clarify the operative risk based on our experience.

The prevalence of chronic AF in patients undergoing mitral valve operation is reported to range from 40% to 60% [4]. Therefore, there is a need to clarify the operative risk, mortality, and morbidity after the combined Cox/maze procedure and mitral valve procedure. In the literature there are some reports describing experience with the Cox/maze procedure combined with mitral valve operation [12, 13]. Kosakai and colleagues [13] reported their experience with 62 Cox/maze procedures in patients with mitral valve disease. They performed 26 procedures combined with mitral valve repair and 36 Cox/maze procedures with mitral valve replacement. No mortality occurred in their series. There is little information regarding the operative risk and early morbidity and mortality rates after combined mitral valve operation and the Cox/maze procedure.

Four deaths occurred postoperatively, all in women. When univariate analysis on mortality was performed in the entire series, it was concluded that the method of mitral valve operation (repair versus replacement) was a significant risk factor associated with postoperative mortality. Higher preoperative NYHA class was also a predictor of postoperative mortality. The reason for the association of type of mitral operation and mortality is not clearly demonstrable in this study. However, it is noteworthy that two of the four deaths were related to postoperative left ventricular rupture. These 2 patients were thin and had a long history of mitral valve disease. They had no history of previous cardiac operation. Both of them were in NYHA class III status preoperatively. One had a huge left atrium (82 mm). Both had a relatively small left ventricle. The end-diastolic LV dimensions were 49 and 53 mm. Left ventricular rupture is a rare but often fatal complication after mitral valve replacement. There seem to be some predisposing factors and technical pitfalls in the incidence of this devastating complication [18]. Every technical effort was made to eliminate this complication in patients with a replaced mitral valve in our practice. Bleeding after cardiopulmonary bypass from the long left atrial suture line in a patient with replaced mitral valve was a challenging problem. In this replacement group, the posterior mitral valve leaflet was preserved during the replacement in some patients according to surgeon’s preference but unfortunately not in these 2 patients with postoperative left ventricular rupture. One of them received the Carpentier pericardial valve (Edwards CVS, Baxter, Irvine, CA) and the other received the ATS mechanical valve (ATS Medical, Minneapolis, MN).

It has been suggested by our group that the secretion of both atrial and brain natriuretic peptides is impaired after the Cox/maze procedure [19]. However, in our experience, water retention was not a major problem during the postoperative course.

The overall sinus rhythm restoration rate was 79.5% for the survivors, which compares with 86.1% reported by Kawaguchi and colleagues [20] and 98% reported by Feinberg and associates [21]. Differences in patient characteristics in the present study and the one by Feinberg and colleagues may explain our lower rate. In their study, the indication for cardiac operation was the intolerance of AF in 63%, whereas in our study it was the organic mitral valve disease and its morbidity in patients with left atrial volume or pressure overload. Therefore, the frequency and type of concomitant cardiac procedure also differed between the two studies. In the study by Feinberg and associates, 28% of the patients underwent concomitant cardiac procedures, but it was 100% in our study.

The indications for the Cox/maze procedure in patients with mitral valve disease are still evolving and they should be clearly defined based on the clinical characteristics of the patients. Patients with chronic mitral valve disease and resultant AF have different functional characteristics from patients with nonvalvular AF. The differences may affect the outcome and sinus rhythm restoration rate after the Cox/maze procedure. We advised the addition of the Cox/maze procedure for all patients with mitral valve disease and chronic AF during the study period. In the process of our study, Kamata and colleagues [22] reported two clinical factors predicting the failure of sinus rhythm restoration after combined cardiac operation and the Cox/maze procedure for organic heart disease and chronic AF. In their report, preoperative left atrial size and the amplitude of f waves were significant predictors. As for risk factors regarding postoperative sick sinus syndrome, we have suggested in a previous report that a history of previous cardiac operation is associated with the incidence of sick sinus syndrome by univarate analysis [23].

Limitations of the study
There are some limitations in this study. This retrospective and nonrandomized study demonstrated the effectiveness of the Cox/maze procedure combined with mitral valve operation and demonstrated that higher preoperative NYHA class and the method of mitral valve operation (replacement versus repair) were associated with an increased incidence of postoperative mortality. The decision on the operative method used in each patient depended on patient characteristics and intraoperative findings of the mitral valve and its apparatus, although every effort was made to repair the valve instead of replacing it. Thus, it was evident that there were significant differences in patient characteristics between the replacement group and the repair group. Therefore, comparisons regarding the outcome between the groups do not yield a definitive conclusion. Because there were only four deaths in the series, multivariate analysis of factors affecting postoperative mortality was not helpful. However, the value of univariate analysis of the mortality in the entire series is still important.

Taking the results and limitations of the study into consideration, we conclude that the Cox/maze procedure can be combined with mitral valve operation with acceptably low operative risk. The increased mortality in the replacement group might be attributable to different patient characteristics between the groups or part of our learning curve. Left ventricular rupture is a recognized complication when mitral valve replacement is carried out without preservation of the native valve, due to loss of the tethering action of the subvalvular structures, and this probably accounts for the two cases of left ventricular rupture in our series. This mechanism is unrelated to performance of the Cox/maze procedure. Long-term results (quality of life, freedom from reoperation, incidence of thromboembolism, frequency of sick sinus syndrome and pacemaker implantation, and others) from this combined procedure should be clearly demonstrated before its universal acceptance and the operative indications for this combined approach should be defined.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We thank Makiko Mitamura, RN, for her secretarial assistance in collecting data and preparation of the manuscript. We gratefully acknowledge the help of Ichiro Tsuji, MD, PhD, Department of Public Health, Tohoku University School of Medicine, for statistical analysis.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kohei Kawazoe Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Izumoto, H. Articles by Kamata, J. Search for Related Content PubMed PubMed Citation Articles by Izumoto, H. Articles by Kamata, J.