Surgical treatment of atrial fibrillation concomitant to coronary artery bypass grafting: in-hospital and long-term results of maze V procedure

Aim: to assess the efficacy and safety of Maze V procedure for treating atrial fibrillation (АF) concomitant to coronary artery bypass grafting (CABG).

Material and methods: 82 patients with coronary artery disease and concomitant AF were recruited in a single-center study. Patients received hypothermia during on-pump CABG with warm blood hyperkalemia cardioplegia. Maze V was routinely performed before CABG under parallel perfusion without aortic cross-clamping. The primary and secondary endpoints included recurrent arrhythmia, sinus rhythm at discharge and in the long-term period, permanent pacemaker implantation, major cardiovascular and cerebrovascular events(MACCE).

Results: the in-hospital mortality rate was 2.4% (2 patients). The recurrence rate of AF/AFl after surgery was 23.1%. Stable sinus rhythm at dis- charge was recorded in 92.4% of patients. There were no unfavorable cardiovascular and cerebrovascular events during the in-hospital period. The median follow-up was 30.5[18.2;47.7] months. The cumulative freedom from AF/AFl without antiarrhythmic therapy after 12 months was 91%, after 24 months – 88%, and after 48 months - 77%. The freedom from MACCE was 94%.

Conclusion: maze V procedure is a safe and effective procedure for treating concomitant AF without any adverse events in the postoperative peri- od. It has demonstrated favorable results in maintaining the sinus rhythm, both in the in-hospital and long-term period. Therefore, Maze V procedure should be considered for treating AF in patients undergoing CABG.

1. Malaisrie S.C., McCarthy P.M., Kruse J. et al. Ablation of atrial fibrillation during coronary artery bypass grafting: Late outcomes in a Medicare population. J Thorac Cardiovasc Surg. 2021; 161 (4): 1251-1261.e1. DOI: 10.1016/j.jtcvs.2019.10.159

2. McCarthy P.M., Davidson C.J., Kruse J. et al. Prevalence of atrial fibrillation before cardiac surgery and factors associated with concomitant ablation. J Thorac Cardiovasc Surg. 2020; 159(6): 2245-2253.e15. DOI: 10.1016/j.jtcvs.2019.06.062

3. Saxena A., Virk S.A., Bowman S. et al. Preoperative atrial fibrillation portends poor outcomes after coronary bypass graft surgery: A systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2018; 155(4): 1524-1533.e2. DOI: 10.1016/j.jtcvs.2017.11.048

4. Fengsrud E., Englund A., Ahlsson A. Pre- and postoperative atrial fibrillation in CABG patients have similar prognostic impact. Scand Cardiovasc J. 2017; 51(1): 21-27. DOI: 10.1080/14017431.2016.1234065

5. Filardo G., Pollock B.D., da Graca B. et al. Lower Survival After Coronary Artery Bypass in Patients Who Had Atrial Fibrillation Missed by Widely Used Definitions. Mayo Clin Proc Innov Qual Outcomes. 2020; 4(6): 630-637. DOI: 10.1016/j.mayocpiqo.2020.07.012

6. Malaisrie S.C., McCarthy P.M., Kruse J. et al. Burden of preoperative atrial fibrillation in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2018; 155(6): 2358-2367.e1. DOI: 10.1016/j.jtcvs.2018. 01.069

7. Folla C.O., Melo C.C., Silva R.S. Predictive factors of atrial fibrillation after coronary artery bypass grafting. Eistein (San Paolo) 2016; 14(4): 480-485. DOI: 10.1590/S1679-45082016AO3673

8. Kiaii B., Fox S., Chase L. et al. Postoperative atrial fibrillation is not pulmonary vein depends: result from a randomized trial. Heart Rhythm. 2015; 12(4): 701-705 DOI: 10.1016/j.hrthm.2015.01.014

9. Padanilam B.J., Foreman J., Prystowsky E.N. Patient with minimal fibrillation events should not undergo concomitant arterial ablation during open heart procedures. Card. Electrophysiol. Clin. 2017; 7(3): 395-401. DOI: 10.1016/j.ccep.2015.05.003

10. Revishvili A.Sh., Serguladze S.Yu., Kvasha B.I. et al. Early and late outcomes of surgical treatment of lone atrial fibrillation using radiofrequency modification of maze procedure. Journal of Arrhythmology. 2016;(83):23-31 [In Russ].

11. Kirchhof P., Benussi S., Dipak Kotecha et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European heart journal. 2016: 50: e1-e88 DOI: 10.1093/ejcts/ezw313

12. Hindricks G., Potpara T., Dagres N. et al.; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio- Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021; 42(5):373-498. DOI: 10.1093/eurheartj/ehaa612

13. Badhwar V., Rankin J.S., Damiano R.J. Jr. et al. The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. Ann Thorac Surg. 2017; 103(1): 329-341. doi: 10.1016/j.athoracsur.2016.10.076

14. Calkins H., Kuck K.H., Cappato R. et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and re- search trial design. Europace 2012;14: 528- 606 doi: 10.1007/s10840-012-9672-7

15. Churyla A., Desai A., Kruse J. et al. Concomitant atrial fibrillation ablation in patients undergoing coronary artery bypass and cardiac valve surgery. J Cardiovasc Electrophysiol. 2020; 31(8): 2172-2178. DOI: 10.1111/jce.14408

16. Iribarne A., DiScipio A.W., McCullough J.N. et al. Northern New England Cardiovascular Disease Study Group. Surgical Atrial Fibrillation Ablation Improves Long-Term Survival: A Multicenter Analysis. Ann Thorac Surg. 2019; 107(1): 135-142. DOI: 10.1016/j.athoracsur.2018.08.022

17. Mokadam N.A., McCarthy P.M., Gillinov A.M. et al. A prospective multicenter trial of bipolar radiofrequency ablation for atrial fibrillation: early results. Ann Thorac Surg. 2004; 78(5): 1665-70. DOI: 10.1016/j.athoracsur.2004.05.066

18. Soni L.K., Cedola S.R., Cogan J. et al. Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation, but they do increase procedural morbidity. J Thorac Cardiovasc Surg. 2013; 145: 356-361; discussion 361-353 DOI: 10.1016/j.jtcvs.2012.09.091

19. Lockwood D., Nakagawa H., Peyton M.D. et al. Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: Techniques for assessing conduction block across surgical lesions. Heart Rhythm. 2009; 6: 50-63 DOI: 10.1016/j.hrthm.2009.09.010

20. Cox JL. The surgical treatment of atrial fibrillation. IV. Surgical technique. J Thorac Cardiovasc Surg. 1991; 101: 584–592.

21. Lawrance C.P., Henn M.C., Damiano R.J. Jr. Surgical ablation for atrial fibrillation: techniques, indications, and results. Curr Opin Cardiol. 2015; 30(1): 58-64. DOI: 10.1097/HCO.0000000000000125

22. Edgerton J.R, McClelland J.H. Minimally invasive surgical ablation of atrial fi brillation: six-month results. J Thorac Cardiovasc Surg. 2008; 109-113. DOI: 10.1016/j.jtcvs.2008.09.080

23. Khiabani A.J., MacGregor R.M., Bakir N.H. et al.The longterm outcomes and durability of the Cox-Maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg. 2022; 163(2): 629-641.e7. DOI: 10.1016/j.jtcvs.2020.04.100

24. Henn M.C., Lancaster T.S., Miller J.R. et al. Late outcomes after the Cox maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg. 2015; 150(5): 1168-76, 1178.e1-2. DOI: 10.1016/j.jtcvs.2015.07.102

25. Phan K., Xie A., Tsai Y.C. et al. Biatrial ablation vs. left atrial concomitant surgical ablation for treatment of atrial fibrillation: a meta-analysis. Europace. 2015; 17(1): 38-47. DOI: 10.1093/europace/euu220

26. Gillinov A.M., Bhavani S., Blackstone E.H. et al. Surgery for permanent atrial fibrillation: impact of patient factors and lesion set. Ann Thorac Surg. 2006; 82: 502 –13; discussion 513 –427. Musharbash F.N., Schill M.R., Sinn L.A. et al. Performance of the Cox-maze IV procedure is associated with improved long-term survival in patients with atrial fibrillation undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2018; 155(1): 159-170. DOI: 10.1016/j.jtcvs.2017.09.095

27. Schill M.R., Musharbash F.N., Hansalia V. et al. Late results of the Cox-maze IV procedure in patients undergoing coronary artery bypass grafting,The Journal of Thoracic and Cardiovascular Surgery. 2017;153(5). 1087-1094 DOI: 10.1016/j.jtcvs.2016.12.034