Analysis of surgical result of Cox-maze Ⅳ in the treatment of hypertrophic obstructive cardiomyopathy with persistent atrial fibrillation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

MENG Yanhai ¹ , LIU Ping ¹ , ZHANG Yanbo ¹ , YU Qinjun ² , WANG Shengwei ³ , ZHU Changsheng ³ ,  WANG Shuiyun ³

1. Postoperative Recovery Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, P.R.China;
2. Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, P.R.China;
3. Department of Cardiovascular Surgery, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, P.R.China;

Corresponding author：

WANG Shuiyun, Email: wsymd@sina.com

Keywords：

Hypertrophic obstructive cardiomyopathy; persistent atrial fibrillation; Cox-maze Ⅳ; treatment

DOI：

10.7507/1007-4848.201911034

Video：

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Objective To evaluate the efficacy and safety of modified maze Ⅳ (Cox-maze Ⅳ) in hypertrophic obstructive cardiomyopathy (HOCM) patients.Methods From June 2016 to June 2019, 30 HOCM and persistent atrial fibrillation (pAF) patients received Cox-maze Ⅳ operation with modified extended Morrow operation, including 21 males and 9 females. The average age was 51.36±10.27 years and the average weight was 72.48±11.29 kg. All patients underwent left atrial appendectomy. Recurrence of AF, improvement of symptoms, cardiac function (NYHA) were assessed during follow-up.Results There was no death during the perioperative period. Postoperative left ventricular outflow tract gradient was significantly decreased compared with that before operation (P<0.01), and all systolic anterior motion (SAM) signs disappeared after operation. Thirty patients were all effectively followed up for 3-40 (16.24±8.26) months. During the follow-up period, there was no death, and the cardiac function (NYHA) of all patients recovered to gradeⅠ-Ⅱ. At the end of follow-up, twenty-four patients (80.00%) maintained sinus rhythm, and twenty-seven patients (90.00%) maintained sinus rhythm after amiodarone conversion. Univariate analysis showed that the smoking history (P=0.04), left atrial diameter≥55 mm before operation (P=0.03), left atrial diameter≥50 mm after operation (P=0.02), postoperative tricuspid regurgitation (P=0.02) were closely related to postoperative AF recurrence. The increase of left atrial diameter after operation was an independent risk factor for AF recurrence (P=0.02).Conclusion Morrow/Cox-maze Ⅳ procedure is safe and effective in treatment of patients with HOCM complicated with pAF, which helps to maintain postoperative sinus rhythm, and to improve the cardiac function. The increase of left atrial diameter after operation is an independent risk factor for AF recurrence.

Citation： MENG Yanhai, LIU Ping, ZHANG Yanbo, YU Qinjun, WANG Shengwei, ZHU Changsheng, WANG Shuiyun. Analysis of surgical result of Cox-maze Ⅳ in the treatment of hypertrophic obstructive cardiomyopathy with persistent atrial fibrillation. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2020, 27(10): 1211-1216. doi: 10.7507/1007-4848.201911034 Copy

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2.	Elliott P, Andersson B, Arbustini E, <italic>et al</italic>. Classification of the cardiomyopathies: a position statement from the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J, 2008, 29(2): 270-276.
3.	Macintyre C, Lakdawala NK. Management of atrial fibrillation in hypertrophic cardiomyopathy. Circulation, 2016, 133(19): 1901-1905.
4.	Kumar KR, Mandleywala SN, Link MS. Atrial and ventricular arrhythmias in hypertrophic cardiomyopathy. Card Electrophysiol Clin, 2015, 7(2): 173-186.
5.	Siontis KC, Geske JB, Ong K, <italic>et al</italic>. Atrial fibrillation in hypertrophic cardiomyopathy: prevalence, clinical correlations, and mortality in a large high-risk population. J Am Heart Assoc, 2014, 3(3): e1002.
6.	Guo Y, Wu X, Zheng X, <italic>et al</italic>. Usefulness of preoperative transforming growth factor-beta to predict new onset atrial fibrillation after surgical ventricular septal myectomy in patients with obstructive hypertrophic cardiomyopathy. Am J Cardiol, 2017, 120(1): 118-123.
7.	Wang S, Cui H, Song C, <italic>et al</italic>. Obstructive sleep apnea is associated with nonsustained ventricular tachycardia in patients with hypertrophic obstructive cardiomyopathy. Heart Rhythm, 2019, 16(5): 694-701.
8.	Yang S, Mei B, Feng K, <italic>et al</italic>. Long-term results of surgical atrial fibrillation radiofrequency ablation: comparison of two methods. Heart Lung Circ, 2018, 27(5): 621-628.
9.	Wang S, Luo M, Sun H, <italic>et al</italic>. A retrospective clinical study of transaortic extended septal myectomy for obstructive hypertrophic cardiomyopathy in China. Eur J Cardiothorac Surg, 2013, 43(3): 534-540.
10.	Wang S, Cui H, Yu Q, <italic>et al</italic>. Excision of anomalous muscle bundles as an important addition to extended septal myectomy for treatment of left ventricular outflow tract obstruction. J Thorac Cardiovasc Surg, 2016, 152(2): 461-468.
11.	Ruaengsri C, Schill MR, Khiabani AJ, <italic>et al</italic>. The Cox-maze Ⅳ procedure in its second decade: still the gold standard? Eur J Cardiothorac Surg, 2018, 53(suppl_1): i19-i25.
12.	Gaynor SL, Diodato MD, Prasad SM, <italic>et al</italic>. A prospective, single-center clinical trial of a modified Cox maze procedure with bipolar radiofrequency ablation. J Thorac Cardiovasc Surg, 2004, 128(4): 535-542.
13.	Klopotowski M, Kwapiszewska A, Kukula K, <italic>et al</italic>. Clinical and echocardiographic parameters as risk factors for atrial fibrillation in patients with hypertrophic cardiomyopathy. Clin Cardiol, 2018, 41(10): 1336-1340.
14.	Patten M, Pecha S, Aydin A. Atrial fibrillation in hypertrophic cardiomyopathy: diagnosis and considerations for management. J Atr Fibrillation, 2018, 10(5): 1556.
15.	Prutkin JM, Owens DS. Catheter ablation for atrial fibrillation in patients with hypertrophic cardiomyopathy. Heart, 2016, 102(19): 1513-1514.
16.	Providencia R, Elliott P, Patel K, <italic>et al</italic>. Catheter ablation for atrial fibrillation in hypertrophic cardiomyopathy: a systematic review and meta-analysis. Heart, 2016, 102(19): 1533-1543.
17.	Di Donna P, Olivotto I, Delcre SD, <italic>et al</italic>. Efficacy of catheter ablation for atrial fibrillation in hypertrophic cardiomyopathy: impact of age, atrial remodelling, and disease progression. Europace, 2010, 12(3): 347-355.
18.	Contreras-Valdes FM, Buxton AE, Josephson ME, <italic>et al</italic>. Atrial fibrillation ablation in patients with hypertrophic cardiomyopathy: long-term outcomes and clinical predictors. J Am Coll Cardiol, 2015, 65(14): 1485-1487.
19.	Elliott PM, Anastasakis A, Borger MA, <italic>et al</italic>. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J, 2014, 35(39): 2733-2779.
20.	Sedehi D, Finocchiaro G, Tibayan Y, <italic>et al</italic>. Long-term outcomes of septal reduction for obstructive hypertrophic cardiomyopathy. J Cardiol, 2015, 66(1): 57-62.
21.	Boll G, Rowin EJ, Maron BJ, <italic>et al</italic>. Efficacy of combined Cox-Maze Ⅳ and ventricular septal myectomy for treatment of atrial fibrillation in patients with obstructive hypertrophic cardiomyopathy. Am J Cardiol, 2020, 125(1): 120-126.
22.	Bogachev-Prokophiev AV, Afanasyev AV, Zheleznev SI, <italic>et al</italic>. Concomitant ablation for atrial fibrillation during septal myectomy in patients with hypertrophic obstructive cardiomyopathy. J Thorac Cardiovasc Surg, 2018, 155(4): 1536-1542.
23.	Lapenna E, Pozzoli A, De Bonis M, <italic>et al</italic>. Mid-term outcomes of concomitant surgical ablation of atrial fibrillation in patients undergoing cardiac surgery for hypertrophic cardiomyopathy. Eur J Cardiothorac Surg, 2017, 51(6): 1112-1118.

1. Semsarian C, Ingles J, Maron MS, <italic>et al</italic>. New perspectives on the prevalence of hypertrophic cardiomyopathy. J Am Coll Cardiol, 2015, 65(12): 1249-1254.
2. Elliott P, Andersson B, Arbustini E, <italic>et al</italic>. Classification of the cardiomyopathies: a position statement from the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J, 2008, 29(2): 270-276.
3. Macintyre C, Lakdawala NK. Management of atrial fibrillation in hypertrophic cardiomyopathy. Circulation, 2016, 133(19): 1901-1905.
4. Kumar KR, Mandleywala SN, Link MS. Atrial and ventricular arrhythmias in hypertrophic cardiomyopathy. Card Electrophysiol Clin, 2015, 7(2): 173-186.
5. Siontis KC, Geske JB, Ong K, <italic>et al</italic>. Atrial fibrillation in hypertrophic cardiomyopathy: prevalence, clinical correlations, and mortality in a large high-risk population. J Am Heart Assoc, 2014, 3(3): e1002.
6. Guo Y, Wu X, Zheng X, <italic>et al</italic>. Usefulness of preoperative transforming growth factor-beta to predict new onset atrial fibrillation after surgical ventricular septal myectomy in patients with obstructive hypertrophic cardiomyopathy. Am J Cardiol, 2017, 120(1): 118-123.
7. Wang S, Cui H, Song C, <italic>et al</italic>. Obstructive sleep apnea is associated with nonsustained ventricular tachycardia in patients with hypertrophic obstructive cardiomyopathy. Heart Rhythm, 2019, 16(5): 694-701.
8. Yang S, Mei B, Feng K, <italic>et al</italic>. Long-term results of surgical atrial fibrillation radiofrequency ablation: comparison of two methods. Heart Lung Circ, 2018, 27(5): 621-628.
9. Wang S, Luo M, Sun H, <italic>et al</italic>. A retrospective clinical study of transaortic extended septal myectomy for obstructive hypertrophic cardiomyopathy in China. Eur J Cardiothorac Surg, 2013, 43(3): 534-540.
10. Wang S, Cui H, Yu Q, <italic>et al</italic>. Excision of anomalous muscle bundles as an important addition to extended septal myectomy for treatment of left ventricular outflow tract obstruction. J Thorac Cardiovasc Surg, 2016, 152(2): 461-468.
11. Ruaengsri C, Schill MR, Khiabani AJ, <italic>et al</italic>. The Cox-maze Ⅳ procedure in its second decade: still the gold standard? Eur J Cardiothorac Surg, 2018, 53(suppl_1): i19-i25.
12. Gaynor SL, Diodato MD, Prasad SM, <italic>et al</italic>. A prospective, single-center clinical trial of a modified Cox maze procedure with bipolar radiofrequency ablation. J Thorac Cardiovasc Surg, 2004, 128(4): 535-542.
13. Klopotowski M, Kwapiszewska A, Kukula K, <italic>et al</italic>. Clinical and echocardiographic parameters as risk factors for atrial fibrillation in patients with hypertrophic cardiomyopathy. Clin Cardiol, 2018, 41(10): 1336-1340.
14. Patten M, Pecha S, Aydin A. Atrial fibrillation in hypertrophic cardiomyopathy: diagnosis and considerations for management. J Atr Fibrillation, 2018, 10(5): 1556.
15. Prutkin JM, Owens DS. Catheter ablation for atrial fibrillation in patients with hypertrophic cardiomyopathy. Heart, 2016, 102(19): 1513-1514.
16. Providencia R, Elliott P, Patel K, <italic>et al</italic>. Catheter ablation for atrial fibrillation in hypertrophic cardiomyopathy: a systematic review and meta-analysis. Heart, 2016, 102(19): 1533-1543.
17. Di Donna P, Olivotto I, Delcre SD, <italic>et al</italic>. Efficacy of catheter ablation for atrial fibrillation in hypertrophic cardiomyopathy: impact of age, atrial remodelling, and disease progression. Europace, 2010, 12(3): 347-355.
18. Contreras-Valdes FM, Buxton AE, Josephson ME, <italic>et al</italic>. Atrial fibrillation ablation in patients with hypertrophic cardiomyopathy: long-term outcomes and clinical predictors. J Am Coll Cardiol, 2015, 65(14): 1485-1487.
19. Elliott PM, Anastasakis A, Borger MA, <italic>et al</italic>. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J, 2014, 35(39): 2733-2779.
20. Sedehi D, Finocchiaro G, Tibayan Y, <italic>et al</italic>. Long-term outcomes of septal reduction for obstructive hypertrophic cardiomyopathy. J Cardiol, 2015, 66(1): 57-62.
21. Boll G, Rowin EJ, Maron BJ, <italic>et al</italic>. Efficacy of combined Cox-Maze Ⅳ and ventricular septal myectomy for treatment of atrial fibrillation in patients with obstructive hypertrophic cardiomyopathy. Am J Cardiol, 2020, 125(1): 120-126.
22. Bogachev-Prokophiev AV, Afanasyev AV, Zheleznev SI, <italic>et al</italic>. Concomitant ablation for atrial fibrillation during septal myectomy in patients with hypertrophic obstructive cardiomyopathy. J Thorac Cardiovasc Surg, 2018, 155(4): 1536-1542.
23. Lapenna E, Pozzoli A, De Bonis M, <italic>et al</italic>. Mid-term outcomes of concomitant surgical ablation of atrial fibrillation in patients undergoing cardiac surgery for hypertrophic cardiomyopathy. Eur J Cardiothorac Surg, 2017, 51(6): 1112-1118.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Analysis of surgical result of Cox-maze Ⅳ in the treatment of hypertrophic obstructive cardiomyopathy with persistent atrial fibrillation

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