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Ann Thorac Surg 2000;70:1580-1586
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

The maze III procedure for atrial fibrillation: should the indications be expanded?

^a Division of Cardiovascular and Thoracic Surgery, LDS Hospital, Salt Lake City, Utah, USA

Address reprint requests to Dr Millar, Salt Lake Cardiovascular and Thoracic Surgery, 324 Tenth Ave, Suite 160, Salt Lake City, UT 84103

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. We favor the maze III procedure over nonsurgical treatments for atrial fibrillation and have advocated addition of the maze in symptomatic patients with other compelling indications for cardiac surgery.

Methods. Characteristics and perioperative outcomes of our 76 cumulative maze recipients between 1993 to 1998 were reviewed. The original maze III technique was employed without modification.

Results. Isolated maze III was performed in 19 patients (25%) and combined with other procedures in 57 patients (75%), 49 of these involving one or more valves. Patients having combined procedures were taking fewer antiarrhythmics (p < 0.0001), but were older (p < 0.01), more often female (p < 0.05), and more often had chronic atrial fibrillation (p < 0.01) compared with isolated maze III recipients. The mean duration of aortic clamping and cardiopulmonary bypass for isolated maze was 69 ± 11 and 145 ± 22 minutes, and for combined valve procedures it was 122 ± 38 and 205 ± 47 minutes. There was no operative mortality. Complications occurred in 15 patients (19.7%). At 3 months atrial fibrillation was cured in 73 of 75 patients (97.3%). Sick sinus syndrome required pacemaker implantation in 3 patients (4.0%).

Conclusions. The maze III can be performed alone or as a combined procedure with equivalent success, and technical modifications may be unnecessary. A lower threshold for its expanded use in symptomatic patients with atrial fibrillation who require isolated or combined operations is appropriate.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Since its introduction in 1987 [1], the maze procedure stands as the only intervention capable of treating the rate-related, hemodynamic, and thromboembolic sequellae of atrial fibrillation. Its complexity relative to noncurative nodal ablation procedures, however, has tended to restrict its use to patients with solitary atrial fibrillation recalcitrant to medical therapy.

The majority of patients with atrial fibrillation are not sufficiently symptomatic to warrant an intervention aside from rate control and anticoagulation. Conversely, many patients have clearly symptomatic atrial fibrillation in conjunction with other compelling indications for cardiac surgery. Our experience with the maze procedure has focused on this latter group of patients, and we have favored addition of the maze to concurrent cardiac surgical procedures when feasible. Moreover, based on the attendant success of the maze III demonstrated by Sundt and associates [2], we have employed the original maze III without modification, even in combined procedures. This report outlines our cumulative perioperative experience with the maze procedure as an assessment of our less restrictive approach to its implementation.

	Material and methods

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The records and early follow-up of consecutive patients who underwent the maze III procedure in our practice between 1993 and 1998 were examined.

Demographic information, the duration of chronic or paroxysmal atrial fibrillation, number of trialed medications, and the need for hospital admission or electrical cardioversion were reviewed. The New York Heart Association (NYHA) functional classification was determined based on congestive failure symptoms in the majority of patients or anginal symptoms in the remainder. Symptoms of atrial fibrillation included intolerance of uncontrolled or rapid ventricular response, fatigue due to absence of atrioventricular synchrony, or documented thromboembolic episodes. Operative indications were reviewed and the principal indication was categorized as follows: atrial fibrillation symptoms or complications, congestive failure from mitral valve disease, angina, or symptoms from aortic valvular disease. Perioperative complications specifically noted included reoperation for bleeding, stroke, ventilator support beyond 48 hours, intraaortic balloon pump insertion, low cardiac output requiring more than 3 days of catecholamine support, infection, and permanent pacemaker implantation. Rhythm was assessed at discharge and at postoperative visits within the first 3 months.

Operative technique
Operations in all patients were supervised or performed by one surgeon (RCM). The maze III as originally described by Cox and associates [3] was utilized without modification. Cryoablation was limited to the coronary sinus, the posterior mitral annulus, and two sites on the tricuspid valve annulus using -70°C for 3 minutes at the coronary sinus and 2 minutes at the valve annuli. The patient was maintained at normothermia during performance of the right atriotomies. During creation of the left atriotomies, moderate systemic hypothermia and myocardial preservation with intermittently dosed 6°C to 8°C retrograde blood cardioplegia were used uniformly.

Valvular procedures and coronary artery bypass were integrated into the maze operation. Tricuspid annuloplasty was accomplished after completion of the right atriotomies with the aorta unclamped. Distal saphenous vein coronary anastomoses were constructed shortly after aortic clamping. Mitral replacement or reconstruction was perfomed before left atrial closure. Aortic valve replacement or root reconstruction was undertaken after left atrial closure. Right atrial closure was completed after aortic clamp removal.

Postoperative management
Patterns of postoperative recovery were identical to those for routine open heart surgical patients. Temporary pacing if needed was employed for at least 7 days before commitment to permanent pacer implantation for complete heart block or sick sinus syndrome. Negative fluid balance was maintained with intermittent diuretic administration, rather than a continuous infusion, until an optimal dry weight was attained. Antiarrhythmic medication was not routinely used postoperatively; recurrent atrial fibrillation was treated de novo or based on preoperative antiarrhythmic use. Based on Cox’s early practice [5] warfarin anticoagulation was continued for 6 to 8 weeks postoperatively irrespective of the rhythm at discharge. Within the past year this has been omitted for selected patients who do not have specific indications for anticoagulation.

Statistical analysis
The distributions of continuous variables were expressed as mean ± standard deviation, and comparisons were performed using unpaired t tests. Comparisons of categorical variables were performed using ² tests.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Patient characteristics and operative indications
The maze III procedure was performed in 76 consecutive patients, as an isolated procedure in 19 patients (25%), and in combination with other cardiac procedures in 57 patients (75%). The mean age was 59.6 ± 10.0 years (range 43 to 76), and 45 (59%) of patients were male. The mean NYHA functional class was 2.4 ± 0.7 and mean left ventricular ejection fraction was 60% ± 10%.

Presenting features of atrial fibrillation are summarized in Table 1. Chronic atrial fibrillation predominated over paroxysmal and the duration of atrial fibrillation was most commonly 1 to 5 years or more than 10 years. Eighteen patients (24%) presented with complications from atrial fibrillation or its treatment. This included neurologic symptoms from thromboembolism in 13 patients and a history of warfarin intolerance or noncompliance in 4 patients. A DDD pacer had been implanted preoperatively in 1 patient for sick sinus syndrome. Three patients had received a total of five attempts at electrical ablation, but amiodarone was not commonly used.

The primary indication for operation was symptoms or complications from atrial fibrillation alone or in combination with congestive failure symptoms from mitral valve disease in 52 patients (68%). Symptoms of atrial fibrillation were present in 24 other patients (32%) but atrial fibrillation was not itself the compelling indication for operation.

Operative procedures
The operative experience by year is shown in Figure 1, and the distribution of procedures performed is outlined in Table 2, along with the mean durations of aortic cross-clamp application and cardiopulmonary bypass. The maze was combined with one or more valve procedures in 49 patients (64%). Coronary artery bypass grafting was included in 12 patients (16%) with a mean of 3.0 ± 1.5 distal anastomoses per patient constructed. Septal myomectomy for hypertrophic cardiomyopathy was performed in 1 patient, and 5 underwent atrial septal defect closure. The longest duration of aortic clamping and cardiopulmonary bypass occurred in 3 patients who underwent mitral homograft implantation.

View larger version (12K): [in this window] [in a new window]   Fig 1. Experience with the maze III procedure by year.

Perioperative outcomes
There was no operative mortality. Major complications occurred in 15 patients (19.7%) and are outlined in Table 4. Reoperation for bleeding occurred in 3 patients (3.9%). Intraaortic balloon pump insertion was performed in 1 patient, following a reexploration for bleeding. Prolonged inotropic or respiratory support was required in 8 patients, all of whom had combined procedures. Intraoperative cerebrovascular accidents occurred in 2 patients, 1 of whom had preoperative neurologic symptoms and underwent concomitant coronary bypass grafting and another with associated mitral pathology. Two patients who required permanent pacemaker implantation for complete heart block had undergone combined operations, which included a tricuspid valve replacement in the one and a reoperative mitral replacement in the other. One isolated maze patient with early postoperative ventricular tachycardia, who showed sinus rhythm at discharge and 1 month postoperatively, died suddenly 7 weeks after operation. She was not taking any antiarrhythmic medication but had frequent premature ventricular contractions.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The maze III procedure offers a solution for patients with symptomatic atrial fibrillation, but one which is complex and technically challenging. This concern is consistent in reports from American centers [4, 5] and particularly from Asian institutions [6–8], where substantial experience with the maze procedure has been acquired. Interruption of macroreentrant ciruits responsible for atrial fibrillation requires performance of 10 directed incisions in the right and left atria and the interatrial septum. Although injury to coronary arterial and venous structures has been infrequently reported [9], bleeding from less accessible suture lines has been a common concern with isolated maze procedures. This may become a significant consideration when the maze is combined with mitral valve replacement or other cardiac procedures [6, 7].

The complexity of patients undergoing the maze in our series resulted from a lack of isolated atrial fibrillation patient referrals in our practice. Our experience reflects a motivation for its performance in patients referred specifically for correction of valvular pathology rather than for correction of symptomatic atrial fibrillation. Consequently, our 57 patients (75%) who underwent combined procedures were fundamentally different from the 19 patients (25%) who received an isolated maze III. Recipients of combined procedures were more likely to have presented with chronic atrial fibrillation (p < 0.01) and had received fewer trialed antiarrhythmics (p < 0.0001) or cardioversion attempts (p < 0.01) than isolated maze recipients. Although isolated maze III patients were frequently young males, patients having combined maze operations were older (p < 0.01), and more often female (p < 0.05). Consistent with this description, the most common combined operation was a mitral valve procedure, performed on 75% of these 57 patients.

The complexity in our maze experience is distinct from all other American series (Table 6) with regard to the proportions of combined procedures, mitral valve procedures, and multiple valve procedures. Our geographic location in the Intermountain West region is associated with a continued incidence of rheumatic valvular disease, which was observed in 65% of combined valve and maze procedures, nearly twice that of degenerative valve disease. The NYHA class in patients with rheumatic disease was higher than in other patients (p = 0.001) and 23 of 32 patients (72%) had NHYA class III or IV function. Each of the two multiple reoperative and 86% (6 of 7) of singly reoperative procedures, as well as 79% (15 of 19) of multiple valve and maze operations occurred in patients with underlying rheumatic valvular disease.

The restoration of sinus rhythm has validated our motivation toward performance of the maze procedure in this complex group of patients. In the early postoperative period, atrial fibrillation recurred in 30 patients (39%), consistent with a temporarily shortened atrial refractory period as outlined by Cox [5]. Our approach to perioperative atrial fibrillation since 1996 has been to individualize treatment and to avoid routine antiarrhythmic prophylaxis. Utilizing this strategy, 75% of all patients were able to be discharged in sinus rhythm, with 33% taking antiarrhythmic medication. By 3 months, the majority of patients discharged in junctional rhythm, atrial fibrillation, or atrial flutter converted to sinus rhythm, increasing the recovery of sinus rhythm to 90.6%. According to Cox’s definition [5], the cure rate of atrial fibrillation has been 97.3%, and there has been equivalent success among combined and isolated maze III recipients.

The complexity of the maze III procedure has been the principal incentive for the development of technical modifications, predominantly from Japanese centers. Although several maze variations [14, 15] share only modest resemblence to any iterations of the maze incisions, most modifications [16, 17], including that of Kamata and associates [18], involve substitution of linear cryolesions for full thickness atriotomies in order to decrease the duration of the procedure and the risk of suture line bleeding. Kosakai’s modification [19] additionally aims to minimize injury to the arterial supply of the sinoatrial node. The recently introduced radial procedure for atrial fibrillation [20, 21] seeks additionally to optimize left atrial transport function. The complexity in our series is similar to mature experience reported by Kosakai’s group [22] and Kamata and associates [23] (Table 6); however, our rate of cure of atrial fibrillation exceeded that obtained with modifications and was accomplished with favorable aortic cross-clamp and bypass times. Assessment of left atrial transport in the current series warrants further investigation, but our outcomes favor continued use of the original maze III procedure and suggest that technical modifications may not be necessary.

The aortic cross-clamp and cardiopulmonary bypass times (Table 3) among categories of operations parallel our experience in combining valve operations with the maze III procedure. Comparison of the 69 ± 11 minute aortic clamp and 145 ± 22 minute bypass duration for isolated maze III to 107 ± 25 and 187 ± 40 minutes, respectively, for mitral valve procedures demonstrates that mitral valve repair or replacement added roughly 40 minutes of additional aortic clamp and bypass time to the maze. Tricuspid valve procedures, when added to mitral valve procedures, required no additional aortic clamp time and 20 minutes of bypass time. The exposure for these atrioventricular valve procedures is provided in the course of performance of the maze III and no additional incision is necessary. Aortic valve replacement, however, is a separate procedure from the maze; the additional 65 minutes include the time necessary to create and close an aortotomy. Combination of aortic and mitral valve operations with the maze III was not undertaken until recently; the shorter time increment reflects a level of experience that was not present while learning to combine single valve operations with the maze III procedure.

If the goal of the maze III procedure is to eliminate all of the symptoms or complications associated with atrial fibrillation, then a limitation of our series might be the utilization of mechanical prostheses, particularly in the mitral position. Given that these patients will require life-long warfarin anticoagulation with its attendant risks of hemorrhage and thrombosis, addition of the maze procedure might appear to carry excess risk in order to provide the benefit of atrioventricular synchrony as well as rate control.

Although implantation of a thrombogenic prosthesis might seem an incomplete solution for combined valvular heart disease and atrial fibrillation, it attests to the pronounced incidence of rheumatic valvular disease in our practice. Our approach to rheumatic mitral valve disease has included an attempt at mitral repair in patients with less extensive fusion of the subvalvar apparatus. Our attempts at mitral repair were successful in only 1 of 3 patients with rheumatic disease compared with 9 of 10 patients with degenerative disease. Published results for repair of rheumatic disease [24–26] have been considerably less favorable than for degenerative disease [27, 28]. Homograft replacement of the mitral valve combined with the maze III procedure was performed in 3 patients in this series and has been separately reported by our group [29]. In addition to avoiding anticoagulation, this combination may provide durable restoration of mitral anatomy and physiology. It should, however, be reserved for patients with rheumatic disease limited to the mitral valve, given the long ischemic time and cardiopulmonary bypass time required for this demanding procedure. As our experience with homograft mitral replacement matures, we anticipate its more frequent use in combination with the maze procedure.

Our encouraging early outcomes with the maze III performed alone or as a combined operation raise implications regarding patient selection for the maze procedure. Our surgical recommendation for adding the maze III to recipients of combined procedures was based on the coexistence of moderately symptomatic atrial fibrillation; traditional criteria involving failure of an exhaustive medical regimen were applicable only to patients undergoing an isolated maze procedure. This less restrictive approach was most evident in 32% of our patients who underwent the maze III, but did not, retrospectively, appear to have symptoms or complications of atrial fibrillation as a compelling indication for operation. This observation demonstrates that atrial fibrillation has not been the only symptom of concern when a combined procedure was undertaken. We have felt, however, that the maze III carries substantial benefit, and we have extended it to patients taking fewer medications or having fewer cardioversion attempts than cardiologists generally administer.

Although longer follow-up of our patients is necessary, it will not be possible to rigorously evaluate the quality-of-life improvement in the current series of patients, owing to a lack of formal preoperative assessment. Quality-of-life assessment has been incorporated into trials [30, 31] of therapy for atrial fibrillation as a measurement for success of nonsurgical approaches, and limited enrollment in the maze treatment arm of the multicenter Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial [31] can be anticipated. Confirmation of the superiority of the maze procedure over nonsurgical treatments will require demonstration of a quality-of-life advantage. Our early success supports using a lower threshold for addition of the maze III to other cardiac procedures. It seems appropriate, therefore, to recommend a lower threshold for referral of patients requiring an isolated maze III as well. [10]

	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): Joseph M. Arcidi, Jr Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Millar, R. C. Articles by Alison, P. J.M. Search for Related Content PubMed PubMed Citation Articles by Millar, R. C. Articles by Alison, P. J.M.