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Ann Thorac Surg 2004;77:1277-1281
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Long-term follow-up after the mini-maze procedure

Zoltan A. Szalay, MDa, Ali Civelek, MDa, Thorsten Dill, MDb, Wolf Peter Klövekorn, MDa, Iram Kilb, MDa, Erwin P. Bauer, MDa*

a Department of Cardiovascular Surgery, Kerckhoff-Clinic Foundation, Bad Nauheim, Germany
b Department of Radiology, Kerckhoff-Clinic Foundation, Bad Nauheim, Germany

Accepted for publication September 11, 2003.

* Address reprint requests to Dr Bauer, Kerckhoff-Clinic Foundation, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
e-mail: ebauer{at}eccr.ch


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKGROUND: Atrial fibrillation (AF) is associated with significant morbidity and mortality. The standard to treat AF surgically is the Cox maze III procedure but owing to its complexity it is not performed on a regular basis. Meanwhile several maze variants have been developed but their long-term results are still not well known.

METHODS: From November 1995 until May 2002 a mini-maze procedure was performed upon 77 patients aged 64 ± 8.7 years with chronic symptomatic AF. Electrophysiological evaluation, magnetic resonance imaging, echocardiography and electrocardiographic evaluations were performed after 3 and 12 months. After a mean follow-up of 50 ± 2.6 months a standard questionnaire was sent to all patients.

RESULTS: Early and late mortality was 1.2% and 9.3% respectively. Actuarial survival was 91%, 90%, and 87% after 1, 3, and 5 years respectively. Left bundle branch block was an independent risk factor for late death (p = 0.02). Patients who were in sinus rhythm at follow-up had significantly better survival rate as compared with the patients still in AF. Seventy-one percent of patients were in sinus rhythm or paced by an atrial pacemaker. Predictors for restoration of sinus rhythm were absence of preoperative mitral insufficiency (p = 0.03) and larger left atrium (p = 0.04). The presence of preoperative tricuspid insufficiency (p = 0.03) and larger right atrium (p = 0.017) were predictors for postoperative pacemaker implantation.

CONCLUSIONS: The mini-maze procedure can be carried out with satisfactory early and long-term results regarding mortality and restoration of sinus rhythm. Prophylactic implantation of biventricular pacemakers in patients with left bundle branch block may decrease late mortality. Every effort should be done to cure AF as it affects long-term survival.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Atrial fibrillation (AF) is the most common arrhythmia associated with poor prognosis in clinical practice [1]. Although many patients may well tolerate this arrhythmia, others suffer from unpleasant sensations or may show intolerance to certain medications, for example warfarin. The Cox maze III procedure is acknowledged to be the standard for surgical procedure for atrial fibrillation. In at least 90% of the patients AF can be converted into sinus rhythm early and late after this operation [2]. Because the Cox maze procedure is very complex it is therefore not performed as a routine by the surgeons. In order to simplify this procedure several variants of the Cox maze III operation have been developed [3–5]. Furthermore new technologies such as radiofrequency ablation, cryotherapy, and microwave have been introduced to the market [6–8]. Early results of these procedures are promising but little is known about long-term results.

In 1995 we developed a variant of the Cox maze procedure with the aim to reduce cross-clamp time, which is of great value especially in patients with concomitant heart disease. This variant includes all Cox maze III incisions except the incision to mitral anulus, the incision through atrial septum toward the coronary sinus, and the two incisions toward the tricuspid valve anulus [9]. The 1-year results after this mini-maze procedure were convincing in terms of early and late mortality, conversion to sinus rhythm and atrial transport function [9, 10]. In order to evaluate late results we controlled our patients in early 2003 again.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Between November 1995 and May 2001, a mini-maze procedure was performed upon in 77 patients with chronic symptomatic atrial fibrillation. There were 38 men and 39 women with a mean age of 64 ± 8.7 years (range, 40 to 83). Patient characteristics and baseline data are depicted in Table 1. Atrial fibrillation persisted in all patients despite antiarrhythmic therapy. Mean duration of preoperative AF was 6.6 ± 6.2 years (range, 1 to 35). All patients complained of severe unpleasant sensations related to tachycardia. The technique of the mini-maze procedure has been described previously [9]. Concomitant procedures were carried out in 75 of 77 patients (97.5%; Table 2).


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  		Table 1. Patient Characteristics and Baseline Data

 

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  		Table 2. Operative Variables and Concomitant Procedures

 
Patients who had persistent postoperative AF were treated with antiarrhythmic agents, for example sotalol. If patients did not respond to medical therapy, electrical cardioversion was performed before discharge and antiarrhythmic medication was continued. If a patient showed bradycardia 3 weeks postoperatively an electrophysiological evaluation was performed and a permanent pacemaker was implanted when indicated. All patients were anticoagulated with warfarin for at least 3 months. Electrophysiological evaluation, magnetic resonance imaging, transthoracic echocardiography, right-side heart catheterization, and 24-hour electrocardiography were performed in 100% of patients after 3 months and in 97.5% of patients after 12 months. The test battery performed in all patients after 3 and 12 months was electrophysiologic examination, echocardiography, and magnetic resonance imaging. Details are described elsewhere [10]. Electrophysiological evaluation at follow-up showed that atrial flutter was inducible in 14 patients with sinus rhythm. However, atrial flutter was terminated spontaneously in 12 patients and in 2 patients overdrive pacing was necessary to convert into sinus rhythm. Two patients with atrial flutter had successful ablation and one patient showed atrial flutter resistant to any therapy. Anticoagulation was discontinued after 3 months when significant atrial transport function was demonstrated in either echocardiography or magnetic resonance imaging and electrophysiologic stimulation was not able to induce any kind of arrhythmia. In patients with mechanical valves anticoagulation was maintained for obvious reasons.

Follow-up
In May 2003, a standard questionnaire was sent to all patients operated on between November 1995 and May 2001 to evaluate New York Heart Association (NYHA) classification, heart rhythm disturbances, pacemaker implantation, number of rehospitalizations, occurrence of stroke, and actual medication. Furthermore, a 12-lead electrocardiogram with long DII derivation was demanded from the referring physicians. Mean follow-up time was 50 ± 22.2 months and was 92% complete (71 of 77 patients).

Statistical analysis
Statistical analysis was performed with Solo 6.0.4 for Windows (BMDP Statistical Software, Inc, Los Angeles, CA). The distribution of continuous variables is expressed as mean ± SD and comparison was tested by two-tailed t test (Mann-Whitney U test). Categorical variables were compared by Fisher's exact test. Multivariate analysis was performed by logistic regression. All p values less than 0.05 were considered significant. Survival was calculated according to Kaplan-Meier analysis.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Survival
One of 77 patients (1.2%) died within 30 days after operation and late death occurred in 7 of 76 (9.3%). Actuarial survival was 91%, 90%, and 87% after 1, 3, and 5 years respectively. Sudden death was the cause of late mortality in 6 patients and 1 patient died of subphrenic abscess after an abdominal surgical procedure in another hospital. One of the 6 patients had coronary artery disease combined with mitral insufficiency and 5 of 6 patients did not have ischemic heart disease. Multivariate logistic regression analysis revealed that the only independent risk factors for late death was presence of preoperative total left bundle branch block (p = 0.02). Patients who were in sinus rhythm or were paced by atrial stimulation had a significantly better overall survival than patients with persistent atrial fibrillation although there were no differences between both groups with regard to age and preoperative risk factors (Fig 1).



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  		Fig 1. Long-term survival after mini-maze procedure: patients with sinus rhythm (dashed line) versus patients with persistent atrial fibrillation (straight line).

 
NYHA functional class
Fifty-six of 61 contacted survivors (92%) were in NYHA class I or II, whereas 5 of 61 (8%) patients were in NYHA class III at time of follow-up. Three of the NYHA class III patients suffered from AF at follow-up. Judgment of NYHA class was not possible in 1 patient owing to a metastatic rectum cancer. There was no independent predictor for higher NYHA classification after the mini-maze operation.

Sinus rhythm
Forty-four of 62 (71%) contacted survivors were in sinus rhythm or paced by an atrial pacemaker at follow-up. Nine patients who were in stable sinus rhythm or were paced by an atrial pacemaker at 1-year follow-up converted to AF at late follow-up. Patients converting to AF were not different from patients who did not especially with regard to duration of AF (9.1 ± 7.4 versus 4.8 ± 4.0 months; p = 0.078) and preoperative left atrial diameter (64 ± 5.8 versus 62 ± 7.3 mm). One patient who had AF at 1-year follow-up showed stable sinus rhythm at late follow-up.

Independent predictors for no restoration of sinus rhythm and regular heart rhythm with atrial pacemaker stimulation were presence of preoperative mitral insufficiency (p = 0.03) and larger left atrial diameter (p = 0.04). Longer duration of preoperative atrial fibrillation was not a predictor for failure in this study (p = 0.57).

Pacemaker implantation
Postoperative pacemaker implantation was necessary in 15 of 77 patients (19%): 8 of 15 owing to postoperative sick sinus syndrome and 7 of 15 owing to brady-tachycardia syndrome. During follow-up another 5 patients required pacemaker implantation: 3 of 5 owing to bradycardy-tachycardy syndrome and 2 of 5 because of sick sinus syndrome. There were no surgical complications due to pacemaker implantation of which 10 were single-chamber atrium mode programmed and 10 dual-chamber pacing mode programmed.

Multivariate analysis showed that presence of preoperative tricuspid insufficiency (p = 0.03) and larger right atrium (p = 0.017) were independent predictors for postoperative pacemaker implantation.

Medication
At follow-up 6 patients were still receiving anticoagulation therapy with warfarin owing to incomplete atrial transport function or persistent AF. Thirty-nine of 62 patients (63%) still had antiarrhythmic medication. The reason why a high number of patients still had antiarrhythmic therapy could not be evaluated by the questionnaire.

Cerebral stroke
In 1 patient intraoperative cerebral stroke with hemiplegia occurred. Another patient suffered from cerebral stroke during follow-up. This patient had to stop anticoagulation therapy owing to roentgenographically documented proctitis and gastrointestinal bleeding although he suffered from persistent atrial fibrillation.

Rehospitalization
Nine of 62 patients (14%) contacted were rehospitalized during the follow-up period. Rhythm disturbances were the main cause for rehospitalization. Five of these patients were in AF. The others were rehospitalized because of hyperglycemia (1), stroke (1), gastrointestinal bleeding (1), and heart failure (1).


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Atrial fibrillation is the most common arrhythmia and is associated with significant morbidity and mortality. In the United States 2.2 million people currently are affected by this arrhythmia and this number increases by 120,000 cases annually [1]. The Cox maze procedure has proven to be extraordinarily effective in treating AF [2]. However, this procedure is very complex and not many surgeons perform it on a regular basis. For this reason several mini-variants have been developed in order to simplify the procedure and to reduce cross-clamp time and cardiopulmonary bypass time [3–5]. We have developed our own mini-maze procedure, which is published elsewhere [9]. With this mini-variant we could significantly reduce mean cross-clamp time from 127 ± 40 minutes (full maze and comparable cases) to 87 ± 21 minutes as shown in an earlier study [9].

Other less invasive techniques with new devices have been developed in order to motivate more surgeons doing AF ablation surgery. These include cryoablation, unipolar and bipolar radiofrequency energy, microwave energy, laser energy, and ultrasound [6–8]. The initial results are promising although not comparable with the results achieved by the Cox maze procedure [2].

Survival
In our series, the early mortality rate was 1.2% and the late mortality rate, 9.3%. Cause of late mortality was sudden death in most patients. Other authors performing mini-maze operations describe early mortality rates between 0% and 2.7% [3–5, 11]. Actuarial survival after the mini-maze operation was 91% after 1 year, 90% after 3 years, and 87% after 5 years. Izumoto and associates [12] found 1- and 5-year survival rates of 95.1% and 87.8% after a modified maze procedure, which concurs with our results. The only independent predictor for overall mortality was presence of left bundle branch block in our study. This is not surprising since others confirmed that complete left bundle branch block affects overall mortality indeed [13]. One of the reasons is that left bundle branch block is known to adversely influence ventricular function owing to nonsynchronized contractions of left and right ventricle. Biventricular pacing is able to resynchronize contraction of both ventricles leading to improvement of left ventricular ejection fraction. This is even true in patients with AF as stated by Leon and colleagues [14]. Since left bundle branch block was an independent predictor for increased overall mortality in our population one may suggest that biventricular pacing may improve long-term survival.

We found that actuarial survival in patients with sinus rhythm or regular rhythm due to AAI pacing had a better long-term survival compared with the group of patients still suffering from AF. This result is not surprising, as it is well known that patients with AF have increased risk for late death [15].

NYHA classification
Most of our patients were in good clinical conditions at follow-up. Only 5 patients or 8% were in NYHA class III or IV. Three of these patients had unsuccessful operation concerning AF. We could not find any independent predictor for higher NYHA classification. This is not surprising as NYHA classification is a subjective variable seldom correlating with objective hemodynamic measurement. In the study published by Izumoto and colleagues [12], the NYHA class at follow-up was 1.5 ± 0.5.

Sinus rhythm
At follow-up 71% of patients were in sinus rhythm or had regular heart rhythm due to AAI pacing. This result is inferior to the results published by the Cox group, which found freedom from recurrent AF of 93% after 14 years as stated at the 2003 AATS meeting by Damiano. However, others performing mini-variants of the Cox maze III procedure found similar results. Izumoto and associates [12] reported that 64.8% of patients undergoing a modified maze operation were in sinus rhythm whereas Raanani and colleagues [16] reported a 75% success rate at 3 years. We are fully aware that our 71% success rate is significantly inferior to the 93% success rate of Cox. However, since we combined rather complex operations with the mini-maze procedure we were afraid that longer cross-clamp time would impair the survival rate of the patients. If the main purpose for the operation would be restoration of sinus rhythm we would also perform the full Cox maze III procedure to achieve a better success rate. Interestingly in our series 9 patients having sinus rhythm after 1 year showed AF at follow-up. In the series of Izumoto and associates [12], only 72% of 104 patients having sinus rhythm immediately after operation showed stable sinus rhythm at follow-up. Sixteen patients (22%) converted to AF and 4 patients (6%) developed sick sinus syndrome [12]. The authors think that underlying heart disease could have an impact on recurrent AF. Another factor for this high recurrency rate might be selective use of cryoablation lines. In our study, 1 patient having AF after 1 year converted to sinus rhythm during follow-up. This has also been shown by Izumoto and associates [12] who observed 2 patients converting from AF to sinus rhythm during follow-up. There is no explanation for this interesting observation.

In our study, independent predictors for no restoration of sinus rhythm and regular heart rhythm with AAI mode stimulation were presence of preoperative mitral insufficiency and larger left atrium. This concurs with the Katamatas group [17] who also found larger diameter of left atrium to be a predictor for no sinus rhythm restoration after the original Cox maze III procedure. Furthermore they found that amplitude of atrial fibrillatory wave was also predictive for no sinus rhythm restoration. In a previous analysis, we found that presence of mitral valve stenoses and longer duration of atrial fibrillation were predictors for failure after the mini-maze operation [18]. After this analysis we did not perform the mini-maze operation in patients with mitral valve stenosis and presence of atrial fibrillation for more than 8 years. This may explain the different results.

Pacemaker implantation
Early postoperative pacemaker implantation was necessary in 19% of our patients and another 5 patients needed a pacemaker later on. Sick sinus syndrome and brady-tachycardy syndrome were indications in 10 patients each. Cox and associates [2] reported pacemaker requirement in 15% of patients early after operation. In the series of Izumoto, 6% of patients underwent early postoperative pacemaker implantation owing to sick sinus syndrome. During follow-up 4 patients developed sick sinus syndrome and required pacemaker implantation. There is no statement in this paper regarding DDD pacemaker implantation owing to the brady-tachycardia syndrome.

In our study, independent predictors for postoperative pacemaker implantation was preoperative tricuspid insufficiency and larger right atrium. Indeed secondary tricuspid insufficiency due to mitral valve disease was frequently observed in our study group. As a consequence the right atrium was enlarged quite often and this might be the reason why the frequency of pacemaker implantation was higher compared with others.

Medication
At follow-up, 6 patients were still receiving anticoagulation therapy with warfarin since atrial transport function was not restored. However, Cox and colleagues [19] stated that even if atrial transport function is not adequate anticoagulation may be stopped.

More than 50% of patients still had antiarrhythmic medication at follow-up although most of them were in sinus rhythm or had regular heart rhythm with AAI mode pacing. We could not evaluate why so many patients were still treated with antiarrhythmic drugs. Although we informed the family doctors and cardiologists that medication may be stopped when heart rhythm is regular and atrial transport function sufficient, we assume that they either were afraid in doing so or they ignored our advice.

Cerebral stroke
Cerebral stroke is the most disastrous complication for patients with AF. In the Framingham study there was a more than fivefold increase of strokes in the presence of atrial fibrillation compared with patients having sinus rhythm [20]. One of our patients suffered intraoperative stroke and one patient after cessation of warfarin medication. Cox and coworkers [19] observed only 2 perioperative strokes in a study group of 340 patients and there was only 1 minor stroke during the follow-up period. As a result of this large study Cox suggests discontinuing anticoagulation therapy for all patients 3 months postoperatively even if there is no or minor atrial transport function.

Rehospitalization
Nine patients or 14% were readmitted to hospital during follow-up period. Five of them were in AF and 1 of the patients had congestive heart failure. Four patients were rehospitalized for cardioversion during the follow-up period: in 1 patient cardioversion was successful. The other reasons for rehospitalization were not cardiac related.

It is well known that frequency of hospitalization in patients with atrial fibrillation is significantly higher compared with patients with sinus rhythm. Therefore the health care cost for patients with this dysrhythmia increase dramatically [21]. For this reason it is of huge socioeconomic importance to decrease the total number of patients suffering from atrial fibrillation.

In conclusion, the mini-maze procedure can be carried out with good early and long-term results in terms of early and late mortality. Left bundle branch block was an independent risk factor for late death. Prophylactic implantation of a biventricular pacemaker could probably reduce mortality in patients with left bundle branch block. Restoration of SR can be achieved in 71% of patients. Predictors for restoration of sinus rhythm were absence of mitral insufficiency and larger left atrium. Frequency of postoperative pacemaker implantation was necessary in 19%. Predictors for postoperative pacemaker implantation were presence of postoperative tricuspid insufficiency and larger right atrium.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Kannel W.B., Abbott R.D., Savage D.D. Epidemiologic features of chronic atrial fibrillation: the Framinghan study. N Engl J Med 1982;306:1018-1022.[Abstract]
  2. Cox J.L., Ad N., Palazzo T., et al. Current status of the maze procedure for the treatment of atrial fibrillation. Semin Thorac Cardiovasc Surg 2000;12:15-19.[Medline]
  3. Sueda T., Nagata H., Orihashi K., et al. Efficacy of a simple left atrial procedure for chronic atrial fibrillation in mitral valve operations. Ann Thorac Surg 1997;63:1070-1075.[Abstract/Free Full Text]
  4. Takami Y., Yasuura K., Takagi Y., et al. Partial maze procedure is effective treatment for chronic atrial fibrillation associated with valve disease. J Card Surg 1999;14:103-108.[Medline]
  5. Tuinenburg A.E., Van Gelder I.C., Tieleman R.G., et al. Mini-maze suffices as adjunct to mitral valve surgery in patients with preoperative atrial fibrillation. J Cardiovasc Electrophysiol 2000;11:960-967.[Medline]
  6. Sie H.T., Beukema W.P., Ramdat Misier A.R., Elvan A., Ennema J.J., Wellens H.J. The radiofrequency modified maze procedure. A less invasive surgical approach to atrial fibrillation during open-heart surgery. Eur J Cardiothorac Surg 2001;19:443-447.[Abstract/Free Full Text]
  7. Gaita F., Gallotti R., Calo L., et al. Limited posterior left atrial cryoablation in patients with chronic atrial fibrillation undergoing valvular heart sugery. J Am Coll Cardiol 2000;36:159-166.[Abstract/Free Full Text]
  8. Knaut M., Spitzer S.G., Karolyi L., et al. Intraoperative microwave ablation for curative treatment of atrial fibrillation in open heart surgery—the MICRO-STAF and MICRO-PASS pilot trial. Microwave application in surgical treatment of atrial fibrillation. Microwave application for the treatment of atrial fibrillation in bypass surgery. Thorac Cardiovasc Surg 1999;47(Suppl 3):379-384.
  9. Szalay Z.A., Skwara W., Pitschner H.F., Faude I., Klovekorn W.P., Bauer E.P. Midterm results after the mini-maze procedure. Eur J Cardiothorac Surg 1999;16:306-311.[Abstract/Free Full Text]
  10. Bauer E.P., Szalay Z.A., Brandt R.R., et al. Predictors for atrial transport function after mini-maze operation. Ann Thorac Surg 2001;72:1251-1254.[Abstract/Free Full Text]
  11. Izumoto H., Kawazoe K., Kitahara H., Kamata J. Operative results after the Cox/maze procedure combined with a mitral valve operation. Ann Thorac Surg 1998;66:800-804.[Abstract/Free Full Text]
  12. Izumoto H., Kawazoe K., Eishi K., Kamata J. Medium-term results after the modified Cox/maze procedure combined with other cardiac surgery. Eur J Cardiothorac Surg 2000;17:25-29.[Abstract/Free Full Text]
  13. Hesse B., Diaz L.A., Snader C.E., Blackstone E.H., Lauer M.S. Complete bundle branch block as an independent predictor of all-cause mortality: report of 7073 patients referred for nuclear exercise testing. Am J Med 2001;110:253-259.[Medline]
  14. Leon A.R., Greenberg J.M., Kanuru N., et al. Cardiac resynchronization in patients with congestive heart failure and chronic atrial fibrillation: effect of upgrading to biventricular pacing after chronic right ventricular pacing. J Am Coll Cardiol 2002;39:1258-1263.[Free Full Text]
  15. Benjamin E.J., Wolf P.A., D'Agostino R.B., Silbershatz H., Kannel W.B., Levy D. Impact of atrial fibrillation on the risk of death. Circulation 1998;98:946-952.[Abstract/Free Full Text]
  16. Raanani E., Albage A., David T.E., Yau T.M., Armstrong S. The efficacy of the Cox/maze procedure combined with mitral valve surgery: a matched control study. Eur J Cardiothorac Surg 2001;19:438-442.[Abstract/Free Full Text]
  17. Kamata J., Kawazoe K., Izumoto H., et al. Predictors of sinus rhythm restoration after Cox maze procedure concomitant with other cardiac operations. Ann Thorac Surg 1997;64:394-398.[Abstract/Free Full Text]
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