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The Maze Procedure in Mitral Vale Disease Ki-Bong Kim, MD Dept. of Thoracic & Cardiovascular Surgery Seoul National University Hospital.

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Presentation on theme: "The Maze Procedure in Mitral Vale Disease Ki-Bong Kim, MD Dept. of Thoracic & Cardiovascular Surgery Seoul National University Hospital."— Presentation transcript:

1 The Maze Procedure in Mitral Vale Disease Ki-Bong Kim, MD Dept. of Thoracic & Cardiovascular Surgery Seoul National University Hospital

2 Atrial Fibrillation Atrial Fibrillation Prevalence : % of general population 8-17 % of population > 60 yrs % in pts w/ MV disease % in pts undergoing surgery for Tx of MV disease Incidence of asso. thromboembolism : 33 % 75 % of episodes can involve the brain 60 % of those events can result in death or severe morbidity

3 Three Untoward Effects of AF Unpleasantness of an irregular heart beat Impaired hemodynamics because of the loss of AV synchrony Vulnerability to the thromboembolic complications

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7   The extended op time needed for complicated multiple atrial incisions may preclude application of the CM-III as a concomitant op w/ standard OHS.   We modified the CM-III to decrease op time, while retaining the important principles of the maze incisions. The Cox-Maze III Procedure

8 Conventional CM-IIIModified CM-III Modification of the Cox-Maze III Procedure Ki-Bong Kim, et al Ann Thorac Surg 2001;71:816-22

9 An 8½ -Year Clinical Experience with Surgery for Atrial Fibrillation Cox JL, et al Ann Surg 1996;224:267-75

10 Methods  Sept 1987 – March 1996  164 pts between 3 mo & 8½ yrs after op CM-I ; 32 pts CM-II ; 14 pts CM-III ; 118 pts  59 pts (33%) underwent concomitant op in addition to the Maze procedure Ann Surg 1996;224:267

11 Surgical Indications  Arrhythmia intolerance ; DOE, easy fatigability, lethargy, malaise, general sense of impending doom during AF  Drug intolerance ; unsuccessful tx of max amount of tolerable drug therapy  Previous TE ; significant temporary or permanent neurological deficit  Documented cerebral TE in the absence of other demonstrable etiologies  absolute Ix for surgery because anticoagulation does not protect from a second stroke Ann Surg 1996;224:267

12 Indications for Surgical Tx for AF Indication n / Total % Arrhythmia Intolerance 118 / Drug Intolerance 16 / Previous TE 44 /

13 Results  93 % ; arrhythmia free w/o any antiarrhythmic medication  7 % ; converted to SR w/ medical tx  Of the 107 pts who were documented to have normal SA node pre-op, only 1 pt required a permanent PM Ann Surg 1996;224:267

14 Restoration of Atrial Transport Function Following the MAZE procedure Procedure RA Function (+) LA Function (+) Maze-I 32/32 (100%) 23/32 (72%) Maze-II 11/11 (100%) 7/11 (64%) Maze -III 80/82 (98%) 77/82 (94%) Total 123/125 (98%) 107/125 (86%)

15 Contraindications  Significant LV dysfunction, not attributable to the arrhythmia itself  Concomitant cardiac / non-cardiac disease that constitutes an excessive surgical risk  Pts w/ severe HOCM because of the excessive risk asso. w/ the combined procedures Ann Surg 1996;224:267

16 Restoration of Atrial Function After the Maze Procedure for Patients with Atrial Fibrillation ; Assessment by Doppler Echocardiography Feinberg MS, et al Circulation 1994;5 (pt II):II

17 METHODS  46 pts  8 ± 7 mo after the Maze  Additional procedures in 13 pts Circulation 1994;5 (pt II):II-285

18 RESULTS Restoration of RA contraction ; 83% (38/46) LA contraction ; 61% (28/46) % atrial filling fraction of RA that of LA % atrial filling fraction of RA in pts w/ active atrial contraction was comparable to that of control (32±7 vs 33±8 %, p=NS), whereas that of LA was smaller (20±5 vs 36±7 %, p<0.05). Circulation 1994;5 (pt II):II-285

19 The Outcome and Indications of the Cox Maze III Procedure for Chronic Atrial Fibrillation With Mitral Valve Disease Isobe F, et al J Thorac Cardiovasc Surg 1998;116:220-7

20 METHODS  30/34 pts w/ AF + MV disease  4 pts were excluded  3 w/ incomplete cut & suture d/t severe calcification & adhesions  1 died of post LV rupture  21 Rheumatic 8 Degenerative 1 PVF JTCVS 1998;116:220

21 RESULTS  F/U > 6 mo after the op (2.1±0.9 yrs)  SR was restored in 27 pts (90%)  RA contractility (+) in 100 % (27/27)  LA contractility (+) in 67 % (18/27)  AF persisted in 3 pts (10%) JTCVS 1998;116:220

22 RESULTS (SR group vs AF group RESULTS (SR group vs AF group )  f-wave voltage in lead V1  0.23±0.10 vs 0.06±0.05 mV p=0.01  CTR  60±5 vs 78±10 % p=  LA systolic dimension (Doppler)  57±8 vs 95±24 mm p=  AF duration  5.1±4.6 vs 11.8±5.5 yrs p= » » Predisposing factors for the post-op persistence of AF JTCVS 1998;116:220

23 RESULTS  No pts resumed SR when CTR ≥ 70 % & LA systolic dimension ≥ 80 mm before the op JTCVS 1998;116:220

24 RESULTS  A/E ratio of trans-mitral flow was low in pts w/ the Maze procedure as compared w/ the normal valve  Regarding the restoration of LA function, f-wave voltage, CTR, & LA systolic dimension showed no significant difference between the pts w/ positive & negative a-waves, & only the duration of AF showed statistically significant difference ( p=0.011 ). JTCVS 1998;116:220

25 Rationale of the Cox Maze Procedure for Atrial Fibrillation During Redo Mitral Valve Operations Kobayashi J, Kosakai Y, Isobe F, et al J Thorac Cardiovasc Surg 1996;112:

26 METHODS  42 pts w/ redo MV + Maze procedure  37 Kosakai’s modified Maze 2 CM-II 3 CM-III  F-U after op : 25.5 ± 10.8 mo.  Control group : 54 pts w/ redo MV w/o Maze procedure JTCVS 1996;112:1216

27 RESULTS  SR was regained in 28/42 pts (67 %)  Doppler study LA contraction in 16/28 pts (57%) RA contraction in 21/28 pts (75 %) JTCVS 1996;112:1216

28 Comparison between pts w/ & w/o restored sinus rhythm Variables SR (+) SR(-) p-value No Age (yr) 57.8± ±9.3 NS Rheumatic 23(82%) 13(94%) NS Duration of AF (yr) 9.0± ± f-wave on V1 (mV) 0.18± ± CT ratio (%) 63±8 67± LAD (mm) 57±9 57±6 NS

29 JTCVS 1996;112:1216 Results of op in the maze & control groups Maze group Control groupp-value Maze group Control group p-value No ACC time (min) 133±28 121± CPB time (min) 211±43 197± C-tube drainage(ml) 890± ±480 NS Blood transfusion (ml) 2120± ±1760 NS # Transfusion 7(17%) 11(20%) NS Hospital Mortality 0(0%) 4(7.4%) NS Bleeding reop 6(14%) 4(7.4%) NS Mediastinitis 0(0%) 2(3.7%) NS

30 CONCLUSION  The Maze procedure should be considered in selected pts who have a high possibility of regaining SR during redo MV op.  The Maze procedure should be performed concomitantly w/ MVR while preserving the MV apparatus for moderately depressed LV function, inasmuch as atrial contraction is very important. JTCVS 1996;112:1216

31 The Cox Maze III Procedure for Atrial Fibrillation Associated With Rheumatic Mitral Valve Disease Ki-Bong Kim, et al Ann Thorac Surg 1999;68:

32 METHODS  75 CM-III pts for AF asso w/ rheumatic MV disease  14 cases ; Reop because of PVF ANTS 1999;68:799

33 INDICATIONS  Indications to perform concomitant CM-III Chronic AF >1 yr LA thrombi (+) Medical history of previous TE events in the absence of other demonstrable etiologies ANTS 1999;68:799

34 RESULTS  In-hospital Mortality ; 2.7% (2/75)  73 survivors were followed for 30±13 mo (12-56) ANTS 1999;68:799

35 Cardiac Rhythms in the Latest F-U NSR 66 / 73 (90 %) NSR 66 / 73 (90 %)  w/o drug therapy 60 (82 %)  w/ addition of one drug 6 (8 %) AF 3 / 73 (4 %) AF 3 / 73 (4 %) JR 2 / 73 (3 %) JR 2 / 73 (3 %) PM implantation 2 / 73 (3 %) PM implantation 2 / 73 (3 %) ANTS 1999;68:799

36 Follow-Up TTE  66 pts w/ NSR  RA contractility (+) : 66 / 66 (100 %) LA contractility (+) : 41 / 66 (62 %)* LA contractility (+) : 41 / 66 (62 %)*  Restoration of RA contractility : 69±93 days Restoration of LA contractility :126±136 days* Restoration of LA contractility :126±136 days* * * p < 0.05 ANTS 1999;68:799

37 Factors Predisposing to Persisting AF Factors NSR (n=66) AF (n=3) p-value (univariate) Age (>60 yrs) 13.6 % 33.3 % ns AF Duration (>60 Mo) 40.9 % % ns LAD (>55 mm) 63.1 % 66.7 % ns LVEDD (>55 mm) 36.9 % 33.3 % ns EF (<45 %) 23.1 % 33.3 % ns

38 Factors Affecting Recovery of LA Contractility Factors LA(+) LA(-) p-value Factors LA(+) LA(-) p-value Univariate Multivariate Univariate Multivariate Age (<60 yrs) 87.5% 92.3% NS Duration of AF (<60 mo) 75.0% 42.3% LAD (<55 mm) 41.0 % 38.5 % NS EF (>45 %) 74.4% 80.8% NS mPAP (<20 mmHg) 19.0% 14.3% NS C.I. (>2.0 L/min/m2) 72.4% 37.5% NS RA contractility (<60 d) 75.0% 37.5% < 0.01

39 Non-redo vs. Redo OHS Non-redo Redo p-value Non-redo Redo p-value AF duration (Mo) 52±57 132±91 <0.01 ACC time (min) 154±45 137±32 ns CPB time (min) 250±69 258±95 ns C-tube drain (ml) 985± ±261 ns Bleeding reop 3 1 ns Conversion rate (%) ns

40 Conclusions  CM-III for AF asso w/ RMVD demonstrated a high sinus conversion rate & recovery of atrial contractility  LA contractility is restored significantly later & a lower rate than RA contractility in RMVD  CM-III can be performed in redo op w/ comparable sinus conversion rate & acceptable op risk ANTS 1999;68:799

41 Restoration of Atrial Mechanical Function After Maze Operation in Patients With Structural Heart Disease Kim Y-J, Sohn D-W, et al Am Heart J 1998;136:1070-4

42 METHODS  32 pts w/ the Maze procedure  SR was restored in 81 % (26/32) By surgery alone in 69 % (22/32)  By the addition of one drug in 13% (4/32)  Of the remaining 6 pts,  Four (13%, 4/32) pts ; paroxysmal AF despite antiarrhythmic therapy  One ; sustained AF  One ; permanent PM insertion d/t SSS Am Heart J 1998;136:1070

43 RESULTS  RA function (+) ; 30 / 30 pts w/ SR or paroxysmal AF  LA function (+) ; 19 / 30 pts (63 %) Am Heart J 1998;136:1070

44 RESULTS  Peak A velocity & A/E ratio of mitral inflow in pts w/ restored LA function, were significantly lower than in the 16 post-op control pts (p<0.01). Am Heart J 1998;136:1070

45 RESULTS  In pts w/ LA mechanical function, duration of AF was significantly shorter than in pts w/o LA mechanical function (1.9±2.9 vs 7.1±3.0 yrs, p<0.01), but there were no significant differences in LA size & volume. Am Heart J 1998;136:1070

46 Surgical Outcome of Maze Procedure for Atrial Fibrillation in Mitral Valve Disease: Rheumatic versus Degenerative JW Lee,et al. STS meeting, 2002

47 Group R (n=86) : Rheumatic Group D (n=43) : Degenerative Study interval : Immediate postop 3 Mo 6 Mo

48 Sinus Conversion Rate (%) P >0.05 P < 0.05

49 Impact of the Maze Procedure on the Stroke Rate in Patients with Atrial Fibrillation Cox JL, et al J Thorac Cardiovasc Surg 1999;118:833-40

50 Methods  Sept March 1999  306 pts w/ the maze procedure  paroxysmal (intermittent) AF ; 61 % chronic (continuous) AF ; 39 % chronic (continuous) AF ; 39 % JTCVS 1999;188:833

51 Peri-op Stroke Rates for the Major Categories of Cardiac Surgical Procedures 5.90 % 5.00 % 4.53 % 4.24 % 3.30 % 3.26 % 2.96 % 2.44 % 0.65 % 1.73 % 1.73 % 1.60 % 1.60 % 1.41 % 1.41 % 1.51 % 1.51 % 1.45 % 1.45 % 0.98 % 0.98 % 1.23 % 1.23 % 0.75 % 0.75 % 0 % 0 % 4.17 % 3.40 % 3.12 % 2.73 % 1.85 % 2.28 % 1.73 % 1.69 % 0.65 % CABG + MVR CABG + AVR CABG + MV repair AVR + MVR MV repair MVRAVRCABG Maze ± other % total stroke % transient % transient stroke stroke % permanent stroke Procedures

52 Whether should the pts w/o LA contractile function after the maze undergo anticoagulation?  Normal RA function & normal RA-RV synchrony  Normal right-sided CO that is delivered to left side of heart through pulmonary circulation  No difference whether LA is contracting (in the presence of normal LV) because LV will immediately adapt to normal right-sided output that has just been delivered to it  Normal LA inflow volume, regular LV filling, & no LAA to serve as a nidus for thrombus formation  There is no reason to suspect that systemic TE would be any higher in these pts than those w/ demonstrable LA contraction JTCVS 1999;188:833

53  When properly performed, the results w/ this combined approach have been excellent, w/ no increase in periop morbidity or op mortality & w/ documented long-term advantages over simply leaving pts in AF. James L. Cox - James L. Cox J Thorac Cardiovasc Surg 2001;122:212 EPILOGUE


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