Abstract
Atrial fibrillation (AF) is common in patients presenting for mitral valve surgery. Routine ablation of AF in such patients, although still not applied universally, is a recent phenomenon. This may be attributable to new data clarifying the pathogenesis of AF, the dangers of leaving it untreated, and development of new technologies that facilitate ablation. With a more comprehensive approach toward treating both the arrhythmia and the structural heart disease, it is estimated that surgeons could perform more than 10,000 ablation procedures annually. The purposes of this review are to (1) present the rationale for surgical ablation of AF in mitral valve patients, (2) describe the classic Maze procedure and its results, (3) detail new approaches to surgical ablation of AF, (4) emphasize the importance of the left atrial appendage, and (5) consider challenges and future directions in the ablation of AF in cardiac surgical patients.
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Cox JL. Intraoperative options for treating atrial fibrillation associated with mitral valve disease. J Thorac Cardiovasc Surg. 2001;122:212-215.
Ad N, Cox JL. Combined mitral valve surgery and the Maze III procedure. Semin Thorac Cardiovasc Surg. 2002;14:206-209.
Grigioni F, Avierinos JF, Ling LH. Atrial fibrillation complicating the course of degenerative mitral regurgitation: determinants and long-term outcome. J Am Coll Cardiol. 2002; 40:84-92.
Obadia JF, el Farra M, Bastien OH. Outcome of atrial fibrillation after mitral valve repair. J Thorac Cardiovasc Surg. 1997;114:179-185.
Chua YL, Schaff HV, Orsulak TA. Outcome of mitral valve repair in patients with preoperative atrial fibrillation. Should the maze procedure be combined with mitral valvuloplasty? J Thorac Cardiovasc Surg. 1994;107:408-415.
Lim E, Barlow CW, Hosseinpour AR. Influence of atrial fibrillation on outcome following mitral valve repair. Circulation. 2001;104:I-59-I-63.
Quader MA, McCarthy PM, Gillinov AM, et al. Does preoperative atrial fibrillation reduce survival after coronary artery bypass grafting? Ann Thorac Surg. 2004; 77: 1514-1522.
Jessurun ER, van Hemel NM, Kelder JC. Mitral valve surgery and atrial fibrillation: is atrial fibrillation surgery also needed? Eur J Cardiothorac Surg. 2000;17:530-537.
Kalil RA, Maratia CB, D’Avila A. Predictive factors for persistence of atrial fibrillation after mitral valve operation. Ann Thorac Surg. 1999;67:614-617.
Bando K, Kasegawa H, Okada Y. The impact of pre- and postoperative atrial fibrillation on outcome after mitral valvuloplasty for nonischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2005;129:1032-1040.
Bando K, Kobayashi J, Kosakai Y. Impact of Cox maze procedure on outcome in patients with atrial fibrillation and mitral valve disease. J Thorac Cardiovasc Surg. 2002;124: 575-583.
Handa N, Schaff HV, Morris JJ. Outcome of valve repair and the Cox maze procedure for mitral regurgitation and associated atrial fibrillation. J Thorac Cardiovasc Surg. 1999; 118: 628-635.
Cox JL. The surgical treatment of atrial fibrillation. IV. Surgical technique. J Thorac Cardiovasc Surg. 1991; 101(4): 584-592.
Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J. 2001; 22(20): 1852-1923.
Cox JL. Atrial fibrillation I: a new classification system. J Thorac Cardiovasc Surg. 2003;126(6):1686-1692.
Wu T-J, Kerwin WF, Hwang C. Atrial fibrillation: focal activity, re-entry, or both? Heart Rhythm. 2004;1:117-120.
Haissaguerre M, Jais P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339:659-666.
Todd DM, Skanes AC, Guiraudon G, et al. Role of the posterior left atrium and pulmonary veins in human lone atrial fibrillation: electrophysiological and pathological data from patients undergoing atrial fibrillation surgery. Circulation. 2003;108(25):3108-3114.
Lee S-H, Tai C-T, Hsieh M-H, et al. Predictors of non-pulmonary vein ectopic beats initiating paroxysmal atrial fibrillation: implication for catheter ablation. J Am College Cardiol. 2005;46(6):1054-1059.
Lin W-S, Tai C-T, Hsieh M-H, et al. Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy. Circulation. 2003;107(25):3176-3183.
Oral H, Chugh A, Good E, et al. A tailored approach to catheter ablation of paroxysmal atrial fibrillation. Circulation. 2006;113(15):1824-1831.
Nitta T, Ishii Y, Miyagi Y. Concurrent multiple left atrial focal activations with fibrillatory conduction and right atrial focal or reentrant activation as the mechanism in atrial fibrillation. J Thorac Cardiovasc Surg. 2004;127:770-778.
Yamauchi S, Ogasawara H, Saji Y. Efficacy of intraoperative mapping to optimize the surgical ablation of atrial fibrillation in cardiac surgery. Ann Thorac Surg. 2002;74:450-457.
Harada A, Konishi T, Fukata M. Intraoperative map guided operation for atrial fibrillation due to mitral valve disease. Ann Thorac Surg. 2000;69:446-450.
Harada A, Sasake K, Fukushima T, et al. Atrial activation during chronic atrial fibrillation in patients with isolated mitral valve disease. Ann Thorac Surg. 1996;61:104-112.
Sueda T, Imai K, Ishii O. Efficacy of pulmonary vein isolation for the elimination of chronic atrial fibrillation in cardiac valvular surgery. Ann Thorac Surg. 2001;71: 1189-1193.
Schuessler RB. Do we need a map to get through the maze? J Thorac Cardiovasc Surg. 2004;127:627-628.
Kondo N, Takahashi K, Minakawa M. Left atrial maze procedure: a useful addition to other corrective operations. Ann Thorac Surg. 2003;75:1490-1494.
Gaita F, Gallotti R, Calo L. Limited posterior left atrial cryoablation in patients with chronic atrial fibrillation undergoing valvular heart sugery. J Am Coll Cardiol. 2000;36:159-166.
Tuinenburg AE, van Gelder IC, Tieleman R. Mini-maze suffices as adjunct to mitral valve surgery in patients with preoperative atrial fibrillation. J Cardiovasc Electrophysiol. 2000;11:960-967.
Kalil RAK, Lima GG, Leiria TLL, et al. Simple surgical isolation of pulmonary veins for treating secondary atrial fibrillation in mitral valve disease. Ann Thorac Surg. 2002;73(4): 1169-1173.
Deneke T, Khargi K, Grewe PH, et al. Left atrial versus bi-atrial Maze operation using intraoperatively cooled-tip radiofrequency ablation in patients undergoing open-heart surgery: safety and efficacy. J Am College Cardiol. 2002; 39(10):1644-1650.
Barnett SD, Ad N. Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis. J Thorac Cardiovasc Surg. 2006;131(5):1029-1035.
Calo L, Lamberti F, Loricchio ML, et al. Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a prospective and randomized study. J Am College Cardiol. 2006;47(12):2504-2512.
Usui A, Inden Y, Mizutani S. Repetitive atrial flutter as a complication of the left-sided simple maze procedure. Ann Thorac Surg. 2002;73:1457-1459.
Cox JL, Schuessler RB, Boineau JP. The development of the Maze procedure for the treatment of atrial fibrillation. Semin Thorac Cardiovasc Surg. 2000;12(1):2-14.
McCarthy PM, Gillinov AM, Castle L, Chung MK, Cosgrove Dr. The Cox–Maze procedure: the Cleveland clinic experience. Semin Thorac Cardiovasc Surg. 2000;12(1):25-29.
Schaff HV, Dearani JA, Daly RC, Orszulak TA, Danielson GK. Cox–Maze procedure for atrial fibrillation: Mayo clinic experience. Semin Thorac Cardiovasc Surg. 2000;12(1):30-37.
Prasad SM, Maniar HS, Camillo CJ, et al. The Cox maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures. J Thorac Cardiovasc Surg. 2003;126(6):1822-1828.
Cox JL, Ad N, Palazzo T. Impact of the maze procedure on the stroke rate in patients with atrial fibrillation. J Thorac Cardiovasc Surg. 1999;118:833-840.
Gillinov AM. Ablation of atrial fibrillation in mitral valve surgery. Curr Opin Cardiol. 2005;20:107-114.
Gillinov AM, Sirak JH, Blackstone EH. The Cox maze procedure in mitral valve disease: predictors of recurrent atrial fibrillation. J Thorac Cardiovasc Surg. 2005;130:1653-1660.
Nitta T. Surgery for atrial fibrillation: a worldwide review. Semin Thorac Cardiovasc Surg. 2007;19(1):3-8.
Gaynor SL, Schuessler RB, Bailey MS, et al. Surgical treatment of atrial fibrillation: Predictors of late recurrence. J Thorac Cardiovasc Surg. 2005;129(1):104-111.
Scherer M, Dzemali O, Aybek T. Impact of left atrial size reduction on chronic atrial fibrillation in mitral valve surgery. J Heart Valve Dis. 2003;12:469-474.
Isobe F, Kawashima Y. The outcome and indications of the Cox maze III procedure for chronic atrial fibrillation with mitral valve disease. J Thorac Cardiovasc Surg. 1998; 116: 220-227.
Kawaguchi AT, Kosakai Y, Isobe F. Factors affecting rhythm after the Maze procedure for atrial fibrillation. Circulation. 1996;94:II-139-II-142.
Lee JW, Park NH, Choo SJ. Surgical outcome of the maze procedure for atrial fibrillation in mitral valve disease: rheumatic versus degenerative. Ann Thorac Surg. 2003; 75:57-61.
Jatene MB, Marcial MB, Tarasoutchi F. Influence of the maze procedure on the treatment of rheumatic atrial fibrillation – evaluation of rhythm control and clinical outcome in a comparative study. Eur J Cardiothorac Surg. 2000; 17:117-124.
Baek M-J, Na C-Y, Oh S-S, et al. Surgical treatment of chronic atrial fibrillation combined with rheumatic mitral valve disease: effects of the cryo-maze procedure and predictors for late recurrence. Eur J Cardio-Thorac Surg. 2006; 30(5):728-736.
Gillinov AM, Blackstone EH, McCarthy PM. Atrial fibrillation: current surgical options and their assessment. Ann Thorac Surg. 2002;74(6):2210-2217.
Gillinov AM, McCarthy PM. Advances in the surgical treatment of atrial fibrillation. Cardiol Clin. 2004;147-157.
Gillinov AM, McCarthy PM, Marrouche N, Natale A. Contemporary surgical treatment for atrial fibrillation. Pacing Clin Electrophysiol. 2003;26(7 Pt 2):1641-1644.
Raman J, Ishikawa S, Storer MM. Surgical radiofrequency ablation of both atria for atrial fibrillation: results of a multicenter trial. J Thorac Cardiovasc Surg. 2003;126: 1357-1366.
Sie HT, Beukema WP, Elvan A. Long-term results of irrigated radiofrequency modified maze procedure in 200 patients with concomitant cardiac surgery: six years experience. Ann Thorac Surg. 2004;77:512-516.
Luria DM, Nemec J, Etheridge SP. Intra-atrial conduction block along the mitral valve annulus during accessory pathway ablation: evidence for a left atrial “isthmus”. J Cardiovasc Electrophysiol. 2001;12:744-749.
Cox JL, Ad N. The importance of cryoablation of the coronary sinus during the Maze procedure. Semin Thorac Cardiovasc Surg. 2000;12:20-24.
Gillinov AM, Saltman AE. Ablation of atrial fibrillation with concomitant cardiac surgery. Semin Thorac Cardiovasc Surg. 2007;19(1):25-32.
Nath S, Lynch Cd, Whayne JG, Haines DE. Cellular electrophysiological effects of hyperthermia on isolated guinea pig papillary muscle. Implications for catheter ablation. Circulation. 1993;88(4):1826-1831.
Lustgarten DL, Keane D, Ruskin J. Cryothermal ablation: mechanism of tissue injury and current experience in the treatment of tachyarrhythmias. Prog Cardiovasc Dis. 1999; 41(6):481-498.
Khargi K, Hutten BA, Lemke B, Deneke T. Surgical treatment of atrial fibrillation; a systematic review. Eur J Cardiothorac Surg. 2005;27(2):258-265.
Gillinov AM, Pettersson G, Rice TW. Esophageal injury during radiofrequency ablation for atrial fibrillation. J Thorac Cardiovasc Surg. 2001;122(6):1239-1240.
Doll N, Borger MA, Fabricius A, et al. Esophageal perforation during left atrial radiofrequency ablation: is the risk too high? J Thorac Cardiovasc Surg. 2003;125(4):836-842.
Manasse E, Medici D, Ghiselli S, Ornaghi D, Gallotti R. Left main coronary arterial lesion after microwave epicardial ablation. Ann Thorac Surg. 2003;76(1):276-277.
Johnson WD, Ganjoo AK, Stone CD. The left atrial appendage: our most lethal human attachment! Surgical implications. Eur J Cardiothorac Surg. 2000;17:718-722.
Garcia-Fernandez MA, Perez-David E, Quiles J. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. J Am Coll Cardiol. 2003;42: 1253-1258.
Rosenzweig BP, Katz E, Kort S. Thromboembolus from a ligated left atrial appendage. J Am Soc Echocardiogr. 2001; 14:396-398.
Gillinov AM, Pettersson BG, Dr C. Stapled excision of the left atrial appendage. J Thorac Cardiovasc Surg. 2004; 129: 679-680.
Pacifico A, Henry PD. Ablation for atrial fibrillation: are cures really achieved? J Am Coll Cardiol. 2004; 43: 1940-1942.
Saltman AE, Virmani R, Mohan A. Development and testing of a novel device for left atrial appendage occlusion. Heart Surg Forum. 2008;34:766-770.
Shemin RJ, Cox JL, Gillinov AM, Blackstone EH, Bridges CR. Guidelines for reporting data and outcomes for the surgical treatment of atrial fibrillation. Ann Thorac Surg. 2007; 83(3):1225-1230.
Doll N, Kiaii BB, Fabricius AM, et al. Intraoperative left atrial ablation (for atrial fibrillation) using a new argon cryocatheter: early clinical experience*1. Ann Thorac Surg. 2003;76(5 Suppl):1711-1715.
Mohr FW, Fabricius AM, Falk V, et al. Curative treatment of atrial fibrillation with intraoperative radiofrequency ablation: Short-term and midterm results. J Thorac Cardiovasc Surg. 2002;123(5):919-927.
Reade CC, Johnson JO, Bolotin G, et al. Combining robotic mitral valve repair and microwave atrial fibrillation ablation: techniques and initial results. Ann Thorac Surg. 2005; 79(2):480-484.
Acknowledgments
Data presented from The Cleveland Clinic Foundation were drawn from the experience of all staff surgeons and were collected by Kathleen M. Hill, R.N., and analyzed by Eugene H. Blackstone, M.D., and Jeevanantham Rajeswaran, M.Sc. New statistical methodology to assess success of ablation was developed by Dr. Blackstone and Mr. Rajeswaran. We thank Tess Knerik for her expert editorial assistance.
Disclosures
Dr. Gillinov is a consultant to Edwards Lifesciences, LLC, Medtronic, Inc, and St. Jude Medical, Inc. He receives research support from the Atrial Fibrillation Innovation Center, a Third Frontier project funded by the State of Ohio and from the National Institutes of Health through Cleveland Clinic participation in the Cardiac Surgery Clinical Trials Network. The Cleveland Clinic has an indirect equity interest in AtriCure, Inc through its interest in a fund that has an equity interest in AtriCure, Inc.
Dr. Saltman is a consultant to and has received honoraria for speaking from Boston Scientific/Guidant Cardiac Surgery. He has received research support from Guidant, Medical CV and Estech LICS.
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Saltman, A.E., Gillinov, A.M. (2010). Ablation of Atrial Fibrillation with Cardiac Surgery. In: Bonser, R., Pagano, D., Haverich, A. (eds) Mitral Valve Surgery. Springer, London. https://doi.org/10.1007/978-1-84996-426-5_14
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