Pulmonary Vein Isolation Vs Cox-mazev For Concomitant Surgical Treatment Of Paroxysmal Atrial Fibrillation In Cabg
Vadim Popov, MD,PhD, Egor Malyshenko, MD, Maxim Anishchenko, MD,PhD, Natalia Popova, MD, Amiran Revishvili, MD, PhD.
A.V. Vishnevsky National Research Center of Surgery, Moscow, Russian Federation.
BACKGROUND: The aim of this study is to assess the efficiency and safety of radiofrequency pulmonary veins isolation (PVI) and "Cox-Maze V" procedure in treatment of paroxysmal AF in CABG.
METHODS: The study includes 139 patients. Inclusion criteria is CAD with history of AF. Exclusion criteria are non-paroxysmal AF, urgent surgery, concomitant valvular heart disease, decompensation of chronic diseases, malignancy. Using propensity score matching patients, who underwent PVI could be matched with 30 patients, who underwent "Cox-Maze V" procedure. The outcomes were evaluated in terms of primary (AF/AFL recurrence, sinus rhythm at the time of discharge and long-term follow up, permanent pacemaker implantation, MACCE) and secondary endpoints. CABG was performed with normothermic perfusion and warm blood hyperkalemic cardioplegia. PVI and «Cox Maze V» procedure were performed before CABG without aortic cross-clamping using parallel perfusion. «Cox Maze V» procedure included bipolar PV ablation on both sides. Superior and inferior box lesions were created through the purse-string in right superior and inferior PV with bipolar clamp. Right atrium ablation included ablation lines down towards the inferior vena cava, RA appendage, cavo-tricuspid isthmus ablation. LAA was occluded in all cases (isolated or amputated by surgical stapler). RESULTS:After the propensity score matching there were no significant differences between CABG + "Cox Maze V" group and CABG + PVI group in operation time (330(310;375) vs 255(225;270)min, р=0,0001), CPB time (131(113;144) vs 89(74;98)min, р=0,0001), time of ablation (53(44;59) vs 10(9;12) min, р=0,0001). Nevertheless, the type and rate of complications in both groups was consistent. Significantly lower rates of AF/AFL recurrence relative to group I was observed in group II (13,3% vs 33,3%, p=0,044). Sinus rhythm was restored in all cases. Incidence of transient sinus dysfunction (less then 5 days) in I and II group was 6,7% and 16,6%, respectively, but this difference was unreliable (р=0,128). In 12 months, cumulative freedom from AF/AFL without AAT was reliably higher in II group comparing with I group: 97% vs 83,5% (р=0,020). Freedom from MACCE was 96,7% in both groups. CONCLUSIONS:"Cox Maze V" procedure in surgical treatment of concomitant paroxysmal AF, increased the CPB time and operation time, but generally, didn’t have a negative impact on postoperative follow up, that shows low traumatism and sufficient safety of the technique. On the other hand, simultaneous CABG +"Cox Maze V" procedure significantly reduced the incidence of AF recurrence comparing with PVI both at in-hospital and medium-long term follow up, that makes it a reasonable option in patients with paroxysmal AF and a high risk of disease progression.
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