Biatrial maze procedure versus pulmonary vein isolation for atrial fibrillation during mitral valve surgery: New analytical approaches and end points

Abstract

Objective: To use novel statistical methods for analyzing the effect of lesion set on (long-standing) persistent atrial fibrillation (AF) in the Cardiothoracic Surgical Trials Network trial of surgical ablation during mitral valve surgery (MVS). Methods: Two hundred sixty such patients were randomized to MVS + surgical ablation or MVS alone. Ablation was randomized between pulmonary vein isolation and biatrial maze. During 12 months postsurgery, 228 patients (88%) submitted 7949 transtelephonic monitoring (TTM) recordings, analyzed for AF, atrial flutter (AFL), or atrial tachycardia (AT). As previously reported, more ablation than MVS-alone patients were free of AF or AF/AFL at 6 and 12 months (63% vs 29%; P < .001) by 72-hour Holter monitoring, without evident difference between lesion sets (for which the trial was underpowered). Results: Estimated freedom from AF/AFL/ATon any transmission trended higher after biatrial maze than pulmonary vein isolation (odds ratio, 2.31; 95% confidence interval, 0.95–5.65; P = .07) 3 to 12 months postsurgery; estimated AF/AFL/AT load (ie, proportion of TTM strips recording AF/AFL/AT) was similar (odds ratio, 0.90; 95% confidence interval, 0.57–1.43; P .6). Within 12 months, estimated prevalence of AF/AFL/AT by TTM was 58% after MVS alone, and 36% versus 23% after pulmonary vein isolation versus biatrial maze (P<.02). Conclusions: Statistical modeling using TTM recordings after MVS in patients with (long-standing) persistent AF suggests that a biatrial maze is associated with lower AF/AFL/AT prevalence, but not a lower load, compared with pulmonary vein isolation. The discrepancy between AF/AFL/AT prevalence assessed at 2 time points by Holter monitoring versus weekly TTM suggests the need for a confirmatory trial, reassessment of definitions for failure after ablation, and validation of statistical methods for assessing atrial rhythms longitudinally.

Contemporary Surgical Management of Atrial Fibrillation

“…3,28,29 A randomized controlled trial comparing concomitant biatrial maze surgical ablation, pulmonary vein isolation, and no surgical ablation during mitral valve surgery in 228 patients was recently published and reported that the prevalence of atrial fibrillation, atrial flutter, or atrial tachycardia at 12 months was 58% after no surgical ablation, 36% after only pulmonary vein isolation, and 23% after biatrial maze. 30 In isolated CABG operations, concomitant open atrial Coxmaze procedures have been found to be effective in upward of 90% of the patients at 5-year follow-up. 31 A recent metaanalysis reviewed both open and closed atrial procedures showed that there was no significant difference in mortality, stroke, or pacemaker requirement between patients receiving concomitant surgical ablation compared with those without ablation, and that surgical ablation groups demonstrated superior 1-year freedom from atrial fibrillation.…”

Comparative characteristics of biatrial and left atrial ablation in surgical treatment of long-standing persistant atrial fibrillation in patients with concomitant disease

“…В анализе E.H. Blackstone et al [54] сравнивали биатриальную процедуру «Лабиринт» с изо-лированной ЛА у пациентов с митральными пороками. Через 12 мес было показано достоверное снижение случаев ФП, трепетания предсердий и предсердной тахикардии в группе БА.…”

Analysis of the risk factors of valvular atrial fibrillation treated with radiofrequency ablation during valve replacement

“…Atrial fibrillation (AF) is a more common arrhythmia in clinic. some studies have shown that the proportion of patients with rheumatic heart disease in the population of atrial fibrillation patients in china is as high as 23.9% [1] , and the proportion of patients with rheumatic heart disease with atrial fibrillation is as high as 30%-50% [2,3] . China's reports show that its proportion is as high as 40%-70% [4,5] .…”