Abstract
Objectives
We investigated the effect of the maze procedure with intensive pulmonary vein isolation (PVI) guided by ganglionated plexus (GP) mapping (the Maze with GP ablation group) on a long-term postoperative maintenance of sinus rhythm in patients with permanent atrial fibrillation (AF) and compared with that in patients undergoing the maze procedure with the conventional PVI (the Maze group).
Methods and results
We investigated 48 patients who underwent the maze procedure with GP ablation for persistent AF and 43 patients who underwent the maze procedure. The Maze procedure was conducted by the endocardial application of bipolar radiofrequency ablation and cryoablation. Conventional PVI was applied three times for the entrance of right and left PVs, respectively. Intensive PVI for GP ablation was repeated six-to-eight times for both sides of PVs to cover the bilateral GP regions identified by GP mapping. The duration of permanent AF, the prevalence of concomitant primary heart diseases, and the postoperative follow-up period were comparable between the two groups. At discharge, 1 year, 5 years after the surgery, sinus rhythm was maintained in 74.4%, 61%, and 40.5% of the Maze group. In contrast, it was maintained in 93.7%, 88.9%, and 75.7% of the Maze with GP ablation group. The cumulative freedom rate from AF at 10 years after surgery was significantly higher in the Maze with GP ablation group.
Conclusions
More intense PV isolation including adjacent GP may improve long-term results of maze procedure in patients with permanent AF.
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References
Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age distribution, and gender of patients with atrial fibrillation. Anal Impl Arch Intern Med. 1995;155:469–73.
Thom T, Haase N, Rosamond W, Howard VJ, Rumsfeld J, Manolio T, et al. Heart disease and stroke statistics–2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006;113:e85–e151.
Cox JL, Schuessler RB, D'Agostino HJ Jr, Stone CM, Chang BC, Cain ME, et al. The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg. 1991;101:569–83.
Cox JL, Schuessler RB, Lappas DG, Boineau JP. An 8 1/2-year clinical experience with surgery for atrial fibrillation. Ann Surg. 1996;224:267–73.
Prasad SM, Maniar HS, Camillo CJ, Schuessler RB, Boineau JP, Sundt TM 3rd, 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;126:1822–8.
Chiappini B, Martìn-Suàrez S, LoForte A, Arpesella G, Di Bartolomeo R, Marinelli G. Cox/Maze III operation versus radiofrequency ablation for the surgical treatment of atrial fibrillation: a comparative study. Ann Thorac Surg. 2004;77:87–92.
Cummings JE, Pacifico A, Drago JL, Kilicaslan F, Natale A. Alternative energy sources for the ablation of arrhythmias. Pacing Clin Electrophysiol. 2005;28:434–43.
Yamanaka K, Fujita M, Doi K, Tsuneyoshi H, Yamazato A, Ueno K, et al. Multislice computed tomography accurately quantifies left atrial size and function after the MAZE procedure. Circulation. 2006;114(Suppl I):I5–I9.
Yamanaka K, Sekine Y, Nonaka M, Iwakura A, Yoshitani K, Nakagawa Y, et al. Left atrial appendage contributes to left atrial booster function after the maze procedure: quantitative assessment with multidetector computed tomography. Eur J Cardiothorac Surg. 2010;38:361–5.
Voeller RK, Bailey MS, Zierer A, Lall SC, Sakamoto S, Aubuchon K, et al. Isolating the entire posterior left atrium improves surgical outcomes after the Cox maze procedure. J Thorac Cardiovasc Surg. 2008;135:870–7.
Chen J, Wasmund SL, Hamdan MH. Back to the future: the role of the autonomic nervous system in atrial fibrillation. Pacing Clin Electrophysiol. 2006;29:413–21.
Armour JA, Murphy DA, Yuan BX, Macdonald S, Hopkins DA. Gross and microscopic anatomy of the human intrinsic cardiac nervous system. Anat Rec. 1997;247:289–98.
Scherlag BJ, Nakagawa H, Jackman WM, Yamanashi WS, Patterson E, Po S, Lazzara R. Electrical stimulation to identify neural elements on the heart: their role in atrial fibrillation. J Interv Card Electrophysiol. 2005;13(Suppl 1):37–42.
Doll N, Pritzwald-Stegmann P, Czesla M, Kempfert J, Stenzel MA, Borger MA, et al. Ablation of ganglionic plexi during combined surgery for atrial fibrillation. Ann Thorac Surg. 2008;86:1659–63.
Mehall JR, Kohut RM Jr, Schneeberger EW, Taketani T, Merrill WH, Wolf RK. Intraoperative epicardial electrophysiologic mapping and isolation of autonomic ganglionic plexi. Ann Thorac Surg. 2007;83:538–41.
Sakamoto S, Schuessler RB, Lee AM, Aziz A, Lall SC, Damiano RJ Jr. Vagal denervation and reinnervation after ablation of ganglionated plexi. J Thorac Cardiovasc Surg. 2010;139:444–52.
Kondo Y, Ueda M, Watanabe M, Ishimura M, Kajiyama T, Hashiguchi N, et al. Identification of left atrial ganglionated plexi by dense epicardial mapping as ablation targets for the treatment of concomitant atrial fibrillation. Pacing Clin Electrophysiol. 2013;36:1336–411.
Isomura T, Hoshino J, Fukada Y, Kataoka S, Kitamura A, Kondou T, et al. Surgical treatment for atrial fibrillation using ablation devices and ablation of autonomic ganglion plexi. Kyobu Geka. 2010;63:303–7.
Gelsomino S, Lozekoot P, La Meir M, Lorusso R, Lucà F, Rostagno C, et al. Is ganglionated plexi ablation during Maze IV procedure beneficial for postoperative long-term stable sinus rhythm? Int J Cardiol. 2015;192:40–8.
Driessen AHG, Berger WR, Krul SPJ, van den Berg NME, Neefs J, Piersma FR, et al. Ganglion plexus ablation in advanced atrial fibrillation -The AFACT Study-. J Am Coll Cardiol. 2016;68:1155–65.
Watanabe M, Kohno H, Kondo Y, Ueda H, Ishida K, Tamura Y, et al. Is ganglionated plexus ablation effective for treating atrial fibrillation? Surg Today. 2018;48:875–82.
Hayward RM, Upadhyay GA, Mela T, Ellinor PT, Barrett CD, Heist K, et al. Pulmonary vein isolation with complex fractionated atrial electrogram ablation for paroxysmal and nonparoxysmal atrial fibrillation: A meta-analysis. Heart Rhythm. 2011;8:994–1000.
Zhang Y, Wang Z, Zhang Y, Wang W, Wang J, Gao M, et al. Efficacy of cardiac autonomic denervation for atrial fibrillation: a meta-analysis. J Cardiovasc Electrophysiol. 2012;23:592–600.
Kampaktsis PN, Oikonomou EK, Choi DY, Cheung JW. Efficacy of ganglionated plexi ablation in addition to pulmonary vein isolation for paroxysmal versus persistent atrial fibrillation: a meta-analysis of randomized controlled clinical trials. J Interv Cardiac Electrophysiol. 2017;50:253–60.
Wakasa S, Kubota S, Shingu Y, Kato H, Ooka T, Tachibana T, et al. Histological assessment of transmurality after repeated radiofrequency ablation of the left atrial wall. Gen Thorac Cardiovasc Surg. 2014;62:428–33.
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Yamanaka, K., Nishina, T., Iwakura, A. et al. Long-term results of the maze procedure with GP ablation for permanent atrial fibrillation. Gen Thorac Cardiovasc Surg 69, 230–237 (2021). https://doi.org/10.1007/s11748-020-01438-8
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DOI: https://doi.org/10.1007/s11748-020-01438-8