Cox maze IV versus left atrial reduction for atrial contraction restoration

Abstract

Background The Cox maze procedure is the gold-standard concomitant surgical procedure to restore sinus rhythm in rheumatic mitral valve disease with atrial fibrillation. Left atrial reduction surgery was found to be beneficial for rhythm conversion, but no study has investigated its efficacy compared to the Cox maze procedure for atrial contractility restoration. We aimed to compare the early success rate of left atrial contractility restoration with the Cox maze procedure and left atrial reduction in rheumatic subjects. Methods Preoperative and within one-month postoperative electrocardiograms and echocardiograms of patients who underwent a Cox maze IV procedure or left atrial reduction with mitral valve surgery were compared. Effective atrial contraction was defined as A wave peak velocity ≥10 cm·s−1 or atrial filling fraction ≥20%. Results Ninety patients (mean age 40.6 ± 10.2 years, 66.7% female) were divided equally into group A (Cox maze IV) and group B (left atrial reduction). The early sinus rhythm conversion rate was 64.4% versus 24.4% ( p < 0.001) in groups A and B, respectively. In patients with restored sinus rhythm, contractility was restored in 41.4% and 36.4% ( p = 1.000). Postoperative left atrial volume index ≤76 mL·m−2 was an independent variable associated with early atrial contractility restoration in both groups (prevalence rate 0.97, p = 0.007). Conclusions In rheumatic subjects, the early sinus rhythm conversion rate was significantly higher after Cox maze IV compared to left atrial reduction, but for restoring left atrial contractility, left atrial reduction was not inferior to Cox maze IV.

Incremental Prognosis by Left Atrial Functional Assessment: The Left Atrial Coupling Index in Patients With Floppy Mitral Valves

“…The considerable outcome improvement after repair is associated with a narrowing of survival differences between high and low LACI, suggesting that suppression of volume overload may have favorable outcome implications with high preoperative LACI. Whether simultaneous LA volume reduction surgery may provide benefits, 43 and may affect postoperative impaired functional capacity, 24 remains an open question. In patients with no/mild DMR, in whom mitral repair is not considered, the unresolved question is whether medical treatment similar to that for LV dysfunction 44 may yield improved LA contractile function and possibly outcome.…”

Left atrial function

“…Even in the absence of any pathology, LA reservoir function has been shown to be a potent marker of first atrial fibrillation/flutter in persons aged >65 years, particularly those with LA emptying fraction <49% (3). LA volume reduction surgery has also been shown to improve cavity mechanical function as well as electric instability (4), and reduced LA compliance has been reported to be a predictor of exercise capacity (5) and quality of life (6).…”