Right-sided Maze Research Articles

Risk factors for atrial arrhythmia recurrence after atrial arrhythmia surgery with pulmonary valve replacement

ObjectivesAtrial arrhythmias are a significant cause of late morbidity and mortality in patients after tetralogy of Fallot repair. However, reports on their recurrence following atrial arrhythmia surgery are limited. We aimed to identify the risk factors for atrial arrhythmia recurrence after pulmonary valve replacement (PVR) and arrhythmia surgery. MethodsWe reviewed 74 patients with repaired tetralogy of Fallot who underwent PVR for pulmonary insufficiency at our hospital between 2003 and 2021. Twenty-two patients (mean age, 39 years) underwent PVR and atrial arrhythmia surgery. A modified Cox-maze III was performed in 6 patients with chronic atrial fibrillation, and a right-sided maze was performed in 12 with paroxysmal atrial fibrillation, 3 with atrial flutter, and 1 with atrial tachycardia. Atrial arrhythmia recurrence was defined as any documented sustained atrial tachyarrhythmia requiring intervention. The influence of preoperative parameters on recurrence was assessed with the Cox proportional-hazards model. ResultsThe median follow-up period was 9.2 years (interquartile range, 4.5-12.4). Cardiac death and redo-PVR due to prosthetic valve dysfunction were not observed. Eleven patients had atrial arrhythmia recurrence after discharge. Atrial arrhythmia recurrence-free rates were 68% at 5 years and 51% at 10 years after PVR and arrhythmia surgery. Multivariable analysis revealed that right atrial volume index (hazard ratio, 1.04; 95% confidence interval, 1.01-1.08, P = .009) was a significant risk factor for atrial arrhythmia recurrence after arrhythmia surgery and PVR. ConclusionsPreoperative right atrial volume index was associated with atrial arrhythmia recurrence, which may assist in planning the timing of atrial arrhythmia surgery and PVR.

Preliminary Results of Cryoablation for Surgical Treatment of Arrhythmias in Adults With Congenital Heart Disease.

Background: Arrhythmias in adult congenital heart disease (ACHD) are responsible for the majority of hospital admissions and 20–25% of late deaths. Since need for further cardiac operations is frequent in ACHD, concomitant arrhythmia surgery represents a strategic treatment modality.Material and Methods: A two-center retrospective study was undertaken on cryoablation of supraventricular arrhythmias in 25 conescutive ACHD patients (16/9, M/F, median age 38.5 years, IQR 38–60) operated between 01/2017 and 12/2020. Nineteen (76%) had undergone one or more previous cardiac operations and 8 (32%) one or more trans-catheter ablations. Indications included Fontan conversion in seven patients, septal defect repair in 6, pulmonary valve replacement in 10 and tricuspid surgery in 2. Open-heart cryoablation included: 4 cavotricuspid isthmus ablations, 19 right-sided Maze for atrial tachycardia/flutter, and 2 Cox-Maze III for atrial fibrillation.Results: There were 2 (8%) hospital deaths, unrelated to cryoablation, due to low cardiac output syndrome. There were no intraoperative complications related to cryoablation. Seven (28%) patients required pace-maker implantation due to post-operative atrioventricular block. All patients were discharged on oral antiarrhythmic and anticoagulantion for 6 months. After a median follow-up of 14 months (IQR 7–27) no late mortality was observed. At follow-up, 16/23 (69%) patients are in stable sinus rhythm, 12 without anti-arrhythmic therapy. Two (8.6%) patients had relapse of arrhythmia. Freedom from arrhythmia was 90.9% and cumulative risk of recurrence was 9.6%.Conclusions: Intraoperative cryoablation is safe and effective procedure. Surgical treatment of arrhythmias should always be considered in ACHD, whenever further open-heart repair is needed.

Novel technique of repairing right partial anomalous pulmonary venous connection with intact atrial septum using in situ interatrial septum as a flap in a 68-year-old-woman: a case report

BackgroundPartial anomalous pulmonary venous connection draining into the right atrium with an intact atrial septum is a very rare clinical entity in the adult population. Partial anomalous pulmonary venous connection must be suspected as a differential diagnosis when the cause of right heart enlargement and pulmonary artery hypertension is unknown.Case presentationThis study describes the surgical case of an isolated right partial anomalous pulmonary venous connection to the right atrium in a 68-year-old woman, who underwent tricuspid ring annuloplasty and right-sided maze procedure simultaneously. She had complaints of gradually progressing dyspnea on exertion. However, a diagnosis could not be established despite consultations at multiple hospitals for over a year. Right heart catheterization revealed severe pulmonary artery hypertension with a mean pulmonary artery pressure of 46 mmHg, step-up phenomenon of oxygen saturation at the mid-level of the right atrium with a pulmonary-to-systemic blood flow ratio of 2.4, and a pulmonary vascular resistance of 3.1 Wood Units. As medical treatment with pulmonary artery vasodilator therapy did not improve her symptoms, she underwent surgical repair. An atrial septal defect was created surgically with a curvilinear tongue-shaped cut. The right anomalous pulmonary veins were rerouted through the surgically created atrial septal defect into the left atrium with a baffle comprised of the interatrial septum flap, kept in continuity with the anterior margin and sutured while mobilizing the enlarged right atrium. The patient had an uneventful postoperative course and remains asymptomatic.ConclusionsThe described surgical technique could be considered an effective alternative for patients undergoing surgical repair for a partial anomalous pulmonary venous connection isolated to the right atrium. The indication for surgery must be judged on a case-by-case basis in these patients with prevalent systemic-to-pulmonary shunting.

Cardiac implantable device outcomes and lead survival in adult congenital heart disease

BackgroundLong-term outcomes of cardiac implantable electronic devices (CIEDs) are ill-defined in adult congenital heart disease (ACHD). ObjectiveTo assess outcomes of transvenous (TV) and epicardial (EPI) CIEDs in ACHD. MethodsA retrospective review of CIEDs implanted in patients >18 yrs. followed at the Ahmanson/UCLA ACHD Center was performed. Patients were grouped by implant approach. Primary outcomes included time to CIED dysfunction, lead dysfunction and unplanned CIED reintervention. ResultsOver a 27-year period, 283 CIEDs (208 TV, 75 EPI) were implanted in 260 ACHD patients. Dysfunction developed in 77 CIEDs (50 TV, 27 EPI) for which 62 underwent unplanned reintervention (47 TV, 15 EPI). Time to CIED dysfunction and unplanned reintervention did not differ by implant approach; however lead dysfunction was greater for EPI vs TV (HR 2.0, 95% CI 1.2–3.2, p = 0.01). Independent predictors of lead failure included cyanosis (HR 2.6, 95% CI 1.1–6.3; p = 0.03), implant indication other than bradycardia (HR 3.3, 95% CI 1.6–6.5; p < 0.01), right-sided Maze operation (HR 2.5, 95% CI 1.3–5.0; p = 0.01), and unipolar lead design (HR 4.5, 95% CI 1.8–11.5; p < 0.01). Importantly, EPI vs TV approach was not associated with lead dysfunction after adjusting for baseline covariates (HR 0.6, 95% CI 0.6–4.3; p = 0.3). ConclusionOverall CIED system dysfunction and reinterventions are similar, whereas lead dysfunction is greater among EPI than TV devices. Patient and procedural differences, rather than EPI vs TV implant approach alone, appear to drive CIED lead outcomes in the ACHD population.

Reconstruction of right ventricular outflow tract stenosis and right ventricular failure after Ross procedure \u2013 comprehensive assessment of adult congenital heart disease with four-dimensional imaging: a case report

BackgroundRe-intervention after Ross procedure into the right ventricular outflow tract might be needed in patients in the long term. However, right ventricular outflow tract re-intervention indications are still unclear. Comprehensive assessment of total hemodynamics is needed.Case summaryA 42-year-old Japanese woman was referred to our hospital for moderately severe pulmonary regurgitation and severe tricuspid regurgitation after a Ross–Konno procedure. Thirteen years after surgery, she developed atrial fibrillation and atrial flutter and complained of dyspnea. Electrophysiological studies showed re-entry circuit around the low voltage area of the lateral wall on the right atrium. Four-dimensional flow magnetic resonance imaging revealed moderate pulmonary regurgitation, severe tricuspid regurgitation, and a dilated right ventricle. Flow energy loss in right ventricle calculated from four-dimensional flow magnetic resonance imaging was five times higher than in normal controls, suggesting an overload of the right-sided heart system. Her left ventricular ejection fraction was almost preserved. Moreover, the total left interventricular pressure difference, which shows diastolic function, revealed that her sucking force in left ventricle was preserved. After the comprehensive assessments, we performed right ventricular outflow tract reconstruction, tricuspid valve annuloplasty, and right-side Maze procedure. A permanent pacemaker with a single atrial lead was implanted 14 days postoperatively. She was discharged 27 days postoperatively. Echocardiography performed 3 months later showed that the size of the dilated right ventricle had significantly reduced.DiscussionA four-dimensional imaging tool can be useful in the decision of re-operation in patients with complex adult congenital heart disease. The optimal timing of surgery should be considered comprehensively.

Outcomes of atrial arrhythmia radiofrequency catheter ablation in patients with Ebstein's anomaly.

Atrial arrhythmias are common in patients with Ebstein's anomaly (EA) despite cardiac surgical repair and concomitant Maze procedures. We aimed to evaluate the outcome of radiofrequency catheter ablation in this group of patients. All patients with EA and atrial arrhythmias who underwent catheter ablation for atrial arrhythmias between 1/1999 and 1/2016 were included. Atrial arrhythmia recurrence was identified as the primary outcome; secondary outcomes included repeat ablation, need for antiarrhythmic medications after ablation, and death. Predictors of recurrence were sought using univariate analysis. 22 patients (median age 42 years, 54.5% male) were included. Atrial flutter was the most common presenting arrhythmia (n = 14 patients, 63.5%), whereas focal atrial tachycardia (FAT) and atrial fibrillation were identified in 5 (22.7%) and 2 patients (9.1%), respectively, with both atrial flutter/fibrillation evident in a single patient 1 (4.5%). 8 patients (36.4%) had a history of right-sided maze procedures. Cavotricuspid isthmus atrial flutter (CTI-AFl) was the most commonly induced arrhythmia (n = 13, 59.1%), followed by incisional intra-atrial re-entrant tachycardia (IART; n = 4, 18.2%), and FAT (n = 4, 18.2%); 3 patients also underwent left-side ablation with concomitant pulmonary vein isolation (13.6%). 1-year and 5-year atrial arrhythmia recurrence rates were 10.0% and 41.2%, respectively. 7 patients (31.8%) underwent redo ablations, and anti-arrhythmic medication was utilized in 8 patients (36.4%) post-ablation. Neither ablation location nor echocardiographic parameters were found to be predictors of arrhythmia recurrence. Catheter ablation of atrial arrhythmias in patients with EA has a favorable outcome overall with an acceptable recurrence and safety profile; left-sided ablations are rarely necessary. Despite prior Maze and catheter ablation procedures, CTI-AFl and IART recurrences predominate.

Surgery for supraventricular tachycardia and congenital heart defects: long-term efficacy of the combined approach in adult patients

Supraventricular arrhythmias are a major cause of morbidity and mortality in adult patients with congenital heart disease (CHD). Intraoperative ablation offers an alternative for patients who failed ablation procedures or are requiring concomitant surgical intervention. We present our long-term results with the surgical treatment of arrhythmias in adults with CHD (ACHD) undergoing elective cardiac surgery and the clinical predictors for arrhythmia recurrence. Between 2002 and 2013, 80 consecutive patients with CHD, mean age of 39 years, underwent intraoperative ablation with monopolar irrigated radiofrequency during cardiac surgery procedures. Significant clinical predictors of arrhythmia recurrence were determined by univariate analysis. We performed 47 right-sided Maze procedures, and 33 Cox-Maze III procedures. In 75 survivors, the ablation was effective immediately. Over an average follow-up period of 72 months (12-155 months), arrhythmias recurred in nine (20%) patients after right-sided Maze, and in six (19%) patients after Cox-Maze III. Eleven patients were controlled with medical therapy, three underwent catheter ablation of the arrhythmia, and one required a permanent pacemaker. Preoperative arrhythmia length ≥3 years (P ≤ 0.001), tetralogy of Fallot (P ≤ 0.006), and preoperative atrial fibrillation (P ≤ 0.016) were associated with recurrence arrhythmia. Conversely, NYHA class <3 (P ≤ 0.047) was associated with a lower risk of recurrence. Surgical treatment of unresponsive supraventricular arrhythmia during concomitant cardiac surgery in ACHD is a safe and effective procedure. Freedom from arrhythmias recurrence is 75% after 6 years of follow-up. Long-term recurrence of arrhythmia in these patients seems to be strongly correlated to preoperative arrhythmia duration.

Optimal Surgical Ablation of Atrial Tachyarrhythmias During Correction of Ebstein Anomaly

Ebstein anomaly (EA) is commonly associated with atrial flutter or fibrillation (AFl/F), which adversely affects outcome. Surgical ablation of AFl/F during surgery for EA has been shown to be effective, but the optimal lesion set remains unknown. Between 1995 and 2010, 86 patients had corrective surgery for EA and concomitant maze procedure for associated AFl/F. Median age at operation was 40 years (range, 1 to 72 years), and 49 patients (60%) were male. Preoperative AFl/F was paroxysmal in 43 patients (50%). All patients who had diagnosis of or treatment for accessory pathways and reentrant tachycardia were excluded from this analysis. All patients underwent tricuspid valve surgery for EA and concomitant maze procedure, including right-sided maze (RSM) in 62 patients (72%) and biatrial maze (BAM) in 24 patients (28%). Early mortality occurred in 3 patients (3.5%). During median follow-up of 52 months (range, 3 months to 17 years), overall freedom from AFl/F without antiarrhythmic medications was 79% (RSM, 80% versus BAM, 76%; p = 0.97). Although there was no difference in rhythm outcome between RSM and BAM for patients with paroxysmal AFl/F (p = 0.08), there was a trend toward higher freedom from AF without antiarrhythmic medications in patients with persistent AFl/F for BAM (86%) versus RSM (71%; p = 0.053). Overall, there were no late strokes, and 84% were free from sodium warfarin anticoagulation. Overall, surgical ablation of preoperative AFl/F is effective in patients undergoing surgery for EA. Although rhythm outcome of RSM and BAM did not differ in patients with preoperative paroxysmal AFl/F, those with persistent or permanent AFl/F may benefit from a biatrial lesion set.

Surgical outcome of Fontan conversion and arrhythmia surgery: Need a pacemaker?

Atrial tachyarrhythmias are frequent complications in the late period after the Fontan procedure, and important risk factors for a poor prognosis. The impact of Fontan conversion and arrhythmia surgery in failed Fontan patients has been described in many reports. We evaluated our experience with Fontan conversion procedures, concomitant arrhythmia surgery, and pacemaker implantation. We reviewed the hospital records of 25 consecutive patients who underwent a Fontan conversion procedure from January 2004 to March 2012. Twenty-four patients had arrhythmia surgery using cryoablation and radiofrequency ablation at the time of conversion. A bilateral atrial maze procedure was performed in 6 patients, right-side maze in 15, and isthmus block in 3. Three patients with a diagnosis of corrected transposition of the great arteries underwent simultaneous pacemaker implantation electively. There was no early death and one late death during a mean follow-up period of 21.2 months. Three tachyarrhythmia recurrences developed, and there were 4 occurrences of sinus bradycardia. Five of these patients required postoperative pacemaker implantation. The mid-term results of Fontan conversion and arrhythmia surgery in our institute were satisfactory. The occurrence of unexpected postoperative pacemaker requirement was high in the patients who underwent a right atrial or bilateral atrial maze procedure. Pacemaker or lead implantation is recommended for patients planned to undergo a right-side or full maze procedure.

The mid-term surgical results of Fontan conversion with antiarrhythmia surgery

We investigated the mid-term surgical results of Fontan conversion with antiarrhythmias surgery and permanent pacemaker implantation, which were complications of a previous Fontan operation. From January 1996 to November 2011, we performed Fontan conversion in 31 of 260 Fontan cases (M:F = 17:14, mean age = 19.0 years). The Fontan conversion from atriopulmonary connection (APC) to extracardiac conduit (ECC) was performed in 20 patients, APC to lateral tunnel in 5 and lateral tunnel to ECC in 6. The clinical outcomes and improvements of arrhythmias were analysed. The types of arrhythmias included atrial flutter in 21 patients, atrial fibrillation with flutter in 4 patients and junctional tachycardia in 3 patients. Twenty-six patients (83.9%) required antiarrhythmia surgery (isthmus cryoablation = 9, right-sided maze = 13, bilateral maze = 4). In addition, 23 patients (74.2%) received a permanent pacemaker. The New York Heart Association functional class (NYHA Fc) was statistically improved after the surgery during the 6.5-year median follow-up duration (preoperative NYHA Fc = 1.77, postoperative NYHA Fc = 1.13, n = 15, P = 0.001). There were 4 late mortalities. Actuarial 5-year survival was 90.0 ± 5.5%. And freedom from arrhythmia was 91.8 ± 5.5%, at 5 years. Normal sinus rhythm was maintained in 12 patients (38.7%), pacing-dependent rhythm in 10 patients (32.3%) and intermittent pacing-dependent rhythm in 4 patients (12.9%). Fontan conversion with antiarrhythmia surgery and permanent pacemaker implantation is safe and improves the clinical outcome and arrhythmias.

Invited Commentary

Nitta and coworkers are to be commended for a highly insightful article investigating the pathophysiology of atrial fibrillation (AF) [1]. Earlier experience with concomitant ablation in patients with atrial septal defect (ASD) or other congenital conditions with right-sided overload seemed to indicate that a right-sided Maze operation could actually fix the problem in most cases. Interestingly, in patients with ASD this seems to be the case only with paroxysmal AF. Although not unexpected, this is an important finding.

Efficacy of the Maze Procedure for Atrial Fibrillation Associated with Atrial Septal Defect

BackgroundAtrial fibrillation (AF) is a common complication in elderly patients with atrial septal defect (ASD). The purpose of this study was to examine the efficacy of the maze procedure in these patients.Materials and MethodsBetween February 2000 and May 2011, 46 patients underwent the maze procedure as a concomitant operation with ASD closure. Three patients who underwent a right-sided maze were excluded, and one patient was lost to follow-up. The mean follow-up duration was 3.2±2.5 years. Electrocardiography was performed 1 month, 3 months, 6 months, and 1 year after surgery, and checked annually after that.ResultsAF persisted in 4 patients after surgery. One year after surgery, among 38 patients, 55.3% remained in sinus rhythm without antiarrhythmic drugs. However, when including the patients who took antiarrhythmic drugs, 92.1% were in sinus rhythm. Freedom from AF recurrence at 3 months, 6 months, 1 year, 2 years, 3 years, and 5 years after surgery were 97.4±2.6, 94.4±3.8, 91.2±4.9, 87.8±5.8, 79.5±7.6, and 68.2±12.4, respectively. There was no early mortality after operation.ConclusionConcomitant treatment with the maze procedure and ASD closure is safe and effective for restoring the sinus rhythm.

Pulmonary Hypertension Following Maze Surgery for Atrial Fibrillation

Purpose The Maze procedure is considered the definitive surgical approach to atrial fibrillation. Pulmonary hypertension (PH) has not been reported following Maze, but has been associated with radiofrequency ablation due to left atrial scarring and diastolic dysfunction (stiff left atrial syndrome). We sought to investigate the development of PH following Maze using echocardiographic indices. Methods and Materials Data from all patients undergoing Maze surgery between 1/1/1999 and 12/31/2004 at Mayo Clinic Rochester was retrospectively reviewed. Patients with adequate pre- and post-operative transthoracic echocardiograms (TTE) (>90 days after surgery) were included. Patients with congenital heart disease, isolated right-sided Maze, mitral stenosis, and pre-existing elevated right ventricular systolic pressure (RVSP ≥40 mm Hg) were excluded. Diastolic parameters including left atrial volume index, E/e’, and E:A were reported when available. Results Forty-one patients (26 males) met inclusion criteria. Mean age at surgery was 63 ± 10 years, with normal ejection fraction pre- and post-operatively (60 vs 58%). Two patients underwent Maze surgery only, 5 had coronary bypass grafting, 36 had concomitant valvular operations (29 mitral, 4 aortic, 3 tricuspid), and 2 underwent septal myectomy for hypertrophic obstructive cardiomyopathy. Median RVSP increased from 32 mm Hg (interquartile range [IQ] 27;37) pre-operatively to 41 mm Hg (IQ 33;58) post-operatively. RVSP ≥40 mm Hg was observed in 26/41 patients on 150 total post-operative TTEs at a median follow-up of 1545 days (IQ 610;2339). Measures of left ventricular diastolic function worsened, with median pre-operative E/e’ of 14 (IQ 10;18) increasing to 22 (IQ 15;28), and median E:A ratio increasing from 1.8 (IQ 1.1;2.4) to 2.33 (IQ 2.0;3.3). Conclusions Maze surgery may be complicated by the development of increased right heart pressures and worsening diastolic function, raising the possibility that stiff left atrial syndrome may be a significant sequela of Maze surgery warranting further study.

Arrhythmia surgery for atrial fibrillation associated with atrial septal defect: Right-sided maze versus biatrial maze

Although it has been inferred that a biatrial maze procedure for atrial fibrillation in left-sided heart lesions may lead to better outcomes compared with a limited left atrial lesion set, it remains controversial whether the biatrial maze procedure is superior to the right atrial maze procedure in right-sided heart lesions. A retrospective review was performed for 56 adults who underwent surgical closure of atrial septal defect and various maze procedures for atrial fibrillation between June 1998 and February 2011. The median age at operation was 59 years (range, 34-79 years). Clinical manifestations of atrial fibrillation were paroxysmal in 8 patients, persistent in 15 patients, and long-standing persistent in 33 patients. A right atrial maze procedure was performed in 23 patients (group 1), and a biatrial maze procedure was performed in 33 patients (group 2). Treatment failure was defined as atrial fibrillation recurrence, development of atrial flutter or other types of atrial tachyarrhythmia, or implantation of a permanent pacemaker. The Cox proportional hazards model was used to identify risk factors for decreased time to treatment failure. During the median follow-up period of 49 months (range, 5-149 months), there was no early death and 1 late noncardiac death. On Cox survival model, group 1 showed a significantly decreased time to treatment failure in comparison with group 2 (hazard ratio, 5.11; 95% confidence interval, 1.59-16.44; P = .006). Maintenance of normal sinus rhythm without any episode of atrial fibrillation recurrence at 2 and 5 years postoperatively was 57% and 45% in group 1, respectively, and 82% and 69% in group 2, respectively. Left-sided ablation in addition to a right atrial maze procedure leads to better electrophysiologic outcome in atrial fibrillation associated with atrial septal defect.

The Surgical Treatment of Concomitant Atrial Arrhythmias During Redo Cardiac Operations

With improving surgical care yielding better outcomes, patients who have undergone a cardiac operation are surviving longer, and surgeons will inevitably face an increasing number of reoperative procedures. There are few data reporting risk and outcome for patients undergoing atrial fibrillation ablation in this clinical setting. From January 1994 through May 2009, we performed surgery for AF in 245 patients (134 female) who have had at least1 prior cardiac operation. Median age was 45 years (range 1 to 75 years) and preoperative atrial fibrillation was paroxysmal in 161 patients (66%). Most common cardiac diagnoses included Ebstein anomaly (n=43), tetralogy of Fallot (n=36), and acquired valvular or ischemic heart disease (n=35). Median prior sternotomies was 1 (range 1 to 6). Ablative lesions most commonly included isolated right-sided maze (n=123; cryothermy in 84, cut and sew in 39), biatrial maze (n=52; cryothermy in 26, cut and sew in 26), and right atrial isthmus ablation (n=41; isolated in 30, concomitant in 11). There were 14 early deaths (5.7%). New permanent pacemaker was required in 39 patients (18%); indication was complete heart block in 9. Rhythm at late follow-up (median: 4.1 years, maximum: 17.2 years) was 89% in the setting of congenital heart disease and 78% in acquired heart disease. Atrial fibrillation is common with a variety of pathologies requiring redo cardiac surgery. Lesion set and energy source are dependent on primary procedure. Concomitant AF ablation during redo cardiac reoperations can be performed with reasonable safety and success.

Aortic Dissection Type a after Right Atrial Cryoablation during Port Access Mitral Valve Surgery

The case of a 63-year-old woman who underwent minimal invasive mitral and tricuspid valve repair and a concomitant CryoMaze is described. During creation of the last lesion of the right-sided maze procedure, dissection of the ascending aorta occurred that necessitated emergency sternotomy, replacement of the ascending aorta, and aortocoronary bypass grafting to the right coronary artery (RCA) because of detachment of the RCA from the aortic annulus. Repair of this complication was successful; nevertheless, the patient died 5 days after the operation because of multiorgan failure. The cause of this complication can only be speculated, but a relation to the CyroMaze is obvious. Because of the restricted incision with impaired vision especially in the area of the right atrial appendage, the cryoprobe could have come into contact with the orifice of the RCA during the last lesion, with subsequent detachment of the RCA from the aorta, which could subsequently have caused dissection.

Abstract 8609: Long-Term Outcomes of Surgical Treatment for Atrial Fibrillation in a Complex Population

Objective: Surgical procedures are increasingly used to treat patients with long-standing persistent atrial fibrillation (AF). We sought to evaluate the safety and efficacy of various surgical approaches to AF at a high-volume tertiary surgical referral center. Methods: In this retrospective, single center study, we analyze our experience with the surgical treatment of AF. We evaluated 272 consecutive patients operated on, over a 9 year period. The surgical procedure for AF performed on each patient varied and was left up to the discretion of the surgeon with 29.8%(n=80) of patients receiving a complete right and left-sided Maze procedure including pulmonary vein isolation, 20.5%(n=55) of patients receiving a left-sided Maze procedure including pulmonary vein isolation, 4.9%(n=13) of patients receiving a right-sided Maze procedure including pulmonary vein isolation and 44.8%(n=120) of patients receiving pulmonary vein isolation alone. The vast majority of patients underwent at least one concomitant surgical procedure (93.7% AF surgery + concomitant surgical procedure, 6.3% stand-alone Maze). Patients were followed for a mean period of 42.3 months (+/-27 months). Cardiac rhythm was analyzed at discharge, 1-year follow-up visit and then re-analyzed on an annual basis. Results: In total 265 patients were analyzed, 4 patients were lost to follow-up and 3 expired prior to one year follow-up. Survival rates at 1-year were 96.5%. 50.2% of our patients were discharged in sinus rhythm. Additionally, 12.7% of patients received a new permanent pacemaker prior to their initial hospital discharge. At the 1-year follow-up visit 77% of patients were found to be in sinus rhythm or atrial paced rhythm and 23 % of patients were in AF/flutter. Our most recent analysis revealed 71.8 % of patients remain in sinus rhythm or atrial paced rhythm at up to 9 years post-surgical intervention. Conclusions: Surgical procedures for AF resulted in 1-year maintenance of sinus rhythm rates of 77%. These success rates appear largely maintained over a follow-up period of up to 9 years. Our patients were taken from a complex surgical population at a busy academic surgical center. We believe these numbers reflect real-world success rates in this patient population.

Not too old to be closed….

Not too old to be closed….

Surgical Therapy of Arrhythmias in Single‐Ventricle Patients Undergoing Fontan or Fontan Conversion

Arrhythmia is detrimental to Fontan hemodynamics. Clinical outcomes among Fontan patients who underwent antiarrhythmic treatment were retrospectively reviewed. From January 1996 to January 2007, 182 patients underwent a Fontan procedure, including Fontan conversion. Thirty-nine of the 182 patients showed various arrhythmias pre- or post-Fontan operations, and were treated surgically including Fontan conversion (18 patients) or medically. The authors analyzed the outcomes of arrhythmia treatments retrospectively. Thirty-nine patients (21.4%) showed various arrhythmias, such as atrial flutter, atrial fibrillation, junctional rhythm, sinus node dysfunction, or brady tachyarrhythmia pre- or post-Fontan procedure. Follow-up duration was 13.1 +/- 8.7 years (11 months to 325 months).Atrial flutter and fibrillation only developed in 17 patients who received atriopulmonary connection Fontan, and who were treated by Fontan conversion with concomitant procedures such as Cox-maze procedure (two patients), right-side maze and pacemaker implantation (five patients), right atrial isthmus ablation (four patients), right atrial isthmus cryoablation and pacemaker implantation (five patients), and only pacemaker implantation (one patient). The 21 patients who showed arrhythmia at the time of the Fontan procedure underwent the following procedures concomitantly: right atrial isthmus cryoablation with pacemaker implantation (one patient), right atrial isthmus cryoablation (one patient), or pacemaker implantation (nine patients). The remaining 10 patients, who showed junctional rhythm, sinus bradycardia, or intermittent ectopic beats, were managed medically. There were two late mortalities due to protein-losing enteropathy. As a result, 33 patients (89.2%) maintained atrioventricular synchrony, 19 in sinus rhythm and 14 supported by a DDD-type pacemaker. The remaining four patients (10.8%) showed persistent junctional rhythm with a stable hemodynamic status. The various arrhythmias in Fontan patients were well controlled by aggressive surgical management.

Successfully completed total cavopulmonary connection with a right-sided maze procedure after a modified Starnes’ operation in a neonate with Ebstein’s anomaly

The symptomatic newborn infant with Ebstein's anomaly is in critical condition and is difficult to treat successfully. Furthermore, supraventricular tachyarrhythmia in patients with Ebstein's anomaly may determine the early and late results. We report a successfully treated case of extracardiac total cavopulmonary connection with a right-sided maze procedure after a modified Starnes' operation during the neonatal period.