HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Eric Berreklouw Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Berreklouw, E. Articles by Relik, D. Search for Related Content PubMed PubMed Citation Articles by Berreklouw, E. Articles by Relik, D.

Ann Thorac Surg 1999;68:1065-1066
© 1999 The Society of Thoracic Surgeons

---

Case Reports

Cardiogenic shock due to coronary narrowings one day after a MAZE III procedure

^a Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
^b Cardiology, Catharina Hospital, Eindhoven, The Netherlands

Address reprint requests to Dr Berreklouw, Department of Cardiothoracic Surgery, Catharina Hospital, Michelangelolaan 2, 5602 ZA Eindhoven, The Netherlands
e-mail: eberr{at}compuserve.com

	Abstract

Top Abstract Introduction Comment References

 
A MAZE III procedure was performed on a patient with a small body surface area. On the first postoperative day, the patient developed severe dysfunction of the left ventricle, due to significant narrowings of the right and circumflex coronary arteries in the areas that were cryo-ablated during the MAZE III procedure. The coronary narrowings were treated by percutaneous transluminal coronary angioplasty (PTCA). At discharge the coronary anatomy was normal again with an almost normal left ventricular function.

	Introduction

Top Abstract Introduction Comment References

 
The surgical treatment of atrial fibrillation has been well established by the pioneering work of James Cox and coworkers [1]. We describe a patient in whom we performed a MAZE III procedure in combination with mitral valve replacement and in whom a low cardiac output syndrome, with cardiac arrest, developed 1 day after the operation.

A 36-year-old female patient with a height of 155 cm and weight of 51 kg (body surface area 1.40 m²), was admitted to the hospital because of progressive right heart failure due to a severe mitral valve stenosis and atrial fibrillation with a rapid ventricular response of 160 to 220 beats per minute. Coronary angiography showed a normal left and right coronary artery. On October 28, 1997, the mitral valve was replaced with a mitral valve prosthesis, and a standard MAZE III procedure [1] was performed. The patient was placed on full normothermic bypass and during the left-sided procedures antegrade and retrograde intermittent warm blood cardioplegia was administered. Six cryolesions were applied, strictly according to the methods described by Cox [1], with 3-mm and 15-mm cryoprobes (Frigitronics; CooperVision Company, Shelton, CT), for 2 minutes at a temperature of -60°C. The operative technique included the described maneuvers to protect the right and left coronary arteries from direct cryogenic trauma. Before going off bypass, a transesophageal echo showed a good contracting left and right ventricle with normal dimensions. The patient was weaned from bypass with the use of low-dose inotropics with a cardiac index of 1.9 L/min/m². Because the patient showed no spontaneous rhythm, atrial and ventricular pacing by temporary wires was necessary. Shortly after extubation at the first postoperative day, the patient showed no cardiac output and needed to be resuscitated. An intraaortic balloon pump was inserted. A transesophageal echo demonstrated akinesia inferiorly and posteriorly, leading to a poor left ventricular function. The ECG showed pacemaker rhythm. On the coronary angiogram, generalized smaller diameters of the coronary arteries with significant narrowings in the distal circumflex (Fig 1 ) and right coronary arteries were seen. The narrowing inthe circumflex coronary artery was dilated first, with a 3.0-mm angioplasty balloon. When this narrowing was dilated other narrowings developed proximally and distally from this initial point of dilatation. Because these new narrowings did not disappear after intracoronary nitroglycerin, they were also dilated. In total, six dilatations were performed in the circumflex coronary artery. With the same angioplasty balloon, the right coronary artery was dilated. Also in this vessel, new narrowings developed proximally and distally from the location of the first dilatation, without any reaction to intra-coronary nitroglycerin. These new narrowings were dilated as well. In total, three dilatations of the right coronary artery were performed. At the end of the procedure, both coronary arteries were patent again. The patient remained in the hospital for 45 days, but recovered completely. At discharge the echocardiography showed a substantially recovered left ventricular function with hypokinesis in the infero-basal segments. A repeat coronary angiography, 25 days after the PTCAs, no longer showed significant narrowings in the coronary arteries (Fig 2). At 1-year follow-up the patient showed sinus rhythm.

View larger version (151K): [in this window] [in a new window]   Fig 1. Significant narrowing (spasm) of circumflex coronary artery, the first postoperative day. Arrow indicates narrowing.

View larger version (151K): [in this window] [in a new window]   Fig 2. Normal anatomy of circumflex coronary artery, at discharge.

	Comment

Top Abstract Introduction Comment References

Also, in our patient, there was an exact match between the sites of coronary narrowings and the localization of the cryolesions. However, in our patient it is likely that the coronary narrowings were not anatomically fixed lesions, and it is our hypothesis that the narrowings were produced by edema in the perivascular epicardial tissues. If direct surgical trauma had been the cause, it would have been apparent when the patient was weaned from cardiopulmonary bypass. On the other hand, if a typical cryolesion of the coronary arteries, as described in the dog model [2], was involved, it would have been likely that the symptoms would occur after a longer delay.

Theoretically, there are several ways to prevent the described complications. The size of a cryolesion depends on the size and shape of the probe, freezing temperatures, duration of freezing, method of thawing, and kind and temperature of the tissues involved [4–6]. In the MAZE III operation, cryoablation is used on thin (a few millimeters) left and right atrial walls or the connection of these tissues with the valvular annuli, always nearby coronary arteries. For this application it is not necessary that the cryolesion penetrate deeply, especially not in patients with a small body surface area, as was the case in our patient. It is our suggestion to limit the duration of cryoablation in MAZE III procedures to 1 minute for each lesion. Secondly, the cryoablation can be replaced by a radio-frequency catheter that produces only superficial ablation [7]. Thirdly, it can be questioned, as others have done [8], whether cryoablation is essential in the MAZE III procedure as long as, purely by creating the MAZE, the minimum muscular wall substrate to maintain atrial fibrillation is not available anymore.

	References

Top Abstract Introduction Comment References

 

1. Cox J.L., Jaquiss R.D.B., Schuessler R.B., Boineau J.P. Modification of the MAZE procedure for atrial flutter fibrillation and atrial fibrillation. J Thorac Cardiovasc Surg 1995;110:473-495.[Abstract/Free Full Text]
2. Holman W.L., Ikeshita M., Ungerleider R.M., Smith P.K., Ideker R.E., Cox J.L. Cryosurgery for cardiac arrhythmias. Am J Cardiol 1983;51:149-155.[Medline]
3. Sueda T., Shikata H., Mitsui N., Nagata H., Matsuura Y. Myocardial infarction after a MAZE procedure for idiopathic atrial fibrillation. J Thorac Cardiovasc Surg 1996;112(2):549-550.[Free Full Text]
4. Holman W.L., Ikeshita M., Douglas J.M., Smith P.K., Cox J.L. Cardiac cryosurgery. Surgery 1983;93:268-272.[Medline]
5. Iida S., Misaki T., Iwa T. The histological effects of cryocoagulation on the myocardium and coronary arteries. Jpn J Surg 1989;19:319-325.[Medline]
6. Mazur P. Physical-chemical factors underlying cell injury in cryosurgical freezing. In: Rand R.W., Rinfret P.R., von Leden H., eds. Cryosurgery. Springfield: Charles C. Thomas, 1968:32-51.
7. Sie H.T., Beukema W.P., Ramdat Misier A.R., Smeets J.L., Jacobs C.C., Wellens H.J. Radio-frequency ablation of atrial fibrillation in patients undergoing valve surgery. Circulation 1997;96(Suppl):I-450.
8. Gregori F., Cordeiro C.O., Couto W.J., da Silva S.S., de Aquino W.K., Nechar A. Cox MAZE operation without cryoablation for the treatment of chronic atrial fibrillation. Ann Thorac Surg 1995;60:361-364.[Abstract/Free Full Text]

This article has been cited by other articles:

				B. G. Rajbanshi, E. Rodrigues, J. J. Lynch, R. Gulati, and T. M. Sundt III Coronary Artery Spasm After Cryo Maze III Procedure Ann. Thorac. Surg., November 1, 2011; 92(5): 1884 - 1887. [Abstract] [Full Text] [PDF]

				S. Benussi, M. Taramasso, A. Pozzoli, Y. A. Privitera, M. Cioni, A. Giacomini, and O. Alfieri Complete biatrial ablation of atrial fibrillation with bipolar radiofrequency MMCTS, January 1, 2010; 2010(0729): mmcts.2009.004390 - mmcts.2009.004390. [Abstract] [Full Text] [PDF]

				S. Benussi, S. Nascimbene, A. Galanti, A. Fumero, E. Dorigo, V. Zerbi, M. Cioni, and O. Alfieri Complete left atrial ablation with bipolar radiofrequency Eur J Cardiothorac Surg, April 1, 2008; 33(4): 590 - 595. [Abstract] [Full Text] [PDF]

				K. Khargi, A. Laczkovics, K. Muller, and T. Deneke A possible surgical technique to avoid esophageal and circumflex artery injuries using radiofrequency ablation to treat atrial fibrillation Interact CardioVasc Thorac Surg, June 1, 2004; 3(2): 352 - 355. [Abstract] [Full Text] [PDF]

				G. Bonanomi, D. Schwartzman, D. Francischelli, K. Hebsgaard, and M. A. Zenati A new device for beating heart bipolar radiofrequency atrial ablation J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 1859 - 1866. [Abstract] [Full Text] [PDF]

				S. Benussi, S. Nascimbene, S. Calvi, and O. Alfieri A tailored anatomical approach to prevent complications during left atrial ablation Ann. Thorac. Surg., June 1, 2003; 75(6): 1979 - 1981. [Abstract] [Full Text] [PDF]

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): Eric Berreklouw Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Berreklouw, E. Articles by Relik, D. Search for Related Content PubMed PubMed Citation Articles by Berreklouw, E. Articles by Relik, D.