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Ann Thorac Surg 2002;73:1457-1459
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Repetitive atrial flutter as a complication of the left-sided simple maze procedure

^a Department of Cardio-Thoracic Surgery, Nagoya University Graduate School of Medicine Nagoya, Japan
^b First Department of Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan

Accepted for publication February 6, 2002.

* Address reprint requests to Dr Usui, 65 Tsurumai, Showa-ku, Nagoya 466-8550, Japan
e-mail: ausui{at}med.nagoya-u.ac.jp

	Abstract

Top Abstract Introduction Patients, methods, and results Comment References

 
Background. Of 41 patients who had undergone a left-sided simple maze procedure, 4 (9.8%) developed repetitive tachycardia due to atrial flutter, and required radiofrequency catheter ablation. Linear ablation of the right atrial isthmus was effective to treat atrial flutter.

Methods. We conducted an electrophysiologic study of atrial flutter and determined its reentry circuit on the atrium. We consider how to reduce atrial flutter after the left-sided simple maze procedure.

Results. Common atrial flutter through the right atrial isthmus was induced in all 4 patients, and linear ablation on the right atrial isthmus was effective in 3 of these. An incisional atrial flutter around the right atriotomy was also induced in 2 of 4 patients; both were successfully treated by linear ablation between the right atriotomy and the inferior vena cava.

Conclusions. Common atrial flutter through the right atrial isthmus is a risk after the left-sided simple maze procedure. When a left-sided simple maze procedure is performed, sufficient cryoablation on the right atrial isthmus of the arrested heart should be administered to prevent postoperative atrial flutter.

	Introduction

Top Abstract Introduction Patients, methods, and results Comment References

 
Surgical treatment of atrial fibrillation has been developed by Cox and colleagues [1], with some variation [2]. Sueda and colleagues [3] developed a simple maze procedure to ablate the left atrium alone. Since 1994 we have used a modified Cox’s maze III procedure, combined with valvular surgery, in patients with chronic atrial fibrillation. One third of these patients required more than 1 week of temporary cardiac pacing because of delayed recovery of sinus node function. In 1997 we therefore changed to a left-sided simple maze procedure to shorten the time needed for recovery of sinus node function. Another complication that is likely to occur after the maze procedure is supraventricular arrhythmia. Of 4 patients who underwent the left-sided simple maze procedure (10%, n = 41) repeatedly experienced tachycardia due to atrial flutter and required radio-frequency ablation (RFA) after surgery, whereas only 1 patient required RFA for tachycardia due to atrial flutter after the modified Cox’s maze III procedure (3%, n = 32). We present here an electrophysiologic study of induced atrial flutter that was conducted to determine its reentry circuit on the atrium, and we consider how to reduce atrial flutter after the left-sided simple maze procedure.

	Patients, methods, and results

Top Abstract Introduction Patients, methods, and results Comment References

 
Left-sided simple maze procedure
The left-sided simple maze procedure is performed as follows. The patient is placed on cardiopulmonary bypass with bicaval venous drainage and arterial return to the ascending aorta. After aortic cross-clamping, the heart is arrested with antegrade or retrograde cold blood cardioplegia. The left atrial appendage is then resected and sutured at its base, and an extended right-sided left atriotomy is made. Cryoablation is delivered at -60°C for 90 seconds at the left margin of both left pulmonary venous orifices toward the left atriotomy ridge to isolate all four pulmonary venous orifices. Cryoablation is also directed adjacent to the center of the posterior mitral valve annulus and the base of the excised left atrial appendage. In recent cases, further cryoablation has been delivered toward the anatomical right atrial isthmus, between the tricuspid valvular annulus and the inferior vena cava.

Surgery and electrophysiologic study
Patient 1 was a 55-year-old man who had experienced chronic atrial fibrillation for 10 years as a result of combined rheumatic valvular disease. His aortic and mitral valves were replaced with mechanical valves at the same time as a left-sided simple maze procedure was performed, but no cryoablation was delivered at the right atrial isthmus. The patient’s normal sinus rhythm recovered but he suffered several postoperative episodes of paroxysmal atrial flutter (heart rate 140 beats/min). An electrophysiologic study indicated two kinds of atrial flutter: a counterclockwise common atrial flutter through the right atrial isthmus, and a left atrial tachycardia (see 1 and 4 in Fig 1). Radio-frequency ablation (RFA) was performed to create an anatomical linear block on the right atrial isthmus 11 months after surgery (11 times and total 12,407J; see area (a) of Fig 1). No more episodes of atrial flutter took place.

View larger version (32K): [in this window] [in a new window]   Fig 1. Schema of left-sided simple maze procedure and induced atrial flutter in an electrophysiologic study. Upper portion is a visceral view of both atria, whereas lower portion is a dorsal view. Black lines represent incisions and gray area shows cryoablation at surgery. Black area shows linear block with radio-frequency ablation. Gray ovals show expected reentry circuits of atrial flutter induced in electrophysiologic study. Ovals (1) and (2) are counterclockwise and clockwise common atrial flutter, respectively. Oval (3) is an incisional atrial flutter around the right atriotomy. Oval (4) refers to left atrial tachycardia. Black area (a) indicates anatomical linear ablation of right atrial isthmus, whereas black area (b) is linear block between the atriotomy and the inferior vena cava (IVC). (LAA = left atrial appendage; MV = mitral valve; PV = pulmonary vein; RAA = right atrial appendage; SVC = superior vena cava; TV = tricuspid valve.)

Patient 3 was a 56-year-old woman with a 10-year history of chronic atrial fibrillation due to mitral valve stenosis. She had undergone mitral valve replacement with a mechanical valve, combined with a left-sided simple maze procedure. No cryoablation was performed at the right atrial isthmus. Normal sinus rhythm was restored, but several times the patient experienced faintness due to paroxysmal atrial flutter. An electrophysiologic study performed 3 years after surgery revealed three distinct types of atrial flutter. These were counterclockwise and clockwise common atrial flutter (see 1 and 2 in Fig 1) and an incisional atrial flutter around the right atriotomy (see 3 in Fig 1). A complete linear ablation was created at the right atrial isthmus 30 times, total 70,824J (see area (a) in Fig 1). Another linear ablation between the right atriotomy and the inferior vena cava was made 15 times with a total 32,050J delivery (see area (b) in Fig 1). There were no further episodes of atrial flutter.

Patient 4 was a 56-year-old man who had undergone closed mitral commisurotomy 25 years earlier as a result of mitral valve stenosis. The mitral valve was replaced in response to mitral valve restenosis, and a left-sided simple maze procedure was included to tackle the 25-year history of chronic atrial fibrillation. A total of 60 seconds of cryoablation was delivered at -60°C at the right atrial isthmus through the right atriotomy on the beating heart. The patient’s sinus rhythm recovered, but atrial flutter then developed and was sustained as a 2:1 block at a heart rate of 130/min. One year after surgery an electrophysiologic study found an incisional atrial flutter around the right atriotomy (see 3 in Fig 1). A linear ablation was created between the right atriotomy and the IVC (22 times, total 30,152J; see area (b) in Fig 1). The incisional atrial flutter was cured, although a counterclockwise common atrial flutter through the right atrial isthmus remained (2:1 block and 100/min heart rate).

	Comment

Top Abstract Introduction Patients, methods, and results Comment References

 
The left-sided simple maze procedure was originally reported by Sueda and colleagues. They did not perform surgical ablation on the right atrium because chronic atrial fibrillation associated with mitral valve disease can be caused by the shortened refractory period of the distended left atrium [3]. The simple maze procedure shortens the aortic cross-clamp time, facilitates postoperative hemostasis, and reduces postoperative complications as a result of the shorter incision line on the right atrium.

Incomplete or delayed recovery of sinus node function is a major complication of the original maze procedure because of major transect variations of the sinus node arteries. The incidence of sick sinus syndrome, which necessitated the implantation of a cardiac pacemaker, has been reported as 3.2% to 25% [1, 2, 4, 5]. The absence of invasion of the sinus node area is a further advantage of the left-sided simple maze procedure. This shortens the time needed for recovery of sinus node function and reduces the incidence of sick sinus syndrome. In our series, 4 patients required more than 1 week of temporary cardiac pacing as a result of delayed recovery of sinus node function after left-sided simple maze procedures (10%, n = 41). The incidence of sick sinus syndrome is 32% for modified Cox’s maze III procedures (n = 32; p = 0.0418, ² test). Cardiac pacemaker implantations were required in 2 cases after Cox’s maze III procedure and in 1 case after the left-sided simple maze procedure, at 2 to 4 months after surgery. The former 2 cases were implanted VVI for sinus bradycardia or sinus arrest, and the last case was performed DDD for sick sinus syndrome with brady and tachycardia.

Paroxysmal atrial tachycardia developed due to atrial flutter in 4 cases (10%) in the left-sided simple maze procedure, but in only 1 case (3%) in Cox’s maze III procedure. The left-sided simple maze procedure clearly has a higher incidence of atrial flutter in our series. Common atrial flutter through the right atrial isthmus was induced in all 4 cases, and linear ablation on the right atrial isthmus was effective in 3 of these. An incisional atrial flutter around the right atriotomy was also induced in 2 of these 4 cases; both were cured with a linear ablation between the right atriotomy and the IVC. We consider that common atrial flutter through the right atrial isthmus carries a clear risk after the left-sided simple maze procedure. Therefore, cryoablation between the tricuspid annulus and the IVC on the arrested heart is recommended at a sufficient level to prevent postoperative atrial flutter tachycardia. When a right atriotomy was performed, we delivered 2 minutes of cryoablation several times at -60°C between the tricuspid valvular annulus and the IVC orifice. Additional cryoablation on the outside IVC is effective when the venous cannula or IVC tape obstructs cryoablation.

Around a right atriotomy, incisional atrial flutter is also significant. We therefore recommend that the right atriotomy should be longitudinally, at the lower part of the right atrium, and that additional cryoablation should occur between the atriotomy ridge and the IVC. Imai and colleagues [6] reported that new supraventricular arrhythmia occurred in more than 20% of patients who recovered their sinus rhythm after the left-sided simple maze procedure. They performed RFA in 2 of 32 cases. Linear block of the right atrial isthmus was successful in 1 case, and modification of the atrioventricular node and implantation of a permanent cardiac pacemaker was performed in the others [6]. The modified lesser maze procedures give rise to a higher incidence of recurrent supraventricular arrhythmias than the standard maze procedure.

In our series, possible predictors of postoperative atrial flutter after the left-sided simple maze procedure were evaluated by univariate unconditional logistic regression. Of the variables noted in preoperative clinical profiles and operative factors, only age was significantly associated with a reduced chance of postoperative atrial flutter (odds ratio = 0.879, p = 0.0347). Patients who developed postoperative atrial flutter were significantly younger than other patients (47.7 ± 12.5 vs 60.9 ± 8.7, p = 0.0093). Atrial flutter and atrial fibrillation are both intraatrial reentrant arrythmias, with differing complexity in their activation pattern and mechanism. They frequently coexist in clinical practice [7]; however, it is possible in some cases that postoperative atrial flutter either preexists or develops de novo.

Restoration of sinus rhythm after surgery was at 74% in the left-sided simple maze procedure for our series. There are no significant differences between the rate of 74% reported by Imai and colleagues [6] and the rate that we found for Cox’s maze procedure (78% with ² test, n = 32). Although a left-sided simple maze procedure reduces operative invasiveness without reducing the defibrillation rate, it can be complicated by tachycardia due to atrial flutter. We make no recommendation for the choice of the maze procedure or its modification. When a left-sided simple maze procedure is performed, sufficient cryoablation on the right atrial isthmus should be deployed to prevent postoperative atrial flutter.

	References

Top Abstract Introduction Patients, methods, and results Comment References

 

1. Cox J.L., Jaquiss R.D.B., Schuessler R.B., Boineau J.P. Modification of the maze procedure for atrial flutter and atrial fibrillation. II. Surgical technique of the maze III procedure. J Thorac Cardiovasc Surg 1995;110:485-495.[Abstract/Free Full Text]
2. Kosakai Y., Kawaguchi A.T., Isobe F., Sasako Y., Kilo Y., Kawashima Y. Cox maze procedure for chronic atrial fibrillation associated with mitral valve disease. J Thorac Cardiovasc Surg 1994;108:1049-1055.[Abstract/Free Full Text]
3. Sueda T., Nagata H., Shikata H., et al. Simple left atrial procedure for chronic atrial fibrillation associated with mitral valve disease. Ann Thorac Surg 1996;62:1796-1800.[Abstract/Free Full Text]
4. Chua Y.L., Schaff H.V., Orszulak T.A., Morris J.J. Outcome of mitral valve repair in patients with preoperative atrial fibrillation. J Thorac Cardiovasc Surg 1994;107:408-415.[Abstract/Free Full Text]
5. Pasic M., Musci M., Siniawski H., Edelmann B., Tedoriya T., Hetzer R. Transient sinus node dysfunction after the Cox-maze III procedure in patients with organic heart disease and chronic fixed atrial fibrillation. J Am Coll Cardiol 1998;32:1040-1047.[Abstract/Free Full Text]
6. Imai K., Sueda T., Orihashi K., Watari M., Matsuura Y. Clinical analysis of results of a simple left atrial procedure for chronic atrial fibrillation. Ann Thorac Surg 2001;71:577-581.[Abstract/Free Full Text]
7. Nabar A., Rodriguez L., Timmermans C., Dool A., Smeets J., Wellens H. Effect of right atrial isthmus ablation on the occurrence of atrial fibrillation. Circulation 1999;99:1441-1445.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Akihiko Usui Yuichi Ueda Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Usui, A. Articles by Ueda, Y. Search for Related Content PubMed PubMed Citation Articles by Usui, A. Articles by Ueda, Y. Related Collections Electrophysiology - arrhythmias