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Does Cryomaze Injure The Circumflex Artery? A Preliminary Search For Occult Post-Procedure Stenoses
Faisal H. Cheema1, Mohammad B. Pervez2, Mansoor Mahmood2, Muhammad J. Younus2, Mohammad B. Munir2, Gianluigi Bisleri2, Fabio Barili2, Ivan L. Ayala3, Niv Ad4, James L. Cox5, Harold G. Roberts, Jr6.
1College of Physicians & Surgeons of Columbia University - New York Presbyterian Hospital, New York, NY, USA, 2Aegis Cardiovascular Research Foundation, Fort Lauderdale, FL, USA, 3Atlantic Coast Radiology, Sunrise, FL, USA, 4Fairfax Hospital, Falls Church, VA, USA, 5Washington University School of Medicine, LaGrange, KY, USA, 6Aegis Cardiovascular Research Foundation & Holy Cross Hospital, Fort Lauderdale, FL, USA.
OBJECTIVE: Concerns of circumflex artery injury have been expressed during the epicardial application of the cryoprobe over the coronary sinus as the artery courses on the posterior surface of the sinus in the atrioventricular (AV) groove. The objective of this study was to analyze the incidence of significant injury to the circumflex artery in patients undergoing the cryomaze procedure.
METHODS: Between Sep. 2004 and Dec. 2009, 223 patients underwent argon based cryoablation [120 sec application at -150°C]. After WIRB approval, 20 consecutive patients with normal preoperative coronary angiograms [coronary artery disease: none; right dominance: 75%, left: 15% and 10% co-dominant circulation] were enrolled. Mean age was 60.7 years, 35% were male and 50% had NYHA III/IV. Average AF duration was 23 months (65% were paroxysmal). Ten percent (n=2) had primary cryomaze, 40% (n=8) had cryomaze plus mitral valve repair and 50 (n=10) had 2 or more concomitant valvular procedures. Sixteen patients underwent biatrial and four had left-sided only cryomaze. All consented patients prospectively underwent a 24-hour Holter monitor, ECG stress test and a CT angiogram.
RESULTS: At discharge, 75% had normal sinus rhythm while 25% patients were paced. On follow up at 19.5 months Holter showed AV synchrony (18 in sinus rhythm, 1 paced) in all patients save an incidental finding of junctional rhythm in 1 patient who converted to AV synchrony after subsequent pacemaker implantation. Stress test (n=18) was negative in all patients. On CT angiogram 95% patients had completely patent circumflex artery. Significant stenosis was seen in only 1 patient (right dominant circulation) with a 30-40% tubular stenosis of circumflex artery. However, this lesion corresponded to the P1 area of the mitral annulus, and was significantly proximal to the P3 area where the cryoprobe was applied during the cryomaze procedure.
CONCLUSIONS: Barring one case of partial circumflex stenosis, likely due to the on-going normal progression of coronary artery disease, these data derived from a limited prospective trial suggest that epicardial application during the cryomaze procedure does not cause any anatomic or physiological compromise of the circumflex artery.
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