What size of left atrium significantly impairs the success of maze surgery for atrial fibrillation?

Abstract

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was in adults with atrial fibrillation (AF), what preoperative size of left atrium impairs maze surgery success in terms of recurrence of AF. Altogether 422 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal. date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Nine of 12 papers found that preoperative left atrial (LA) size was significantly larger in patients who experienced recurrent AF. When left atrial diameter (LAD) was found to be statistically different between sinus conversion and recurrent AF groups the mean LAD was consistently >60 mm in the recurrent AF group, whereas it was <60 mm in all but one of the sinus conversion groups. In terms of a cut-off value for LA size, a left atrial volume index >135 ml/m(2) was found to confer 100% specificity for maze failure and a LAD >60 mm was found to be 100% sensitive for maze failure. A preoperative LAD <48.3 mm was shown in one study to be 100% sensitive for sinus conversion by the maze procedure. Despite much evidence highlighting preoperative LAD as a risk factor for maze failure, relatively few studies seek to define a definitive cut-off value for LA size beyond which the risks of the procedure (such as bleeding, infection or stroke) outweigh the chance of sinus recovery. We conclude that since mean preoperative LAD in AF groups is consistently over 60 mm caution should be exercised when offering these patients the maze procedure. Furthermore, the relationship between preoperative LAD and maze failure appears continuous and so patients should be counselled as to their increased risk of failure the further they deviate from a LAD of 60 mm. There is some evidence for and no available evidence to the contrary that a LAD < 43 mm is associated with complete maze success. Hence, these patients should be offered the maze procedure unless there are alternate strong contraindications.

Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study

“…Analysis of left atrial cryo-ablation failure risk factors found age, size of the LA, and pre-operative duration of AF to be risk factors of failure-to-restore SR in the whole set of patients; this was in accordance with other publications. 32–34 …”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…Te wyniki potwierdza również analiza bazy danych Towarzystwa Chirurgów Klatki Piersiowej (Society of Thoracic Surgeons) obejmującej 67 389 pacjentów z AF poddanych operacji na otwartym sercu, w której stwierdzono, że jednoczesne chirurgiczne leczenie AF nie wpływało na umieralność ani poważną chorobowość (skorygowany OR 1,00; 95% CI 0,83-1,20), ale częściej konieczne było wszczepienie stymulatora (skorygowany OR 1,26; 95% CI 1,07-1,49) [799]. Do wskaźników predykcyjnych nawrotu AF po operacji należą powiększenie lewego przedsionka, starszy wiek, ponad 10-letnie wywiady AF oraz AF inne niż napadowe [800][801][802][803][804]. Jeżeli chodzi o rodzaj AF, to wydaje się, że chirurgiczna PVI jest skuteczna w napadowym AF [805], natomiast zabiegi z wytworzeniem uszkodzeń w obu przedsionkach mogą być bardziej skuteczne w przypadku przetrwałego i długotrwale przetrwałego AF [797,803,806].…”

Late Results of Cox Maze III Procedure in Patients with Atrial Fibrillation Associated with Structural Heart Disease

“…Left atrial diameter as a predictor of late AF recurrence after CM surgery was analyzed in a meta-analysis by Sunderland et al 12 A diameter > 60 mm showed a sensitivity of 100% for AF recurrence, whereas as a diameter < 48.3 mm showed a sensitivity of 100% for reversal of the sinus rhythm. In the study by Gillinov et al.…”