Optimized Technical and Electrophysiological Approach for Treatment of Atrial Fibrillation
The maze procedure initially proposed by Cox for primary atrial fibrillation treatment somehow, in its complexity, increases the morbidity risk associated with mitral valve surgery.
Objective. We sought to describe a surgical technique that considers the concepts of electrophysiology and to describe the initial results of a new surgical and electrophysiological approach that blocks the main atrial circuits as defined by Frame, and to optimize the surgical tactic for treatment of atrial fibrillation.
Material and Methods. Eight patients with chronic atrial fibrillation and mitral valve dysfunction, with tricuspid valve regurgitation in 1 case, were operated on. The following modifications of the classic Cox procedure were employed: (1) exclusion of the left atrium appendage with an inner suture that closed the left atrial ostium, (2) exclusion of the right atrium appendage by 1 purse-string suture used for fixation of the superior vena cava draining cannula, (3) a single atrial incision, (4) transendocardium electrocauterization in the left atrium wall around all pulmonary vein ostia, and (5) substitution of the incisions and sutures in the left atrium with transendocardium electrocauterization.
Results. The extracorporeal circulation time varied from 64 min to 133 min (mean, 107.5 min), and the cardioplegia time varied from 40 min to 105 min. (mean, 76.7 min). All patients were in regular atrial rhythm at the end of surgery. The postoperative period was uneventful, and all patients were discharged from the hospital showing regular atrial rhythm, without definitive pacemaker implantation. In the postoperative period 6 months after surgery, 6 patients (75%) were in regular atrial rhythm with preserved atrial contractions, and 2 (25%) with atrial fibrillation, clinically controlled (New York Heart Association class II). There were no embolic complications or evidence of thrombosis in the echodopplercardiography control.
Conclusion. It is concluded from this initial series of cases that the electrophysiolgical approach and the surgical technique employed improved the surgical treatment of atrial fibrillation, making possible the correction of mitral and tricuspid valve lesions without additional morbidity.
Gregori F Jr, Cordeiro C, Goulart M, et al. 1993. Cox technique without cryoablation in atrial fibrillation surgical treatment. Rev Bras Cir Cardio-vasc 8(3):220-4nChiappini B, Martìn-Suàrez S, LoForte A, Arpesella G, Di Bartolomeo R, Marinelli G. 2004. Cox/maze III operation versus radiofrequency ablation for the surgical treatment of atrial fibrillation: a comparative study. Ann Thorac Surg 77:87-92.nKawaguchi AT, Kosakai Y, Sasako Y, Eishi K, Nakano K, Kawashima Y. 1996. Risks and benefits of combined maze procedure for atrial fibrillation associated with organic heart disease. JACC 28:985-90.nBath, in discussion of: Benussi S, Pappone C, Nascimbene S, et al. 2000. >A simple way to treat chronic atrial fibrillation during mitral valve surgery: the epicardial radiofrequency approach. Euro J of Cardio Tho-rac Surg 17:524-29.nBenussi S, Pappone C, Nascimbene S, et al. 2000. A simple way to treat chronic atrial fibrillation during mitral valve surgery: the epicardial radiofrequency approach. Euro J of Cardio Thorac Surg 17:524-9.nRauschel F. 1836. De arteriarum et venarum structura, Breslau. In: Burch GE, Romney RB. 1954. Functional anatomy and "throttle valve" action of the pulmonary veins. Am Heart J 47:58-68.nRothberger CJ, Winterberg H. 1914. Uber vorhofflimmern und vorhof- flattern. In: Cox JL, Schuessler RB, Boineau JP. 1991. The surgical treatment of atrial fibrillation I summary of the current concepts of the mechanisms of atrial flutter and atrial fibrillation. J Thorac Cardiovasc Surg 101:402-5.nBrick AV, Seixas T, Peres, A, et al. 1999. Reversion of chronic atrial fibrillation by maze technique with intraoperative application of radiofrequency and ultrasound. Rev Bras Cir Cardiovasc 14(4):290-7.nWyndham CR, Arnsdorf MF, Levitsky S, et al. 1980. Successful surgical excision of focal paroxysmal atrial tachycardia. Observations in vivo and in vitro. Circulation 62:1365-72.nJosephson ME, Spear JF, Harken AH, Horowit LN, Dorio RJ. 1982. Surgical excision of automatic atrial tachycardia: anatomic and electrophysiologic correlates. Am Heart J 104:1076-85.nKottkamp H, Hindricks G, Hammel D, et al. 1999. Intraoperative radiofrequency (RF) ablation of chronic atrial fibrillation: a left atrial curative approach by elimination of anatomic "anchor" reetrant circuits. J Cardiovasc Electrophysiol 10:772-80.nLewis T. 1920. Observations upon flutter and fibrillation part IV. Impure flutter: theory of circus movement. Heart 7:293-331.nMcCarthy PM, Castle LW, Maloney JD, et al. 1993. Initial experience with the maze procedure for atrial fibrillation. J Thorac Cardiovasc Surg 105:1087.nRobbins IM, Colvin EV, Doyle TP, et al. 1998. Pulmonary vein stenosis after catheter ablation of atrial fibrillation. Circulation 98:1769-75.nWanderley Neto J. Tratamento cirúrgica da fibrilação atrial. 2003. 30 Congresso Nacional de Cirurgia Cardíaca/Simpósio DEPEX-SBCCV, Goiânia-GO, Brazil.nGomes OM, Pitchon M. 1986. Partial tricuspid annuloplasty "1/4." Coração 1(2):3.nJatene MB, Sosa E, Jatene FB. 1995. Late evolution of Cox operation for atrial fibrillation in mitral valve disease. Rev Bras Cir Cardiovasc 10: 18-24.nGraffigna A, Vigano M, Pagani F, Salerno G. 1992. Surgical treatment for ectopic atrial tachycardia. Ann Thorac Surg 54:338-43.nElischer J. 1869. Ueber quergestreifte muskeln der ins herz mündenden venen des menschen. In: Natham H, Eliakim M. 1966. The junction between the left atrium and the pulmonary veins-an anatomic study of human hearts. Circulation 34:412-21.nCox JL. 1991. The surgical treatment of atrial fibrillation. IV Surgical technique. J Thorac Cardiovasc Surg 101:584-92.nDubost C, Guilmet D, Parades B, Pedeferri G. 1966. La Presse Medicale 76(30):1607-9.nFrame LH, Page RL, Boyden PA, Hoffman BF. 1983. A right atrial incision that stabilized reentry around the tricuspid ring in dogs. Circulation 68(Suppl III):361.nCox JL. 2003. Atrial fibrillation II: rationale for surgical treatment. J Thorac Cardiovasc Surg 126:1693-9.nJatene AD, Sosa E, Tarasoutchi F, Jatene MB, Pomerantzeff PMA. 1992. Surgical treatment of atrial fibrillation with "maze" procedure: initial experience. Rev Bras Cir Cardiovasc 7(2):107-11.nFrame LH, Page RL, Boyden PA, Fenoglio Jr JJ, Hoffman BF. 1987. Circus movement in the canine atrium around the tricuspid ring during experimental atrial flutter and during reentry in vitro. Circulation 76(5):1155-75.nCoumel P, Aigueperse J, Perrault MA, Fantoni A, Scama R, Bouvrain Y. 1973. Reperrage et tentative d'exerese chirurgicale d'un foyer ectopique auriculaire gauche avec tachycardie rebelle. Evolution favorable. Ann Cardiol Angeiol 22:189-99.nWilliams JM, Ungerleider RM, Lofland GK, Cox JL. 1980. Left atrial isolation-new technique for the treatment of supraventricular arrhythmias. J Thorac Cardiovasc Surg 80:373-80.nGomes OM, Gomes ES. 2002. Nova abordagem técnica e eletrofisiológ-ica para tratamento da fibrilação atrial. Apresentado no 29 Nacional de Cirurgia Cardíaca da Sociedade Brasileira de Cirurgia Cardiovascular - DEPEX/SBCCV, Natal-RN, Brazil.nJazbik JC, Coutinho JH, Amar MR. 1993. Surgical treatment of the atrial fibrillation in patients with mitral regurgitation: initial proposal of new approach. Rev Socer J 6:142-5.nLewis T, Feil HS, Stroud WD. 1920. Observations upon flutter and fibrillation part II. The nature of auricular flutter. Heart 7:191. In: Frame LH, Page RL, Boyden PA Fenoglio JJ, Hoffman BF. 1987. Circus movement in the canine atrium around the tricuspid ring during experimental atrial flutter and during reentry in vitro. Circulation 76(5):1155-75.nKalil RAK, Lima GG, Abrahão R, et al. 2000. Técnica cirúrgica simplifi-cada pode ser eficaz no tratamento da fibrilação atrial crônica secundária à lesão valvar mitral? Rev Bras Cir Cardiovasc 15(2):129-35.nBrick AV. 2000. Surgical treatment of chronic atrial fibrillation with ultrasound. Tese de Mestrado, Fundação Cardiovascular, São Francisco de Assis, Belo Horizonte-MG, Brazil.nGarrey WE. 1924. Auricular fibrillation. Physiol Rev 4:215-50.n
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