Cox-maze ? Procedure For Structural Heart Disease Associated With Atrial Fibrillation

BackgroundAtrial fibrillation is the most common arrhytlhmia in the clinic,and its incidence increases with aged[1,2]The latest research shows that the incidence of atrial fibrillation in the population is 0.4-1.0%,and there are currently about 33.5 million people with atrial fibrillation worldwide,and the incidence of atrial fibrillation will continue to increase with the global aging trend[3].In recent decades,as the incidence of atrial fibrillation has increased,complications associated with disability and death have also increased significantly.There are several major hazards in atrial fibrillation in clinical practice[1]:1.The rapid and extremely irregular ventricular rate causes the patient to have many discomforts such as palpitations,chest tightness,dizziness,fatigue,etc.2.When the atrial fibrillation occurs,the atrium loses its contractile function,and the hemodynamics is abnormal,which in turn produces various degrees of heart failure;3.Blood stagnant in the atria increase the risk of thrombosis and thromboembolism.Once atrial fibrillation occurs and complications such as heart failure,stroke,organ or limb arterial embolism(severe amputation may occur)will have a great impact on the patient's quality of life and activity endurance,and significantly increase the hospitalization rate of patients and medical expenses.Therefore,early detection,clear diagnosis and active treatment of atrial fibrillation are necessary.The incidence of atrial fibrillation in structural heart disease is significantly increased,especially in patients with valvular heart disease.The main treatment for structural heart disease with atrial fibrillation is surgery.Its development has undergone left atrial isolation,atrioventricular nodal catheter ablation,corridor surgery,Cox-maze procedure,etc.Since Cox pioneered and performed Cox-maze procedure,the surgical treatment of atrial fibrillation has made great progress.Through continuous improvement,it has evolved from Cox-maze I procedure to the current Cox-maze ? procedure and Cox-maze IV procedure.Although maze type ? surgery has been described as the "gold standard”for the treatment of atrial fibrillation,due to its large trauma,complicated operation and long operation time,and with the development of new ablation and minimally invasive techniques,there are only a few domestic and foreign centers carries out Cox-maze? procedure[4].Therefore,there are relatively few studies on the safety and effectiveness of Cox-maze ? procedure,which remains to be further confirmed.ObjectiveTo explore the efficacy and safety of Cox-maze ? procedure for patients with structural heart disease associated with atrial fibrillation.MethodsFrom August 2015 to September 2018,44 patients with structural heart disease associated with atrial fibrillation underwent Cox-maze ? procedure,including 22 males and 22 females with an average age of 30-65(52.34±11.24)years old,and the duration of atrial fibrillation was between 6 months and 20 years;of them 18 underwent mitral valve replacement,13 underwent mitral valve replacement +tricuspid annuloplasty,7 underwent double valve replacement,3 underwent valve replacement + tricuspid valvuloplasty,1 underwent aortic valve replacement,1 underwent mitral valve repair + coronary artery bypass grafting,and 1 underwent atrial septum defect repair + tricuspid valvuloplasty,The operation was the"cut and sew" according to the original Cox-maze III procedure,tricuspid annular,mitral isthmus and coronary sinus were ablated with Atricure monopolar radiofrequency.Intraoperative and postoperative date were collected,including the time from skin to skin,cardiopulmonary bypass time,aortic calmping time,tracheal intubation time,early postoperative complications and mortality,length of hospital stay.Patient's sinus rhythm recovery,free of antiarrhythmia medication,stroke exemption,and cardiac function were followed up postoperatively,of which sinus rhythm recovery and cardiac function were based on 7days dynamic electrocardiogram and echocardiography.ResultsThe average time of skin to skin,cardiopulmonary bypass and aortic-clamping was 279.3±40.2 minutes,172.4±36.3 minutes,114.7±28.9 minutes respectively,the tracheal intubation time was 1.7±0.4 days.2 cases had acute renal insufficiency with bedside CRRT,and 1 case appeared Low cardiac output syndrome after operation.One patient died postoperatively with MODS.Although two patients were placed with permanent pacemaker before discharge,both of them restored sinus rhythm in 3 months postopreatively.Among the 43 patients,42 patients were follow-up with period of 3 months to 3 years,except one missed postoperatively.39 patients restored sinus rhythm with sinus rhythm recovery rate 92.8%.There were no death and stroke.The free of anti-arrhythmia medication was 90.4%.Echocardiography showed left atrial diameter(LAD)and left ventricular diastolic diameter(LVEDD)were significantly reduced,and left ventricular ejection fraction(LVEF)was significantly increased compared with preoperatively.Moreover,the incidence of mitral A peak after operation was 85.71%,and the incidence of tricuspid A peak was 92.86%.ConclusionCox-maze ? procedure is a safe and effective with high recovery rate of sinus rhythm and excellent early and midterm outcomes for structural heart disease associated with atrial fibrillation.