Vol.3 - No.3

In patients with an enlarged left atrium does left atrial size reduction improve mazesurgery success?

By : shakibi

Keywords : -

A best evidence topic in cardiothoracic surgery was written
according to a structured protocol. The question addressed
was: In [adults undergoing a maze procedure for atrial fibrillation
(AF)], [does left atrial size reduction] compared
to [maze surgery alone] improve [maze surgery success]?
A total of 58 papers were found using the reported search,
of which eight 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. Four out
of eight papers compared a volume reduction technique
as an adjunct to the maze procedure to a maze procedure
alone - all four papers reported that atrial volume reduction
significantly increased restoration of sinus rhythm:
89.3% vs. 67.2%, P<0.001; 85% vs. 68%, P<0.05; 84% vs.
68%, P<0.05; 90% vs. 69%, P<0.05. Three out of eight papers
had no control group but reported good rates of sinus
rhythm restoration at last follow-up -90%, 92% and 89%,
respectively - despite the study population including atrial
enlargement, a risk factor for failure of a maze procedure.
One paper reported no benefit of an atrial reduction plastyin patients with a left atrium (LA) >70 mm. An enlarged
LA is a risk factor for failure of a maze procedure, and various
models of AF suggest that reducing atrial mass and/or
diameter may help to abolish the re-entry circuits underlying
AF. Furthermore, AF is uncommon when left atrial
diameter is <40 mm, so there is at least some physiological
basis for atrial reduction surgery in aiding the success of a
maze procedure. The evidence suggests that patients with
an enlarged ( 55 mm) or giant ( 75 mm) LA who are at
risk of failing to obtain sinus conversion after a standard
maze procedure may derive benefit from concomitant atrial
reduction surgery using either a tissue excision or a tissue
plication technique. However, the evidence is not strong
since the papers available are not readily comparable owing
to substantial variations in the populations and procedures
involved. We therefore, emphasise the need for prospective
randomised studies in this area. Keywords: Atrial fibrillation;
Cox maze; Left atrial size reduction; maze, Minimaze;
Recurrence of atrial fibrillation

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