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Ann Thorac Surg 2001;72:1473-1478
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

A new procedure for chronic atrial fibrillation: bilateral appendage-preserving maze procedure

^a Department of Cardiovascular Surgery, Osaka National Hospital, Osaka, Japan

Accepted for publication June 13, 2001.

* Address reprint requests to Dr Isobe, Department of Cardiovascular Surgery, Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka, 540-0006, Japan
e-mail: isobe{at}onh.go.jp

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. Atrial transport and atrial natriuretic peptide secretion is severely reduced from normal after the maze III procedure. To improve these factors, we developed a bilateral appendage-preserving maze procedure (BAP-maze).

Methods. Forty-six patients with chronic atrial fibrillation who underwent the BAP-maze procedure were compared with 40 patients who underwent the maze III procedure. The ratio of the peak velocity of the A and E waves of transmitral flow (transthoracic pulsed Doppler echocardiography), the left atrial appendage ejection fraction (transesophageal echocardiography), and the atrial natriuretic peptide secretory reserve during treadmill exercise test were measured at 6 months postoperatively.

Results. Sinus rhythm was restored in 44 patients (95.7%) by the BAP-maze procedure and in 39 patients (97.5%) by the maze III procedure. The ratio of the peak velocity of the A and E waves was 0.52 ± 0.22 in the BAP-maze group and 0.25 ± 0.19 in the maze III group (p < 0.0001). The left atrial appendage ejection fraction was 44.7% ± 11.5%, and the atrial natriuretic peptide secretory reserve was greater in the BAP maze group (p = 0.037).

Conclusions. The BAP-maze procedure improved atrial transport and atrial natriuretic peptide secretion as well as simplifying the maze operation, without decreasing its effectiveness against atrial fibrillation.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Cox’s maze procedure [1] shows a good efficacy not only for lone atrial fibrillation (AF) but also for chronic AF in patients with organic heart disease, especially valvular heart disease [2, 3]. Its success rate is reported as approximately 84% to 90%. However, it has become apparent that most patients show reduced secretion of atrial natriuretic peptide (ANP) [4] and that atrial transport falls to one third to one half of normal after the maze III procedure, despite the restoration of sinus rhythm (SR) [3]. The atrial appendage is the main source of ANP. If both appendages remained intact, the secretion of ANP would be maintained. The left atrial appendage accounts for 17% to 30% of the total left atrial volume [5, 6]. If atrial appendage contraction could be restored to as near normal as possible, it might contribute to atrial transport. Therefore, the hormonal and hemodynamic state should be closer to normal than after the original maze III operation if both atrial appendages could be preserved. Other procedures for the treatment of AF, such as atrial compartment surgery [7], left atrial isolation [8], and catheter ablation [9, 10], have an almost 70% success rate without the need for removal of the appendages. Thus, we hypothesized that atrial appendectomy was not a necessary part of the maze procedure and that it might not be required to interrupt the atrial macroreentry circuits.

Therefore, we developed a new procedure named the bilateral appendage-preserving maze procedure (BAP-maze) to improve atrial transport, maintain ANP secretion, and simplify the maze procedure without reducing its effectiveness against AF.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Patients
From July 1997 to November 2000, 47 consecutive patients with chronic AF underwent the BAP-maze procedure. It was combined with mitral valve operation in 40 patients (valvuloplasty in 18), with aortic valve operation in 2 patients, with coronary artery bypass graft operation in 2 patients, and with closure of an atrial septal defect in 1 patient. Two patients had lone AF. Before the operation, we explained the details of the surgical procedure and its possible risks to all of the patients and obtained written informed consent. A 69-year-old woman died of low cardiac output syndrome in the early postoperative period after mitral valve replacement with a mechanical valve. Her death was not related to the BAP-maze procedure. Excluding this woman, the remaining 46 patients were investigated. There were 21 men and 25 women who ranged in age from 47 to 73 years (mean ± standard deviation, 60.4 ± 7.7 years). The cardiac rhythm was sustained AF in all patients. The actual duration of AF was not clear, so it was defined on the basis of electrocardiographic data in the medical records as ranging from 5 months to 35 years (9.33 ± 8.10 years). The cardiothoracic ratio ranged from 44% to 70% (57.7 ± 5.7%). Doppler echocardiography showed that the left atrial systolic dimension ranged from 37 to 65 mm (49.5 ± 6.6 mm). Fifteen patients (32.6%) had thromboembolic events preoperatively (13 affecting the brain, 1 involving the coronary artery, and 5 affecting the extremities). We have previously determined that patients with a large left atrium (cardiothoracic ratio 70% or left atrial systolic dimension 80 mm) should be excluded from the maze operation [3], but there was no patient who met this exclusion criterion in the present series.

Bilateral appendage-preserving maze procedure
In the BAP-maze procedure, both atrial appendages are kept intact and three incisions are eliminated from the original maze III procedure: one between the pulmonary vein isolation line and the orifice of the left atrial appendage, one between the tricuspid annulus and the orifice of the right atrial appendage, and one on the right atrial free wall from the right atrial appendage orifice (Fig 1A, 1C). The remainder of the operation is the same as the maze III procedure.

View larger version (32K): [in this window] [in a new window]   Fig 1. Bilateral appendage-preserving maze (BAP-maze) procedure. (A) Diagram of the BAP-maze procedure. (B) Impulse propagation pattern in the right and left atria after the BAP-maze procedure. (C) Diagram of the maze III procedure. Both atrial appendages are kept intact and three incisions are eliminated in the BAP-maze procedure (indicated by arrows). (CS = coronary sinus; FO = foramen ovale; IVC = inferior vena cava; M = mitral; SN = sinus node; SVC = superior vena cava; T = tricuspid.)

As the postoperative anticoagulation protocol to prevent thromboembolism, we administer coumadin and try to control the patient’s international normalized ratio at 2 to 3 as soon as possible after the cessation of bleeding. Treatment is usually started on the first postoperative day, if the patient can take medicine orally. If oral intake is impossible, the activated coagulation time is maintained at up to 150 seconds with heparin. Anticoagulation is continued until 3 months postoperatively as in the case of mitral valvuloplasty.

The present study investigated the BAP-maze procedure and evaluated its efficacy against AF to determine the necessity for atrial appendectomy as a component of the maze procedure. We also compared postoperative atrial transport and ANP secretion after the BAP-maze and maze III procedures.

Data acquisition
We reviewed the electrocardiograms obtained on discharge and once every month postoperatively and assessed whether or not the patients were on antiarrhythmic drugs. At 6 months postoperatively, we measured the A and E wave velocity of transmitral flow (TMF) and transtricuspid flow (TTF) by transthoracic pulsed Doppler echocardiography and also measured the left atrial appendage ejection fraction (LAA-EF) by transesophageal echocardiography. Furthermore, we evaluated the ANP secretory reserve using a treadmill exercise test. Forty patients who underwent the maze III procedure before we started the BAP-maze method were used as controls; mitral valve operation was performed in 38 patients (valvuloplasty in 14), coronary artery bypass graft operation in 1 patient, and atrial septal defect closure in 1 patient. We excluded 3 patients who met the exclusion criterion mentioned above. The 20 men and 20 women ranged from 32 to 72 years old (57.1 ± 10.0 years), and the duration of AF ranged from 4 months to 30 years (6.31 ± 5.97 years). The cardiothoracic ratio ranged from 49% to 71% (59.5% ± 5.5%), and left atrial systolic dimension ranged from 38 to 76 mm (56.6 ± 9.5 mm). Only the left atrial systolic dimension was significantly different from that of the BAP-maze group (p = 0.0007).

Statistical analysis
Continuous variables were compared using the Mann-Whitney U test. Statistical analysis was performed with a StatView J-5.0 software package (Abacus Concepts, Inc, Berkeley, CA).

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Operative mortality and morbidity
We followed up the BAP-maze group at our outpatient clinic for 2.0 to 41.7 months (23.2 ± 12.8 months) and the maze III group for 7.4 to 94.8 months (67.5 ± 20.2 months). One patient in the maze III group died of noncardiac disease during the follow-up period.

A 68-year-old man from the BAP-maze group had lone AF with a huge thrombus in the left atrial appendage and a history of old cerebral infarction preoperatively. He suffered a small cerebral infarct while in SR on postoperative day 4 and developed left hemiparesis, but this recovered completely after 1 month. We routinely performed anticoagulation for 3 months postoperatively after both procedures, but anticoagulation was extraordinarily inadequate at the time of the embolic event in this patient. The other patients had no embolic events postoperatively.

The cardiac arrest time ranged from 78 to 205 minutes (129.3 ± 28.8 minutes) and the cardiopulmonary bypass time was from 127 to 242 minutes (184.7 ± 32.8 minutes) in the BAP-maze group, whereas the respective values were 79 to 229 minutes (147.6 ± 34.5 minutes) and 136 to 305 minutes (224.1 ± 45.9 minutes) in the maze III group. As expected, both times were significantly shorter in the BAP-maze group than those in the maze III group (p = 0.0071 for the arrest time and p = 0.0001 for the cardiopulmonary bypass time).

Postoperative rhythm
Among the 46 patients in the BAP-maze group, SR was restored in 44 patients (95.7%), whereas AF persisted in 1 patient and AF or atrial tachycardia was seen in 1 patient. Among the 40 patients in the maze III group, SR was restored in 39 patients (97.5%) and AF persisted in 1 patient. The AF conversion rate showed no significant difference between the two groups. During the follow-up period, AF or atrial flutter recurred in 1 patient from the BAP-maze group and 5 patients from the maze III group, but antiarrhythmic medications were effective for restoring SR in all patients.

Three patients from the maze III group developed sick sinus syndrome (paroxysmal junctional bradycardia) that required pacemaker implantation, but no patient from the BAP-maze group needed a pacemaker.

Postoperative atrial transport
To evaluate postoperative atrial transport in the patients who were converted to SR, we assessed the A and E waves of TMF and TTF by transthoracic pulsed Doppler echocardiography at more than 6 months after operation. We could obtain data from 38 patients in the BAP-maze group and all 40 patients in the maze III group. An A wave was detected during TMF and TTF in all 38 patients from the BAP-maze group, whereas it was found in 29 of 40 patients (72.5%) during TMF and 38 of 40 patients (95%) during TTF from the maze III group. The ratio of the peak velocity of the A and E waves (A/E ratio) ranged from 0.25 to 1.14 (0.52 ± 0.22) for TMF and from 0.25 to 1.44 (0.65 ± 0.25) for TTF in the BAP-maze group, whereas it was from 0 to 0.67 (0.25 ± 0.19) for TMF and from 0 to 0.95 (0.53 ± 0.19) for TTF in the maze III group, showing a significant difference (p < 0.0001 for TMF and p = 0.0468 for TTF). Atrial transport was not normalized in either group, but the BAP-maze group showed much better transport than the maze III group (Fig 2).

View larger version (24K): [in this window] [in a new window]   Fig 2. The ratio of the peak velocity of the A and E waves (A/E ratio) shown by pulsed Doppler echocardiography after the bilateral appendage-preserving maze (BAP-maze) and maze III procedures. The A/E ratio of transmitral flow was low after both procedures compared with that in normal subjects. However, the A/E ratio was better after the BAP-maze procedure than after the maze III procedure, and there was a significant difference between the two groups (p < 0.0001). (y.o. = years old.)

View larger version (102K): [in this window] [in a new window]   Fig 3. Good contraction of the left atrial appendage after the bilateral appendage-preserving maze (BAP-maze) procedure. Transesophageal echocardiography shows good contraction of the preserved left atrial appendage (LAA) in a patient (H.I., 51 years old) who underwent mitral valvuloplasty and the BAP-maze procedure (left atrial appendage ejection fraction is 58.4%).

View larger version (15K): [in this window] [in a new window]   Fig 4. Left atrial appendage ejection fraction (LAA-EF) measured by transesophageal echocardiography. The LAA-EF was close to normal after the bilateral appendage-preserving maze (BAP-maze) procedure and was between that of normal subjects and that of patients with rheumatic mitral valve disease in sinus rhythm.

View larger version (16K): [in this window] [in a new window]   Fig 5. Atrial natriuretic peptide (ANP) secretory response in the treadmill exercise test. The plasma ANP level at rest and after exercise showed no significant difference between the bilateral appendage-preserving maze (BAP-maze) and maze III groups, but the secretory reserve during exercise was significantly greater in the former group (p = 0.037).

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

On transthoracic pulsed Doppler echocardiography at more than 6 months postoperatively, A waves were detected during TMF and TTF in all patients from the BAP-maze group versus 72.5% during TMF and 95% during TTF in patients of the maze III group. The A/E ratios of TMF and TTF in the BAP-maze group were superior to those in the maze III group, with a significant difference (p < 0.0001 for TMF and p = 0.0468 for TTF; Fig 2). Both the pattern of atrial conduction and the atrial contraction sequence are more physiologic after the BAP-maze procedure than after the maze III procedure, so the BAP-maze group showed much better atrial transport for ventricular filling than the maze III group because of the contribution of atrial appendage contraction as well as the physiologic conduction and contraction sequence of the both atria.

The left atrial appendage showed good contraction with an LAA-EF of 44.7% ± 11.5% at 6 months after the BAP-maze procedure (Fig 3). Hwang and coworkers [11] reported that the LAA-EF was 58.1% ± 17.4% in normal subjects and 29.5% ± 15.0% in patients with rheumatic mitral valve disease in SR. The LAA-EF measured after the BAP-maze procedure was close to normal and between that of the groups reported by Hwang and associates [11] (Fig 4).

As another function of the atrial appendage, it was reported that it might play an important role as a reservoir to protect against atrial pressure increases [5, 12, 13]. The left atrial appendage is more compliant than the left atrial main chamber, because there is a greater increase of the left atrial appendage dimension than that of the main chamber in response to left atrial volume overload and it might improve left atrial reservoir function under physiologic conditions by protecting the pulmonary capillary system from pressure increases. Therefore, the left atrium could also play a greater role as a reservoir to assist left ventricular filling after the BAP-maze procedure than after the maze III procedure.

One of the early postoperative complications of the maze procedure is fluid retention. Yoshihara and colleagues [14] reported that preservation of the right atrial appendage was effective for improving this complication. When a treadmill test was done at 6 months postoperatively, we found that the ANP level at rest and after exercise showed no significant difference (p = 0.782, and p = 0.175, respectively) between the BAP-maze and maze III groups. This might have been because the exercise load was not the same for all patients. However, delta ANP (the secretory reserve during exercise) was significantly greater in the former group (p = 0.035; Fig 5). As expected, the ANP secretory reserve was maintained in the BAP-maze group by preservation of both atrial appendages, because the right and left atrial appendages are the main source of ANP.

Concerning whether it is better or necessary to preserve both atrial appendages rather than one appendage, there have been several important reports that the left and right atria release ANP independently of each other depending on the stimulus [15, 16]. Also, to improve not only ANP secretion but also atrial transport, bilateral preservation of the atrial appendages should be the aim rather than unilateral preservation.

Because appendectomy and three incisions are eliminated in the BAP-maze procedure (Fig 1A), we could shorten the cardiac arrest time and the cardiopulmonary bypass time by simplifying the maze operation.

One of the drawbacks of any maze procedure, including the BAP-maze procedure, is electrical and mechanical isolation of the posterior left atrium between the pulmonary vein orifices. To preserve this area, Nitta and associates [17] have developed the radial incision approach. However, because they had to perform cryoablation of the four pulmonary vein orifices because ectopic beats in the pulmonary veins could initiate AF [9, 10], there may be no significant hemodynamic improvement over the BAP-maze procedure with regard to left atrial posterior wall contraction. Furthermore, pulmonary vein isolation, as performed in the maze procedures, is more reliable than cryothermia for excluding arrhythmogenic foci in the four pulmonary veins.

The ultimate goal of surgical treatment for AF is to reduce the risk of systemic thromboembolism. Cox and colleagues [18] said that the ability of the maze procedure to decrease the risk of stroke associated AF was probably related to the restoration of SR and atrial transport in combination with removal or obliteration of the left atrial appendage. Several studies have shown that thrombus formation and peripheral embolization in AF patients are related to left atrial appendage dysfunction [19, 20]. We found that the LAA-EF after the BAP-maze procedure was much greater than in patients with rheumatic mitral valve disease in SR, so the presence of the atrial appendage itself should not be a risk factor for thromboembolism (Figs 3, 4). Unfortunately, we experienced one patient who had an embolic episode on postoperative day 4 because of inadequate anticoagulation. We routinely performed anticoagulation for 3 months postoperatively with coumadin in every patient, because there is the possibility of thrombus formation at the suture line in the early postoperative period when the endothelium is damaged and a thrombogenic surface exists at this site. To determine whether the preserved appendage is a source of emboli or not, we need to study more patients for a longer follow-up period.

In conclusion, our data indicated that the BAP-maze procedure could improve atrial transport and ANP secretion as well as simplifying the maze operation without reducing its effectiveness against AF. These results support our hypothesis that appendectomy is not a necessary component of the maze procedure.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
This work was supported by the Research Grant for Cardiovascular Diseases (9C-4) from the Japanese Ministry of Health and Welfare.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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