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J Thorac Cardiovasc Surg 1994;107:622-0622
© 1994 Mosby, Inc.

Letters to the Editor

Combined treatment of mitral stenosis and atrial fibrillation with valvuloplasty and a left atrial maze procedure

Department of Cardiothoracic Surgery^a

To the Editor:

Since 1987 the maze procedure described by Cox and associates ¹ has undergone two modifications by its originators. ² Additional modifications have been reported by Johnson ³ and by McCarthy and associates. ⁴ This letter describes a further modification: the left atrial portion of the maze procedure as described by Cox and associates was performed in conjunction with repair of rheumatic mitral stenosis.

A 59-year-old woman had a 9-year history of atrial fibrillation and congestive heart failure. Two years before evaluation she had an embolic cerebrovascular accident without residua. Three months before evaluation she had rapidly conducted atrial fibrillation and syncope that resulted in an open fracture of the left humerus. Because of worsening congestive heart failure the patient was referred for surgical treatment. Preoperative evaluation revealed mitral stenosis with a calculated valve area of 0.9 cm², left atrial size of 6.6 cm ², left ventricular ejection fraction of 76%, and moderate pulmonary hypertension.

Before the operation the patient signed an informed consent form for the left atrial maze procedure as approved by the institutional review board for the protection of human subjects (approval April 1992). The mitral valve was exposed by dissection along the interatrial groove and then entry into the left atrium. A mitral commissurotomy was performed and incisions were made into both thickened and fused papillary muscles. The left atrial incisions for the maze operation were then performed. The interatrial septal incision of the maze procedure was performed through a limited right atriotomy. The patient was weaned from cardiopulmonary bypass in sinus rhythm.

On postoperative day 3, a rapidly conducted atrial fibrillation developed. This responded to digoxin and metoprolol. Two months after the operation she underwent an uneventful emergency cholecystectomy. Two weeks after this procedure she had an episode of chest pain without myocardial infarction and 1 month later she again had an episode of chest pain and palpitations; however, the electrocardiogram in the emergency room showed sinus rhythm. Six months after the heart operation an echocardiogram showed normal atrial contractions and ventricular function, a dilated left atrium, and a calculated mitral valve area of 2.5 cm². Twenty-four–hour ambulatory recording showed normal sinus rhythm and atrial premature contractions.

An electrophysiologic study was performed approximately 8 months after the heart operation with the patient receiving digoxin. Atrial fibrillation was not inducible but 2:1 atrial flutter was inducible, with a maximum ventricular rate of 140 beats/min. The atrial flutter was terminated by rapid atrial pacing. Loop recording, taken because of the palpitations, revealed that sinus rhythm was recorded during episodes of palpitations without any extrasystoles or atrial arrhythmias.

The maze procedure was initially performed in patients with atrial fibrillation and no structural heart disease, but it has now been added to the surgical treatment of those with hypertrophic obstructive cardiomyopathy and mitral valve repair. ^{4, 5} The treatment group has included patients who had atrial fibrillation and required coronary artery bypass grafting and repair of an atrial septal defect. ⁶

On the basis of the experience of Graffigna and associates, ⁷ who performed the left atrial isolation procedure in 100 patients, it would appear that most patients with rheumatic mitral disease or mitral and aortic valve disease who have atrial fibrillation might be well served with a maze procedure limited to the left atrium. A more limited maze operation avoids additional incisions in the right atrium. The left atrial maze procedure is also a more physiologic procedure than the left atrial isolation procedure. A maze procedure confined to the left atrium in appropriate circumstances reduces significantly the time required to perform a procedure controlling atrial fibrillation, preserving left atrial transport function and left atrial synchrony, and reducing the risk of thromboembolism in patients with left-sided valve disease. This further minimizes the additional morbidity associated with longer procedures, because a significant portion of the left atrial maze procedure—the encircling incision around the pulmonary veins—is performed during exposure of the mitral apparatus. The overall results for surgical control of atrial fibrillation with a maze procedure confined to the left atrium and interatrial septum may be less satisfactory than after the maze III procedure.

References

1. Cox JL, Schuessler RB, Cain ME, et al. Surgery for atrial fibrillation. Semin Thorac Cardiovasc Surg 1989;1:67-73.[Medline]
   
2. Cox JL. Evolving applications of the maze procedure for atrial fibrillation. Ann Thorac Surg 1993;55:578-80.[Medline]
   
3. Johnson DC. Early experience with the modified maze operation for atrial fibrillation with and without mitral valve surgery. Aust Assoc J Cardiac Thorac Surg 1992;1:13-6.
   
4. McCarthy PM, Cosgrove DM, Castle LW, White RD, Klein AL. Combined treatment of mitral regurgitation and atrial fibrillation with valvuloplasty and the maze procedure (case report). Am J Cardiol 1993;71:483-6.[Medline]
   
5. Blitz A, McLoughlin D, Gross J, et al. Case report: combined maze procedure and septal myomectomy in a septuagarian. Ann Thorac Surg 1992;54:364-5.[Abstract]
   
6. Bonchek LI, Burlingame MW, Worley SJ, Vazales BE, Lundy EF. Cox/maze procedure for atrial septal defect with atrial fibrillation: management strategies. Ann Thorac Surg 1993;55:607-10.[Abstract]
   
7. Graffigna A, Pagani F, Minzioni G, Salerno J, Vigano M. Left atrial isolation associated with mitral valve operations. Ann Thorac Surg 1992;54:1093-8.[Abstract]
   

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