Valve replacement or valve ring implantation and Cox-Maze III procedure for older adults with mitral valve disease complicated by persistent or long-standing persistent atrial fibrillation

doi:10.3969/j.issn.2095-4344.1753

Abstract

Abstract:

BACKGROUND: Preliminary studies have shown that the Cox-Maze III procedure is safe and effective method to treat persistent or long-standing persistent atrial fibrillation. As the surgical tolerance of elderly patients is poor, the safety and effectiveness of Cox-Maze III for elderly patients are rarely reported.

OBJECTIVE: To evaluate the safety and efficacy of Cox-Maze III procedure in elderly patients with mitral valve disease complicated by persistent or long-standing persistent atrial fibrillation.

METHODS: One hundred and sixty-six patients with mitral valve disease complicated by persistent or long-standing persistent atrial fibrillation admitted at General Hospital of Northern Theater Command (General Hospital of Shenyang Military Region of Chinese PLA) from May 2013 to November 2017 were included. According to the World Health Organization definition of the elderly people, they were divided into elder group (≥ 60 years, n=70) and young group (< 60 years, n=96), followed by undergoing Cox-Maze III procedure and valvular replacement or valvuloplasty. The intraoperative indexes, postoperative safety indexes and early-term and efficacy were compared between two groups. The study was approved by the Ethics Committee of General Hospital of Northern Theater Command (General Hospital of Shenyang Military Region of Chinese PLA), approval number: k(2015)33.

RESULTS AND CONCLUSION: (1) Intraoperative safety indexes: there was no significant difference in the time of aortic clamping, cardiopulmonary bypass time, blood loss and surgical type between two groups (P > 0.05). The elderly group had more patients to conduct the coronary artery bypass grafting and the use of biological valve than the young group (P < 0.05). (2) Postoperative safety indexes: the incidence of adverse events such as the re-thoratomy for hemaostsis, low cardiac output syndrome, stroke, hepatic and renal dysfunction, secondary tracheal intubation, intra-aortic balloon pump implantation, temporary pacemaker application and early-term mortality were insignificant differences between two groups (P > 0.05). There were no significant differences in the intensive care unit stay time and postoperative hospitalization time (P > 0.05) between two groups. The time of ventilator use in the elderly group was significantly longer than that in the young group (P < 0.05). (3) Postoperative efficacy: the New York Heart Association classes at discharge and postoperative 6 and 12 months were significantly improved in all patients compared with the baseline, and there was no significant difference between two groups (P > 0.05). The rate to achieve sinus rhythm at discharge and postoperative 6 and 12 months showed no significant difference between two groups (P > 0.05), which reached above 85%. (4) These results indicate that Cox-Maze III procedure possesses safety for elderly patients with mitral valve disease complicated by persistent or long-standing persistent atrial fibrillation, and the short-term efficacy is satisfactory.

Key words: Cox-Maze procedure, elderly patients, heart valve disease, atrial fibrillation, long-standing persistent atrial fibrillation, artificial valve, mitral valve disease

CLC Number:

R459.9

Han Bing, Wang Huishan, Han Jinsong, Yin Zongtao, Xie Saiqi. Valve replacement or valve ring implantation and Cox-Maze III procedure for older adults with mitral valve disease complicated by persistent or long-standing persistent atrial fibrillation[J]. Chinese Journal of Tissue Engineering Research, 2019, 23(22): 3562-3569.

Figures/Tables 4

2.4 围术期安全性指标 2.4.1 术中情况两组间术中主动脉阻断时间及体外循环时间基本相同，组间比较差异无显著性意义(P > 0.05)；老年组术中出血量较非老年组增加约40 mL，但两组间比较差异无显著性意义(P > 0.05)。老年组冠状动脉旁路移植实施、生物瓣使用多于非老年组(P < 0.05)，两组其余同期手术方式比较差异无显著性意义(P > 0.05)；两组内二尖瓣置换患者均较多，两组间二尖瓣手术类型比较差异无显著性意义(P > 0.05)，见表3。 2.4.2 不良事件发生情况两组间低心排综合征、早期脑卒中、肾衰竭、肝功能不全、肺部感染、起搏器应用、二次开胸止血及同步电复律等不良事件比较差异无显著性意义(P > 0.05)，见表3。 2.4.3 早期死亡率老年组早期死亡1例，早期死亡率为1.4%，该患者为66岁男性患者，术前高血压病史20年，9年前有二尖瓣球囊扩张手术史，因术后无尿行持续血液净化治疗，11 d后多器官脏器衰竭死亡。非老年组早期死亡1例，早期死亡率为1.0%，该患者术前风湿性心脏病左心室萎缩，术中左心室破裂修复成功后，4 d后因多脏器衰竭死亡。两组间早期死亡率比较差异无显著性意义(P > 0.05)，见表3。 2.4.4 主动脉内球囊反搏应用情况老年组中，2例患者应用主动脉内球囊反搏，1例患者术前糖尿病病史15年，左室射血分数为0.54，胸闷气短等心功能不全症状明显，手术过程顺利，术后第3天脱机拔管，1周后发生急性左心衰，给予紧急应用主动脉内球囊反搏辅助循环及再次气管插管行机械辅助呼吸，经抢救治疗后病情逐渐恢复良好出院；另1例为67岁男性患者，术中同期行冠状动脉旁路移植、三尖瓣成形、左房血栓清除术，主动脉阻断时间 140 min，体外循环时间403 min，术毕心脏搏动差，心率血压不稳定，给予应用主动脉内球囊反搏辅助循环，术毕无其他不良事件发生，于术后18 d恢复良好出院。非老年组中，有1例患者应用主动脉内球囊反搏，该患者实施术式为二尖瓣成形、三尖瓣成形术，术中3次转流，主动脉阻断总时长达110 min，体外循环总时长为291 min，术毕心脏搏动情况差，血压偏低，给予应用主动脉内球囊反搏后血压心律等循环指标趋于稳定，于术后15 d病情恢复良好出院。两组间比较无明显统计学差异(P > 0.05)。 2.4.5 再次气管插管情况老年组有2例患者再次气管插管，1例为脱机拔管1周后发生急性左心衰，呼吸困难症状明显，给予再次气管插管辅助呼吸并应用主动脉内球囊反搏辅助循环等紧急对症治疗；另1例为70岁老年患者，术前有支气管扩张、肺气肿病史，脱机拔管后痰多，质稠不易咳出，逐渐出现呼吸困难症状，给予雾化及叩背等处置，症状仍未缓解，动脉血气分析提示血氧饱和度逐步下降，于术后第3天给予再次气管插管，2例患者均恢复良好出院。非老年组中无再次气管插管患者。两组间再次气管插管率比较差异无显著性意义(P > 0.05)，见表3。"

References

[1]Lip GYH,Collet JP,Caterina R,et al.Antithrombotic therapy in atrial fibrillation associated with valvular heart disease: a joint consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology Working Group on Thrombosis, endorsed by the ESC Working Group on Valvular Heart Disease,Cardiac Arrhythmia Society of Southern Africa (CASSA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), South African Heart (SA Heart) Association and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLEACE). Europace.2017;19(11):1757-1758.

[2]Healey JS.The winding path towards rationale anti-thrombotic therapy to prevent stroke in patients with atrial fibrillation.Eur Heart J.2018;39(6):474-476.

[3]Kirchhof P,Benussi S,Kotecha D,et al.2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.Eur Heart J. 2016;37(38):2893-2962.

[4]Marfella R,Sasso F,Siniscalchi M,et al.Brief episodes of silent atrial fibrillation predict clinical vascular brain disease in type 2 diabetic patients.J Am Coll Cardiol.2013;62(6):525-530.

[5]Schnabel RB,Yin X,Gona P,et al.50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study.Lancet. 2015; 386(9989):154-162.

[6]Bai Y,Wang YL,Shantsila A,et al.The Global Burden of Atrial Fibrillation and Stroke: A Systematic Review of the Clinical Epidemiology of Atrial Fibrillation in Asia.Chest. 2017;152(4): 810-820.

[7]黄从新,张澍,黄德嘉,等.心房颤动:目前的认识和治疗建议(2018) [J].中国心律失常学杂志,2018,22(4):279-344.

[8]Rahman F,Kwan GF,Benjamin EJ.Global epidemiology of atrial fibrillation. Nat Rev Cardiol. 2014;11:639-654.

[9]Lee R,McCarthy PM,Wang EC,et al.Midterm survival in patients treated for atrial fibrillation: a propensity-matched comparison to patients without a history of atrial fibrillation.J Thorac Cardiovasc Surg.2012;143(6):1341-1351.

[10]Ad N,Holmes SD,Massimiano PS,et al.Long-term outcome following concomitant mitral valve surgery and Cox maze procedure for atrial fibrillation. J Thorac Cardiovasc Surg. 2018;155(3):983-994.

[11]Ad N,Damiano RJ,Badhwar V,et al.Expert consensus guidelines: Examining surgical ablation for atrial fibrillation. J Thorac Cardiovasc Surg.2017;153(6):1330-1354.e1.

[12]Dunning J,Nagendran M,Alfieri OR,et al.Guideline for the surgical treatment of atrial fibrillation. Eur J Cardiothorac Surg. 2013;44(5):777-791.

[13]Bagheri B,Akbarzadeh F,Parvizi R,et al.Freedom from atrial fibrillation after cox maze III ablation during follow-up.Niger Med J.2015;56(1):59-64.

[14]Khargi K,Keyhan-Falsafi A,Hutten BA,et al.Surgical treatment of atrial fibrillation: A systematic review. Herzschrittmacherther Elektrophysiol.2007;18(2):68-76.

[15]Stulak J,Suri R,Burkhart H,et al.Surgical ablation for atrial fibrillation for two decades: Are the results of new techniques equivalent to the Cox maze III procedure? J Thorac Cardiovasc Surg.2014;147(5):1478-1486.

[16]Griffiths R,Beech F,Brown A,et al.Peri-operative care of the elderly 2014: Association of Anaesthetists of Great Britain and Ireland.Anaesthesia.2014;69 Suppl 1:81-98.

[17]Curiel-Balsera E,Mora-Ordoñez JM,Castillo-Lorente E,et al. Mortality and complications in elderly patients undergoing cardiac surgery.J Crit Care.2013;28(4):397-404.

[18]韩劲松,王辉山,汪曾炜,等. COX迷宫III型手术治疗风湿性二尖瓣病变伴发心房颤动的安全性和有效性[J].中华医学杂志, 2016, 96(13):1011-1015.

[19]Wang H,Han J,Wang Z,et al.A Prospective randomized trial of the cut-sew Maze procedure in patients undergoing surgery for rheumatic mitral valve disease.J Thorac Cardiovasc Surg. 2018;155(2):608-617.

[20]Ad N,Henry L,Hunt S,et al.Results of the Cox-Maze III/IV procedure in patients over 75 years old who present for cardiac surgery with a history of atrial fibrillation. J Cardiovasc Surg (Torino). 2013;54(2):281-288.

[21]January CT,Wann LS,Alpert JS,et al.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol.2014;64(21):e1-76.

[22]Mizrahi EH,Fleissig Y,Arad M,Adunsky A.Short-term functional outcome of ischemic stroke in the elderly: A comparative study of atrial fibrillation and non-atrial fibrillation patients.Arch Gerontol Geriatr. 2014;58(1):121-124.

[23]韩劲松,王辉山,汪曾炜,等.人工瓣环置入和迷宫III型手术治疗退行性二尖瓣环扩张伴发心房颤动[J].中国组织工程研究, 2015, 19(52):8522-8528.

[24]韩劲松,王辉山,尹宗涛,等.人工腱索移植和马鞍环环缩修复退行性二尖瓣关闭不全[J].中国组织工程研究, 2014,18(5):705-711.

[25]韩劲松,王辉山,尹宗涛,等.两种人工瓣环置入修复单纯二尖瓣环扩张引起的二尖瓣关闭不全的比较[J].中国组织工程研究, 2015, 19(16):2578-2582.

[26]Camm AJ,Kirchhof P,Lip GY,et al.Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace.2010;12(10):1360-1420.

[27]Badhwar V,Rankin JS,Damiano RJ,et al.The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. Ann Thorac Surg. 2017; 103(1):329-341.

[28]钱永军,肖锡俊.2017STS外科治疗心房颤动临床实践指南中文版及解读[J].中国胸心血管外科临床杂志, 2017,24(4):249-253.

[29]申聪玉,赵锦宁,钟泰迪.体外循环心脏手术患者围术期大量出血的危险因素分析[J].中华医学杂志,2012,92(5):316-319.

[30]王辉山,汪曾炜,尹宗涛,等.Cox迷宫Ⅲ手术治疗心脏瓣膜病合并持续性房颤[J].中国胸心血管外科杂志,2015,31(12):743-747.

[31]Atik FA,Gomes GG,Rodrigues FF,et al.Is It Conceivable to Still Perform the Cut and Sew Cox Maze III Procedure in the Current Era?Semin Thorac Cardiovasc Surg. 2018;30(4): 429-436.

[32]Cox JL,Ad N,Churyla A,et al.The Maze Procedure and Postoperative Pacemakers.Ann Thorac Surg. 2018;106(5): 1561-1569.

[33]Zhu KF,Wang YM,Zhu JZ,et al.National prevalence of coronary heart disease and its relationship with human development index:A systematic review. Eur J Prev Cardiol. 2016;23(5): 530-543.

[34]Hothi S,Tan D,MacDonald W,et al.93 Does intervention of severe valve lesions always improve cardiac function.Heart. 2015;101(Suppl 4):A52-A53．

[35]Toktas F,Yavuz S,Ozsin KK,et al.Mitral valve repair for ischemic moderate mitral regurgitation in patients undergoing coronary artery bypass grafting.Saudi Med J. 2016;37(8):853-859．

[36]Nishimura RA,Otto CM,Bonow RO,et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2017;70(2):252-289.

[37]Stulak JM,Dearani JA,Sundt TM,et al.Superiority of cut-and-sew technique for the Cox maze procedure: comparison with radiofrequency ablation.J Thorac Cardiovasc Surg.2007;133(4):1022-1027.