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Ann Thorac Surg 2008;86:1878-1882. doi:10.1016/j.athoracsur.2008.07.070
© 2008 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Long-Term Health-Related Quality of Life After Maze Surgery for Atrial Fibrillation

Catharina Lundberg, MDa,*, Anders Albåge, MD, PhDb, Carina Carnlöf, RNc, Göran Kennebäck, MD, PhDc

a Department of Cardiology, Karolinska Institute at Södersjukhuset, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
b Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
c Department of Cardiology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden

Accepted for publication July 22, 2008.

* Address correspondence to Dr Lundberg, Department of Cardiology, Södersjukhuset, Stockholm, SE-118 83, Sweden (Email: lundbergcatharina{at}gmail.com).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Atrial fibrillation (AF) significantly impairs health-related quality of life (QoL). As pharmacologic treatment may have intolerable side effects and is not always effective, other techniques for curing AF have evolved. The maze III procedure has a high long-term success rate in restoring and maintaining sinus rhythm, but the long-term impact on QoL has not been sufficiently demonstrated.

Methods: Thirty-four patients underwent the maze III procedure for paroxysmal (n = 9), persistent (n = 15) or permanent (n = 10) AF. Quality of life was assessed with the Swedish Short Form-36 survey. Mean follow-up time was 35 ± 6 months.

Results: Sinus rhythm was maintained in 32 patients (94%). For all domains except bodily pain, all patients reported substantial worse QoL at baseline as compared with healthy controls. Postoperatively all scores improved significantly to the level of the general population, and for the majority of the scoring items this was observed after 12 months. Improvement was maintained during the remaining observation period.

Conclusions: The maze III procedure significantly improves QoL in patients with AF. The results are consistent during an observation time of 35 months. Based on QoL effects in a long-term perspective, maze surgery should be considered in symptomatic patients with AF refractory to pharmacologic treatment or catheter ablation.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The overall prevalence has been estimated at 0.9% and increases with age [1]. The most common predictors for development of AF are heart failure and hypertension. Atrial fibrillation may have several negative consequences such as disabling symptoms, impaired hemodynamics, and serious thromboembolic complications. The arrhythmia is associated with a nearly two-fold increase in mortality [2]. Quality of life (QoL) is severely impaired among patients with AF when compared with sex-matched and age-matched controls [3–5]. Most patients are treated pharmacologically, aiming for either rate or rhythm control. Antiarrhythmic drug treatment fails frequently and has many side effects, including an intrinsic proarrhythmic risk [6].

In the last two decades, several invasive strategies with intention to cure AF have evolved, among these the maze III procedure. The success rate of this operation has been evaluated in clinical, objective aspects, but there is a lack of data regarding the effects on QoL more than 12 months postoperatively. The aim of this study was to assess QoL after the maze III procedure in a long-term perspective.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patient Characteristics
Thirty-four consecutive patients who underwent the maze III procedure, as described by Cox [7], at the Karolinska University Hospital, between November 1996 and January 2002, were prospectively assessed for QoL analysis. Atrial fibrillation was the primary indication for surgery in 32 patients. The majority of these patients (n = 26) underwent a stand-alone maze III procedure, but in 6 patients preoperative investigations revealed structural heart disease that necessitated concomitant procedures (mitral annuloplasty n = 5, closure of atrial septal defect n = 1, coronary artery bypass grafting n = 2). Two patients had significant and symptomatic mitral valve disease (mitral insufficiency and severe mitral stenosis, respectively) as primary indication for surgery and underwent concomitant mitral valve surgery and maze III.

The mean age of the study group was 57 ± 10 years (range, 33 to 75) and the majority of the patients were male (74%). Nine patients (26%) had paroxysmal, 15 patients (44%) persistent, and 10 patients (29%) permanent AF. The atrial fibrillation was severely symptomatic in all patients and they suffered from dyspnea, dizziness, palpitations, or fatigue. In all patients, several antiarrhythmic drugs had failed or had been withdrawn due to intolerable side effects. The patients had been treated with a mean of 3.7 ± 2 antiarrhythmic drugs (Vaughan Williams class I–IV). Seventeen patients (50%) had tried both classes I and III antiarrhythmic therapy, and 12 patients (35%) had been treated with amiodarone. Twenty-five patients (73%) were on warfarin treatment prior to surgery. Preoperative treatment with anticoagulants was based on the referring cardiologists' preference. Patient characteristics and predisposing factors for AF are depicted in Table 1.


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  		Table 1 Preoperative Patient Characteristics
 
All patients were preoperatively assessed with exercise test, and all patients over 45 year of age underwent a coronary angiogram. Two patients had asymptomatic significant coronary disease; hence, coronary bypass surgery was performed in addition to the maze procedure, as described. One patient had had a previous myocardial infarction and subsequent percutaneous coronary intervention but had neither symptoms of ischemia nor significant angiographic changes preoperatively. Three patients had a diagnosis of heart failure, New York Heart Association (NYHA) class I, as a consequence of mitral valve disease or hypertension. Two patients had nonobstructive hypertrophic cardiomyopathy; one of them had a localized discrete apical hypertrophy but only symptoms related to the AF, the other patient had moderate to severe concentric hypertrophy and congestive heart failure (NYHA class II). Seventeen patients (50%) were considered to have lone AF. The medical ethics committee approved this study, and all patients were included after providing informed consent.

Quality-of-Life Questionnaires
The QoL was assessed with the Swedish Short Form 36 (SF-36) survey elaborated within the framework of International Quality of Life Assessment (IQOLA) in order to match the original US SF-36 Health Survey Manual and Interpretation guide [8]. The SF-36 is an internationally validated generic health scale frequently used in arrhythmia studies. Our patient material has been compared with an age- and sex-matched population norm. Normative data have been collected from a control group consisting of 8,930 Swedish subjects [8]. The scale evaluates eight health domains: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. The scores range from 0 to 100, higher scores reflecting better functional status and well-being. Treatment of missing items and scoring was performed according to the SF-36 manual and a scale score was calculated if a respondent answered at least 50% of the items on that particular scale. The QoL was evaluated before surgery and 6, 12, 24, and 36 months postoperatively. The questionnaire was handed out during visits at the hospital or delivered by mail. Patients who did not return the questionnaire were contacted by phone or by mail. A clinical evaluation including 12-lead electrocardiogram and 24-hour Holter recording was performed annually.

Statistical Analysis and Definitions
All values are expressed as mean ± SD. All patients were compared with the control group using the Student unpaired t test. The differences between baseline and the following 36-months postoperative values were tested using analysis of variance for repeated measures. Statistical significance was selected at p < 0.05. During the study, the definitions of AF elaborated by the International consensus on nomenclature and classification of atrial fibrillation were used [9].


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Sinus rhythm was maintained in 32 patients (94%) at the end of follow-up. During the observation period 2 patients had a single relapse of symptomatic paroxysmal AF-flutter and thus received no treatment. Two patients with recurrent symptomatic episodes received antiarrhythmic drugs. One of them did not have any further symptoms, and the other had several relapses probably due to elevated systolic blood pressure secondary to poor drug compliance. During the observation period, 2 patients (6%) relapsed into permanent AF-flutter and were treated with rate regulation drugs. Pharmacologic treatment eventually failed in one of them and a pacemaker was implanted followed by a subsequent His-bundle ablation. All patients with relapse of AF after surgery had structural heart disease.

Apart from reduced arrhythmia-related symptoms, there was no change in cardiovascular symptoms during the observation time, with the exception for 2 patients. One patient who had mitral stenosis as primary indication for surgery improved substantially regarding exertion dyspnea. Aggravated symptoms were observed in one patient who, for unknown reasons, postoperatively developed pulmonary hypertension and congestive heart failure (NYHA class II).

Perioperative complications in general were minor and transient. Three patients developed symptoms of sinus node disease requiring pacemaker implantation postoperatively. One patient developed a third degree atrioventricular block due to the surgical procedure itself and received a pacemaker, remaining in sinus rhythm.

Five patients (15%) were on warfarin treatment at the end of follow-up. They had a history of thromboembolism preoperatively or had other factors predisposing for thromboembolic events.

SF-36
Mean clinical follow-up time was 35 ± 6 months. Before surgery, patients reported significantly lower QoL scores in all domains except for bodily pain, as compared with the age- and sex-matched control group of the general Swedish population. The lowest preoperative scores were obtained for role-physical and vitality (Table 1; Fig 1). The preoperative scores were compared with the scores obtained at 6, 12, 24, and 36 months follow-up. Missing data were 2%, 15%, 6.9%, 12%, and 5.9%, respectively. All subscales of the SF-36 significantly improved after the maze III procedure except for bodily pain that remained unaltered (p = not significant). Physical functioning, vitality, social functioning, role-emotional, and mental health reached the level of the Swedish population 12 months postoperatively. General health improved earlier, while role-physical significantly differed from the control group until 24 months follow-up. The greatest change in scoring was seen for the items role-physical, vitality, and role-emotional (Table 2; Fig 1). The improvement of QoL was consistent during the rest of the observation time.


Figure 1
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  		Fig 1. Changes in SF-36 quality of life domains at baseline and 36 months after maze III operation compared with an age- and sex-matched population norm; the larger the area the better the quality of life. ({diamondsuit} = control; {blacksquare} = baseline; {blacktriangleup} = 36 month; BP = bodily pain; GH = general health; MH = mental health; PF = physical functioning; RE = role-emotional; RP = role-physical; SF = social functioning; VT = vitality.)

 

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  		Table 2 Health-Related Quality of Life Before and at 6, 12, 24, and 36 Months After Maze Surgery
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Health-related quality of life is severely impaired among patients with AF, which has been demonstrated in several previous studies [3–5]. Both pharmacologic rate and rhythm control treatment strategies are associated with improvements in QoL [4, 5]. Catheter ablation of focal AF triggers [10], ablation of the atrioventricular node with pacemaker implantation [11–13], and pulmonary vein ablation [14, 15] have also been successful in this respect.

The classic maze III procedure has a high success rate in restoring and maintaining sinus rhythm. Freedom from AF has been reported in 64% to 97% of patients in long-term studies with a mean follow-up period of at least 4 years [16–19]. A statistical significant improvement in QoL after the maze III procedure has previously been shown at one-year follow-up in two studies, with 25 and 18 patients, respectively [20, 21], but there is limited documentation on the long-term effects on QoL.

The aim of this study was to evaluate health-related QoL after maze surgery in a long-term perspective of 35 months. The QoL, assessed with SF-36, was markedly impaired preoperatively compared with age- and sex-matched Swedish controls [8]. We found that QoL significantly improved and reached the level of the Swedish control population after the maze III operation in all items except for bodily pain, which was normal already before intervention [8]. The improvement in QoL was maintained during a follow-up of 35 months.

Hemels and colleagues [17] recently presented a study of 29 patients, in which there was no statistically significant difference in reported QoL between the maze patients and healthy control subjects at the end of an observation period of a mean of 4.8 years. In this report, mean age was 48 ± 6 years, and all patients underwent a stand-alone maze III procedure due to lone AF [17]. In our study, mean age was 57 ± 10 years, and 17 patients had structural heart disease with concomitant surgery performed in 8 patients. Despite these differences in patient selection, the results in both studies are very similar regarding both objective measures as restored sinus rhythm and in improvement of QoL during prolonged follow-up. Noteworthy is that in both studies the patients were predominantly male (74% to 93%), why the results should be applied on a female population with caution [17].

The maze III procedure is an open heart procedure that has been perceived as complex and highly invasive, and therefore it has not been widely adopted. Instead, in recent years, surgical ablation procedures have evolved mostly for patients with AF undergoing concomitant surgery. In this study, as well as in other reports [16–18], use of the classic maze III procedure was followed by a high success rate in restoring sinus rhythm and a considerable and consistent improvement in QoL. Thus, despite its invasiveness, maze surgery should be considered in selected severely symptomatic patients with AF refractory to pharmacologic treatment or catheter ablation.

In most patients in this study, AF was the primary indication for surgery, but a few had concomitant mitral valve surgery or coronary bypass grafting. However, results were similar in the study of Hemels and colleagues [17], in which no concomitant procedures were performed. The improvement in one to several domains of QoL after surgery can be secondary to pharmacologic treatment, and a reduction of side effects. The main limitation of this study is the small sample size and that the majority of the patients were men.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age, distribution, and gender of patients with atrial fibrillation: analysis and implications Arch Intern Med 1995;155:469-473.[Abstract/Free Full Text]
  2. Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features of atrial fibrillation: the Framingham Heart Study N Engl J Med 1982;306:1018-1022.[Medline]
  3. Dorian P, Paquette M, Newman D, et al. Quality of life improves with treatment in the Canadian Trial of Atrial fibrillation Am Heart J 2002;143:984-990.[Medline]
  4. Thrall G, Lane D, Carroll D, Lip GY. Quality of life in patients with atrial fibrillation: a systematic review Am J Med 2006;119448e1–19.
  5. Hagens VE, Ranchor AV, Van Sonderen E, et al. RACE study group Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. Results from the Rate Control Versus Electrical Cardioversion (RACE) Study. J Am Coll Cardiol 2004;43:241-247.[Abstract/Free Full Text]
  6. Corley SD, Epstein AE, DiMarco JP, et al. AFFIRM Investigators Relationships between sinus rhythm, treatment, and survival in the atrial fibrillation follow-up investigation of rhythm management (AFFIRM) study Circulation 2004;109:1509-1513.[Abstract/Free Full Text]
  7. Cox JL, Boineau JP, Schuessler RB, Kater KM, Lappas DG. Five-year experience with the maze procedure for atrial fibrillation Ann Thorac Surg 1993;56:814-824.[Abstract/Free Full Text]
  8. Sullivan M, Karlsson J, Taft C. SF-36 Hälsoenkät: Svensk Manual och Tolkningsguide, andra upplagan[Swedish manual and interpretation guide, 2nd ed.]Gothenburg: Sahlgrenska University Hospital; 2002.
  9. Lévy S, Camm AJ, Saksena S, et al. International consensus on nomenclature and classification of atrial fibrillation. A collaborative project of the Working Group on Arrhythmias and the Working Group on Cardiac Pacing of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Europace 2003;5:119-122.[Free Full Text]
  10. Gerstenfeld E, Guerra P, Sparks PB, Hattori K, Lesh, MD. Clinical outcome after radiofrequency catheter ablation of focal atrial fibrillation triggers J Cardiovasc Electrophysiol 2001;12:900-908.[Medline]
  11. Brignole M, Gianfranchi L, Menozzi C, et al. Influence of atrioventricular junction radiofrequency ablation in patients with chronic atrial fibrillation and flutter on quality of life and cardiac performance Am J Cardiol 1994;74:242-246.[Medline]
  12. Fitzpatrick AP, Kourouyan HD, Siu A, et al. Quality of life and outcomes after radiofrequency His-bundle catheter ablation and permanent pacemaker implantation; impact of treatment in paroxysmal and established atrial fibrillation Am Heart J 1996;131:499-507.[Medline]
  13. Natale A, Zimerman L, Tomassoni G, et al. AV node ablation and pacemaker implantation after withdrawal of effective rate-control medications for chronic atrial fibrillation; effect on quality of life and excercise performance Pacing Clin Electrophysiol 1999;22:1634-1639.[Medline]
  14. Pürerfellner H, Martinek M, Aichinger J, Nesser HJ, Kempen K, Janssen JP. Quality of life restored to normal in patients with atrial fibrillation after pulmonary vein ostial isolation Am Heart J 2004;148:318-325.[Medline]
  15. Pappone C, Rosanio S, Augello G, et al. Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation; outcomes from a controlled non-randomized long-term study J Am Coll Cardiol 2003;16:42198–200.
  16. Ballaux P, Geuzebroek G, van Hemel N, et al. Freedom from atrial arrhythmias after classic maze III surgery: a 10-year experience J Thorac Cardiovasc Surg 2006;132:1433-1440.[Abstract/Free Full Text]
  17. Hemels M, Gu Y, Tuinenburg A, et al. Favorable long-term outcome of Maze surgery in patients with lone atrial fibrillation Ann Thorac Surg 2006;81:1773-1779.[Abstract/Free Full Text]
  18. Prasad SM, Maniar HS, Camillo CJ, et al. The Cox maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures J Thorac Cardiovasc Surg 2003;126:1822-1828.[Abstract/Free Full Text]
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  20. Lönnerholm S, Blomström P, Nilsson L, Oxelbark S, Jideus L, Blomström-Lundqvist C. Effects of the maze operation on health-related quality of life in patients with atrial fibrillation Circulation 2000;101:2607-2611.[Abstract/Free Full Text]
  21. Jesserun ER, van Hemel NM, Defauw JA, et al. Results of maze surgery for lone paroxysmal fibrillation Circulation 2000;101(13):1559-1567.[Abstract/Free Full Text]

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