Skip to main content

Multicenter randomized study evaluating the outcome of ganglionated plexi ablation in maze procedure

Abstract

Objective

The benefit of adding ganglionated plexi ablation to the maze procedure remains controversial. This study aims to compare the outcomes of the maze procedure with and without ganglionated plexi ablation.

Methods

This multicenter randomized study included 74 patients with atrial fibrillation associated with structural heart disease. Patients were randomly allocated to the ganglionated plexi ablation group (maze with ganglionated plexi ablation) or the maze group (maze without ganglionated plexi ablation). The lesion sets in the maze procedure were unified in all patients. High-frequency stimulation was applied to clearly identify and perform ganglionated plexi ablation. Patients were followed up for at least 6 months. The primary endpoint was a recurrence of atrial fibrillation.

Results

The intention-to-treat analysis included 69 patients (34 in the ganglionated plexi ablation group and 35 in the maze group). No surgical mortality was observed in either group. After a mean follow-up period of 16.3 ± 7.9 months, 86.8% of patients in the ganglionated plexi ablation group and 91.4% of those in the maze group did not experience atrial fibrillation recurrence. Kaplan–Meier atrial fibrillation–free curves showed no significant difference between the two groups (P = .685). Cox proportional hazards regression analysis indicated that left atrial dimension was the only risk factor for atrial fibrillation recurrence (hazard ratio: 1.106, 95% confidence interval 1.017–1.024, P = .019).

Conclusion

The addition of ganglionated plexi ablation to the maze procedure does not improve early outcome when treating atrial fibrillation associated with structural heart disease.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References

  1. Ruaengsri C, Schill MR, Khiabani AJ, Schuessler RB, Melby SJ, Damiano RJ. The Cox-maze IV procedure in its second decade: still the gold standard? Eur J Cardiothorac Surg. 2018;53(1):i19–25.

    Article  Google Scholar 

  2. Itoh A, Kobayashi J, Bando K, Niwaya K, Tagusari O, Nakajima H, et al. The impact of mitral valve surgery combined with maze procedure. Eur J Cardiothorac Surg. 2006;29(6):1030–5.

    Article  Google Scholar 

  3. Pappone C, Santinelli V, Manguso F, Vicedomini G, Gugliotta F, Augello G, et al. Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation. Circulation. 2004;109(3):327–34.

    Article  Google Scholar 

  4. Scanavacca M, Pisani CF, Hachul D, Lara S, Hardy C, Darrieux F, et al. Selective atrial vagal denervation guided by evoked vagal reflex to treat patients with paroxysmal atrial fibrillation. Circulation. 2006;114(9):876–85.

    Article  Google Scholar 

  5. Ware AL, Suri RM, Stulak JM, Sundt TM 3rd, Schaff HV. Left atrial ganglion ablation as an adjunct to atrial fibrillation surgery in valvular heart disease. Ann Thorac Surg. 2011;91(1):97–102.

    Article  Google Scholar 

  6. 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(9):875–82.

    Article  Google Scholar 

  7. Gelsomino S, Lozekoot P, La Meir M, Lorusso R, Luca 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.

    Article  Google Scholar 

  8. Sakamoto S, Fujii M, Watanabe Y, Hiromoto A, Ishii Y, Tesuro M, et al. Exploration of theoretical ganglionated plexi ablation technique in atrial fibrillation surgery. Ann Thorac Surg. 2014;98(5):1598–604.

    Article  Google Scholar 

  9. Hirose M, Leatmanoratn Z, Laurita KR, Carlson MD. Partial vagal denervation increases vulnerability to vagally induced atrial fibrillation. J Cardiovasc Electrophysiol. 2002;13:1272–9.

    Article  Google Scholar 

  10. Sakamoto S, Schuessler RB, Lee AM, Aziz A, Lall SC, Damiano RJ. Vagal denervation and reinnervation after ablation of ganglionated plexi. J Thorac Cardiovasc Surg. 2010;139(2):444–52.

    Article  Google Scholar 

  11. Qin M, Zeng C, Liu X. The cardiac autonomic nervous system: a target for modulation of atrial fibrillation. Clin Cardiol. 2019;42(6):644–52.

    Article  Google Scholar 

  12. Nitta T, Lee R, Schuessler RB, Boineau JP, Cox JL. Radial approach: a new concept in surgical treatment for atrial fibrillation. I: concept, anatomic, and physiologic bases and development of a procedure. Ann Thorac Surg. 1999;67:27–35.

    CAS  Article  Google Scholar 

  13. Nitta T, Ishii Y, Fujii M, Miyagi Y, Sakamoto S, Hiromoto A, Imura H. Restoration of sinus rhythm and atrial transport function after the maze procedure: U lesion set versus box lesion set. J Thorac Cardiovasc Surg. 2016;151(4):1062–9.

    Article  Google Scholar 

  14. Lau DH, Linz D, Shotten U, Mahajan R, Sanders P, Kalman JM. Pathophysiology of paroxysmal and persistent atrial fibrillation: rotors, foci and fibrosis. Heart Lung Circ. 2017;26(9):887–93.

    Article  Google Scholar 

  15. Lau DH, Schotten U, Mahajan R, Antic NA, Hatem SN, Pathak RK, et al. Novel mechanisms in the pathogenesis of atrial fibrillation: practical applications. Eur Heart J. 2016;37(20):1573–81.

    CAS  Article  Google Scholar 

  16. Nitta T, Ohmori H, Sakamoto S, Miyagi Y, Kannno S, Shimizu K. Map-guided surgery for atrial fibrillation. J Thorac Cardiovasc Surg. 2005;129(2):291–9.

    Article  Google Scholar 

  17. Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339:659–66.

    CAS  Article  Google Scholar 

  18. Lin WS, Tai CT, Hsieh MH, Tsai CF, Lin YK, Tsao HM, et al. Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy. Circulation. 2003;107:3176–83.

    Article  Google Scholar 

  19. 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(2):538–41.

    Article  Google Scholar 

  20. McClelland JH, Duke D, Reddy R. Preliminary results of a limited thoracotomy: new approach to treat atrial fibrillation. J Cardiovasc Electrophysiol. 2007;18(12):1289–95.

    Article  Google Scholar 

  21. Onorati F, Curcio A, Santarpino G, Torella D, Mastroroberto P, Tucci L, et al. Routine ganglionic plexi ablation during maze procedure improves hospital and early follow-up results of mitral surgery. J Thorac Cardiovasc Surg. 2008;136(2):408–18.

    Article  Google Scholar 

  22. Yamanaka K, Nishina T, Iwakura A, Fujita M. Long-term results of the maze procedure with GP ablation for permanent atrial fibrillation. Gen Thorac Cardiovasc Surg. 2021;69(2):230–7.

    Article  Google Scholar 

  23. Wong CX, Ganesan AN, Selvanayagam JB. Epicardial fat and atrial fibrillation: current evidence, potential mechanisms, clinical implications, and future directions. Eur Heart J. 2017;38(17):1294–302.

    CAS  PubMed  Google Scholar 

  24. Kaye MP, Hageman GR, Randall WC. Selective parasympathectomy of the heart. J Appl Physiol. 1975;38:183–6.

    CAS  Article  Google Scholar 

  25. Page PL, Dandan N, Savard P, Nadeau R, Armour JA, Cardinal R. Regional distribution of atrial electrical changes induced by stimulation of extracardiac and intracardiac neural elements. J Thorac Cardiovasc Surg. 1995;109:377–88.

    CAS  Article  Google Scholar 

  26. Fukushima K, Emori T, Shimizu W, et al. Delayed improvement of autonomic nervous abnormality after the maze procedure: time and frequency domain analysis of heart rate variability using 24 hour Holter monitoring. Heart. 1997;78(5):499–504.

    CAS  Article  Google Scholar 

  27. Driessen AHG, Berger WR, Krul SPJ, van den Berg NWE, Neef J, Piersma FR, et al. Ganglion plexus ablation in advanced atrial fibrillation: the AFACT Study. J Am Coll Cardiol. 2016;68(11):1155–65.

    Article  Google Scholar 

  28. 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(6):1822–8.

    Article  Google Scholar 

  29. Ad N, Cox JL. The maze procedure for the treatment of atrial fibrillation: a minimally invasive approach. J Card Surg. 2004;19:196–200.

    Article  Google Scholar 

  30. Robertson JO, Cuculich PS, Saint LL, Schuessler RB, Moon MR, Lawton J, et al. Predictors and risk of pacemaker implantation after the cox-maze IV procedure. Ann Thorac Surg. 2013;95(6):2015–20.

    Article  Google Scholar 

  31. Cox JL, Ad N, Churyla A, Malaisrie SC, Malaisrie SC, Pham DT, Kruse J, et al. The maze procedure and postoperative pacemakers. Ann Thorac Surg. 2018;106(5):1561–9.

    Article  Google Scholar 

  32. Bárta J, Brát R. Assessment of the effect of left atrial cryoablation enhanced by ganglionated plexi ablation in the treatment of atrial fibrillation in patients undergoing open heart surgery. J Cardiothorac Surg. 2017;12(1):69.

    Article  Google Scholar 

Download references

Funding

This study was funded by the Japanese Society of Arrhythmia Surgery.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Shun-Ichiro Sakamoto.

Ethics declarations

Conflict of interest

Goro Matsumiya received a research grant from Century Medical, Edwards Lifescience, and Medtronic. All other author has no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Sakamoto, SI., Ishii, Y., Otsuka, T. et al. Multicenter randomized study evaluating the outcome of ganglionated plexi ablation in maze procedure. Gen Thorac Cardiovasc Surg (2022). https://doi.org/10.1007/s11748-022-01820-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11748-022-01820-8

Keywords

  • Ganglionated plexi ablation
  • Maze procedure
  • Atrial fibrillation