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Ann Thorac Surg 1995;60:359-360
© 1995 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO 63110
This article describes a group of 10 patients who underwent simultaneous surgical correction of atrial fibrillation and mitral valve disease. There are a few minor differences in the technique used by Itoh and associates and that previously described, but the important principles of the maze procedure were retained. Of importance was the performance of cryoablation of strategic sites, especially at the coronary sinus on the left side. I believe that cryoablating the coronary sinus is essential for two reasons: (1) we demonstrated many years ago that it is not possible to isolate the left atrium from the right atrium in a reproducible fashion unless the coronary sinus is cryoablated [1] and (2) in our post--maze procedure patients who have had a recurrence of either atrial flutter or atrial fibrillation and who have undergone subsequent formal electrophysiology studies, 4 of 5 patients (80%) have demonstrated the reestablishment of electrical conduction across the posterior vertical left atriotomy, ie, along the coronary sinus. This suggests that the complete blocking of conduction along this route is critical to the long-term success of the operation. Although complete and permanent electrical block cannot always be assured even with cryoablation, the long-term recurrence rate, especially of atrial flutter, would assuredly be higher without it.
One of the interesting findings in this study is that the left atrium functioned after the maze procedure but at a submaximum level in comparison with control. Although our own studies show essentially the same thing, it is worth noting that in this series of patients, the calculated A/E ratio was reported as being depressed only in comparison with a ``control'' group of patients having coronary artery bypass grafting (Table 3). In fact, the peak A (atrial) contraction in the maze group and in the control group was 56 cm/s and 63 cm/s, respectively (p = not significant). The reason for the alteration in the calculated A/E ratio was a change in the peak E (ventricular filling). Although this does not negate Itoh and associates' conclusions, it does confirm that several factors affect the echocardiographic determinants of apparent atrial function postoperatively and that the quantitation of atrial function in any postoperative patient is a complex task.
Having made these few observations, Itoh and associates' excellent results speak for themselves. They are to be congratulated on obtaining those results in a difficult series of patients.
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