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Ann Thorac Surg 2004;77:512-517
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Long-term results of irrigated radiofrequency modified maze procedure in 200 patients with concomitant cardiac surgery: six years experience

^a Department of Cardiothoracic Surgery and Cardiology, Isala Clinics, Zwolle, The Netherlands

^* Address reprint requests to Dr Sie, Cardiothoracic Surgery, Isala Klinieken, Groot Wezenland 20, Zwolle 8011 JW, The Netherlands
e-mail: hauw.sie{at}hccnet.nl

Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
BACKGROUND: The Cox maze procedure is considered an effective surgical treatment of atrial fibrillation in patients with and without organic heart disease. Radiofrequency energy offers an alternative to the complex surgical maze procedure. We used the radiofrequency modified maze III procedure in patients with atrial fibrillation undergoing elective concomitant cardiac surgery. This study evaluated the long-term results of the irrigated radiofrequency ablation to create linear lines of conduction block endocardially.

METHODS: Between November 1995 and June 2001, 200 patients with mainly structural heart disease and chronic atrial fibrillation underwent intraoperative radiofrequency linear ablation in both atria with concomitant cardiac surgery.

RESULTS: The in-hospital mortality rate was 3.5% (7 patients) and during the mean follow-up of 40 months (range, 12 to 80) 27 patients (13.5%) died. Eight patients (4%) were lost from follow-up and complete data were available in 158 survivors. Sinus or atrial rhythm was present in 116 patients (73.4%) and an atrial driven rhythm in 10 patients (6.3%) with an atrioventricular pacemaker. Atrial fibrillation or flutter was documented in 32 patients (20.3%). Antiarrhythmic drugs were used in 49% of survivors who were free of atrial fibrillation or flutter.

CONCLUSIONS: Intraoperative radiofrequency endocardial ablation is an effective technique to eliminate atrial fibrillation with promising long-term results.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Atrial fibrillation (AF) is the most frequent cardiac arrhythmia and accounts for 0.4% of the general population [1]. In approximately 30% to 40% of patients undergoing mitral valve surgery, chronic AF was present before the operation and in most patients the arrhythmia will persist after correction of the primary disease [2, 3]. Several other studies have reported on long-term follow-up of cardiac rhythm after electrical cardioversion after mitral valve surgery but the maintenance rate of sinus rhythm does not seem satisfactory [4–7]. Cox and associates have developed the maze procedure as a surgical treatment for patients with drug-refractory AF [8, 9]. Nevertheless the Cox maze procedure is complex with long surgical procedure time and this has been hampering the widespread use in cardiac surgical patients with AF. In an attempt to simplify the procedure modifications have been developed including the use of cryoablation and changes in atriotomies [10, 11] and application of radiofrequency energy [12, 13]. In the present study we report the long-term results of the irrigated radiofrequency modified maze procedure as an additional procedure in 200 consecutive patients with chronic AF undergoing concomitant cardiac surgery.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Patients
Between November 1995 and June 2001 a total of 200 consecutive patients underwent the radiofrequency modified maze procedure for chronic AF of at least 1 year's duration. All patients had structural heart disease. The primary indication for surgery was the underlying organic lesions in 195 patients. In 5 patients arrhythmia surgery was the primary reason for cardiac surgery. In these 5 patients additional tricuspid valvuloplasty was performed. Mitral valve replacement or repair was performed in 162 patients as a single procedure or in combination with aortic valve replacement or coronary artery bypass grafting. Aortic valve surgery or coronary artery bypass graft surgery (CABG) alone were carried out in 12 and 13 patients respectively and miscellaneous procedures in the remaining 13 patients (Table 1). Concomitant tricuspid annuloplasty was carried out in 125 patients, closure of atrial septal defect in 3 patients, aortic root replacement and ascending aortic replacement in 2 patients each, and correction of cor triatriatum in 1 patient. Twenty patients had been operated on before (10%). There were 108 female patients (54%) and the mean age of the whole group was 68 years (range, 31 to 84). The mean left atrial dimension was 50 ± 10 mm (range, 31 to 80 mm) as measured on an M-mode tracing taken from a two-dimensional parasternal long-axis view. An atrioventricular sequential or ventricular pacemaker was implanted in 8 patients before surgery.

Surgical procedure
In all patients cardiopulmonary bypass was used with standard aortic cannulation, bicaval cannulation, and moderate hypothermia. Part of the radiofrequency maze was performed during crossclamping of the aorta and cardioplegic arrest with cold crystalloid cardioplegia. The radiofrequency maze procedure and postoperative management were described in detail previously [12]. In summary the radiofrequency ablation part of the surgical procedure is as follows: most of the atrial incisions currently used in the Cox maze III were replaced by radiofrequency ablation lines except for two incisions in the right atrium and a standard left atrial incision in Waterston groove and these incisions were used to enter both atrial cavities. Both the right atrial appendage and the left atrial appendage were excised. In redo operations the left atrial appendage was electrically isolated by a circumferential radiofrequency ablation line around the orifice and subsequently closure of the cul-de-sac with polypropylene. In contrast to the Cox maze III the right and left islands of pulmonary veins were isolated separately and interconnected with an additional line in the left atrial roof to preserve the posterior atrial wall in between (Fig 1). In addition isolation of the coronary sinus at the posterior wall of the left atrium (Fig 1) along with a linear ablation lesion from the tricuspid valve area to inferior vena cava (IVC/TV-isthmus) was performed also (Fig 2). Postoperative care was similar as for routine cardiac surgery. Postoperative atrial arrhythmias were treated with sotalol 80 to 120 mg daily or amiodarone 200 mg daily and combined with direct-current cardioversion whenever necessary. Antiarrhythmic drugs were tapered gradually after cardiac rhythm was considered stable. Anticoagulation therapy was given for at least 3 months and discontinuation of medication was at the discretion of the referring cardiologist. The presence of atrial contraction as documented by transthoracic and transesophageal Doppler echocardiography was performed at 3 and 6 months after surgery and related to the electrocardiogram. After 6 months patient status was determined yearly by screening records of outpatient visits and correspondence with referring cardiologist.

View larger version (91K): [in this window] [in a new window]   Fig 1. View inside left atrium. Incision through the interatrial groove (Waterston) and stay sutures to expose the left atrium. Blue lines depict the endocardial radiofrequency ablation lines. Ablation lines (O) are also performed from the ablation line isolating the left pulmonary veins (LPV) to the base of the excised and resutured left atrial appendage (LAA) amputation site and to the posterior mitral valve (MV) annulus. (p = isolation of the coronary sinus from the posterior left atrial wall; RPV = right pulmonary veins.)

View larger version (105K): [in this window] [in a new window]   Fig 2. View inside right atrium. Bicaval cannulation. Blue lines depict the endocardial radiofrequency ablation lines. The isthmus ablation (F) runs from the inferior caval vein (IVC), across the interatrial septum, up to the caudal aspect of the coronary sinus (CS) ostium and over to the posterior tricuspid valve (TV) annulus. (FO = foramen ovale; RAA = excised and resutured right atrial appendage; SVC = superior vena cava.)

	Results

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Mortality and morbidity
Among the 200 patients, there were 7 in-hospital deaths (3.5%). Three patients died of multiorgan failure, 2 patients died of low cardiac output. One late tamponade and one mitral annulus rupture were the cause of death in another 2 patients. Postoperative in-hospital complications were rethoracotomy in 16 patients, use of an intraaortic balloon pump in 8 patients, and sternal wound infection in 3 patients. Endocarditis, stroke, and atrioventricular conduction block occurred in 1 patient each. There were no complications related to the radiofrequency maze procedure such as collateral damage to adjacent structures. Constrictive pericarditis occurred late in 2 patients. During follow-up 27 patients (13.5%) died because of end-stage heart failure (8 patients), hemorrhagic stroke (4 patients, all but 1 patient using coumadin), cancer (2 patients), gastrointestinal ischemia/infarction (1 patient on coumadin therapy), and miscellaneous causes (13 patients). The overall proportion of patients surviving in this series is shown in Figure 3.

View larger version (12K): [in this window] [in a new window]   Fig 3. Long-term survival after radiofrequency maze. Actuarial survival for the entire study group of 200 patients.

View larger version (13K): [in this window] [in a new window]   Fig 4. Long-term rhythm follow-up after radiofrequency maze. Freedom from atrial fibrillation (AF) and atrial flutter (AFL) using the Kaplan-Meier actuarial curve in 158 patients.

	Comment

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
We describe the long-term results of a large cohort of patients with long-lasting AF who underwent the radiofrequency modified maze procedure as a concomitant procedure as reported previously [12]. The study group consists of an unselected population of patients with a variety of cardiac diseases who underwent intraoperative radiofrequency ablation mainly in combination with additional cardiac procedures. In-hospital mortality in our total patient group was comparable with mortality rates in previous reports of patients who underwent mainly isolated mitral valve surgery with or without AF [2, 14, 15].

In other reports on intraoperative radiofrequency ablation of AF during concomitant cardiac surgery, each containing a limited number of patients with a total number of 216 patients, the follow-up ranged from 1 to 19 months [13, 16–19]. The authors reported freedom of AF between 76% and 92%. However many patients included in these series had a history either of paroxysmal AF or duration of chronic AF of less than one year. Chua and associates [2] and Obadia and coworkers [7] concluded that in patients with intermittent AF or arrhythmia duration of less than 1 year, mitral valve surgery alone is more likely to restore sinus rhythm in the majority of patients. We included only patients with a history of at least 1 year of AF in whom it is unlikely that sinus rhythm will be restored spontaneously after valve surgery. Another large single center report is from Mohr and associates [20]. They performed radiofrequency ablation of AF, average duration 7.8 ± 5.2 years, in 234 patients with or without structural heart disease (30%). At 12 months of follow-up 69.7% of patients with mitral valve surgery (30 of 43) and 61.9% of patients with other surgical procedures were in sinus rhythm. In our study group sinus or atrial rhythm was present in about 80% of survivors who had had mitral valve related surgery and in as many as 67% in other types of cardiac surgery. In previous reports on the surgical Cox maze procedure in patients with mitral valve diseases recovery of sinus rhythm was reported in 63% to 90% of patients during follow-up that ranged from 12 to 56 months [21–24].

Nevertheless there are questions yet to be answered with regard to intraoperative radiofrequency ablation of atrial fibrillation such as, the 42% freedom from AF in our patients in whom only CABG was performed as the primary reason for surgery, which is much lower than in patients with mitral valve surgery. Pasic [13] concluded that the presence of coronary artery disease influences success rate. Is this finding related to a different type of substrate? In which patients is radiofrequency ablation confined to the left atrium an alternative to the radiofrequency modified maze procedure and what is the best set of ablation lesions in relation to the underlying cardiac disease?

Limitations of the study
One of the limitations with using radiofrequency, microwave, or cryoenergy to treat AF is that it is not possible to verify transmurality of the linear lesions at the time of energy delivery. Electrical activity may still traverse nontransmural lesions created endocardially on the epicardial surface of the atrium or through gaps in the ablation lines. However given that there is no real-time method to document complete conduction block one may speculate on the importance of functional block in these ablation lesions on clinical outcome. The radiofrequency modified maze however simplifies the classic cut-and-sew maze operation with long-term results similar to other reports as discussed in the previous chapter. The results of this observational study with a relatively large number of patients are from a single center performed by one same surgeon and multicenter studies are needed. Almost half of the patients are still on antiarrhythmic drugs at latest follow-up because the decision to cease medication was at the discretion of referring physicians. With regard to patients who underwent nonmitral valve surgery and radiofrequency ablation of AF the limited number of patients do not allow us to draw definitive conclusions on the efficacy of this treatment to eliminate the arrhythmia in this particular group of patients.

	Discussion

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
DR DUKE E. CAMERON (Baltimore, MD): You have not had the complication of esophageal perforation as a few other surgeons have been reported? Do you have some thoughts on the mechanism of that injury and any special steps to prevent it?

DR SIE: Well, as you have seen on one of the slides, I mentioned that collateral damage was zero, and I know about the reports of esophageal damage, and I can say that they have been using a different type of energy. First they have been using non-irrigated or dry radiofrequency, secondly they used another lesion pattern: the so called "anchoring" type of ablation, which means that you have to go inside the pulmonary vein and then connect all these pulmonary veins with each other. With non-irrigated or dry radiofrequency energy, to get a transmural lesion you have to use high power settings, and if you do that on the left atrium and going down inside the pulmonary veins, which has a much thinner wall than the atrium itself, one can imagine that the same power setting can easily perforate the PV wall. This is very hard to control. Beside that the PV is in closer vicinity to the esophagus. Whether with or without an echo probe in the esophagus with this technique perforation is more likely to occur. We didn't even have one single perforation and we still keep the esophagus probe in situ during the whole operation.

DR CAMERON: You don't withdraw it?

DR SIE: We don't withdraw it, and we haven't seen any problems until now in over 280 patients.

DR JOSEPH BAVARIA (Philadelphia, PA): I thought this was an outstanding paper and has ramifications on our specialty that are impressive. My question: did all 200 patients get both left atrial and right atrial incisions?

DR SIE: Yes. As I stated in the beginning, I consider the maze procedure as the gold standard and I am much in favor of doing the biatrial full maze. It covers all types of atrial fibrillation and not only the paroxysmal or the near paroxysmal AF, but it covers all, and that is still our philosophy. We only have one chance. I don't want to go back.

DR BAVARIA: Do you have any experience whatsoever with just the left atrial modified RF ablation maze?

DR SIE: No.

DR BAVARIA: And the third question: What were your antiarrhythmic drugs? Were your patients on amiodarone and what was the percentage of patients on amiodarone or other antiarrhythmics in your trial?

DR SIE: The first choice of antiarrhythmic drugs postoperatively is sotalol, and if they cannot tolerate that, we switch over to amiodarone. At the latest follow up approximately 50% are on antiarrhythmic drugs.

DR RICHARD SHEMIN (Boston, MA): I think the great strength of this paper is that you have used a combination of incisions and radiofrequency lesions to perform the Maze procedure as Dr Cox has described it. I would be interested in how much CPB and cross clamp time did it take using this kind of hybrid approach? What was the operative time to do this?

DR SIE: The additional procedure time that we needed, for instance, the left-sided ablation, in the mitral valve procedure when you are supposed to open the left atrium anyway is approximately 14 minutes of extra cross-clamp time. If you do a CABG procedure, of course you have to open up the left atrium additionally and to cut off the left atrial appendage. Then it will be more than that, of course.

DR SHEMIN: Also, did you have a standard time point, like three months postop, when you determined whether the patient was in sinus rhythm or not as your end point?

DR SIE: Yes.

DR SHEMIN: Did you ever see any patient who at that point in time was in sinus rhythm lapse back into atrial fibrillation with further drug manipulation or withdrawal?

DR SIE: Yes. We considered six months as a cutoff point for success or failure, and during the follow-up there were several patients who went back in atrial fibrillation temporarily and reverted into sinus rhythm spontaneously or with electrical cardioversion or with increasing the medication or just by giving back the medication which was abandoned earlier.

DR RALPH DAMIANO (St. Louis, MO): Dr Sie, congratulations on not only a large series and very nice results but continuing to closely follow these patients because I think we are going to learn a lot from what you have done. I recently had the privilege of being able to review the entire Washington University experience, many of which were Dr Cox's patients who underwent the Cox-maze III, and the 10-year success rate with a maze and a concomitant procedure was 97% of patients in sinus rhythm. Your rate is lower than that, and I wonder if you could maybe elucidate for us in the patients who did recur an atrial fibrillation or flutter what were the arrhythmias?

And in looking at those patients, do you think the problem was that you weren't transmural with the lesion, or I wonder if you have been able to identify in your large number of patients what patients were more prone to failure and why?

DR SIE: Well, it is obvious that transmurality is probably the problem that we encountered in some of the patients. I remember some of the patients who had a very thick walled atrium that I was very tempted to do the full Cox-maze, but I didn't do it, and afterwards I regretted that because this patient went into AF very soon after the operation.

I think that transmurality is one of the issues, and there are some reports that indicate that probably transmurality is not necessary to get a conduction block, but in the cases that we had, those were patients with thick or calcified atrial wall or an atrial wall which was covered by thrombi, and probably in those cases it doesn't work very well.

We encountered some patients who had atrial flutter, two of them on the left side around the mitral valve annulus, and probably there was gap in one of the lines and the cardiologist could not terminate that flutter. In four other patients they managed to terminate the flutter because it was on the right side, around the tricuspid valve, and, again, I think it was a problem of a gap in one of the lines.

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