• Journal of Chest Surgery
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• v.33 no.11
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• pp.876-880
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• 2000

배경: Maze수술은 승모판 질환에 동반되는 심방세동의 효과적인 치료방법으로 알려져있다. 이 연구는 승모판 수술과 심방세동 수술을 동시에 시행한 환자에서 심방세동 수술 후 중기적인 결과와 그 재발 여부를 조사하였다. 대상 및 방법: 심방세동 수술과 승모판 수술을 받은 11예의 환자(10예는 류마티스성 승모판 질환)를 대상으로 하였다. Maze II 수술 및 그 변형수술을 6예에서 시행했고, Maze III 수술 및 그 변형수술을 5예에서 시행하였다. 심방세동 수술 후 좌심방의 수축정도를 심방세동 수술 없이 승모판 수술만으로 동율동을 얻은 경우와 비교하였다. 결과: Maze II 수술을 받은 환자 6예 중 5예(83.3%)에서, maze III 수술을 받은 환자 5예 모두에서 동율동을 회복하였다(전체적으로 90.9%). 전자의 1예(20%)와 후자의 2예(40%)에서 수술 후 각각 23, 2, 13개월만에 심방세동이 재발하였다. 그 후 다시 2예는 동율동으로 전환되었으나, 1예는 재발된 심방세동을 그대로 유지하고 있다. 변형술을 받은 3예에서는 심방세동의 재발이 없었다. Maze 수술 후 4예(40%)에서만 좌심방의 수축기능을 보였으며, maze 수술 후 좌심방 수축 정도(승모판의 A파의 속도)도 maze 수술 없이 승모판 수술과 항부정맥제 투여로 동율동을 회복한 경우보다 낮았다. 결론: 심방세동을 동반한 승모판 수술 환자에서 maze 수술로써 심방세동으로부터 동율동을 회복할 수 있으나 중기적으로 재발할 수 있으며, maze 수술 후 좌심방 수축정도는 상당히 떨어질 수 있다고 생각된다.

• Journal of Chest Surgery
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• v.33 no.11
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• pp.881-885
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• 2000

배경: 승모판막 질환에 동반된 심방세동의 경우 그 기간이 길면 승모판막 질환을 수술하여도 동성 율동으로 전환될 가능성이 매우 적다. 본 연구는 승모판막 질환에 동반된 심방세동에 대한 변형 Maze 수술후 장기 결과와 심방세도의 재발에 미치는 요인을 조사 하고자 하였다. 대상 및 방법: 1990년부터 1996년까지 승모판막 질환과 동반된 심방세동으로 외과적 요법을 시행받은 35명의 환자를 대상으로 하였다. 심방세동의 평균 유병기간은 평균 7.7$\pm$4.5년이었고 수술은 승모판막 대치술 34례(재수술 3례)와 승모판막 성형술 1례를 시행하였고 승모판 질환 수술 외에 동반 수술로는 삼첨판륜 성형술 4례, 삼첨판막 대치술 3례 였다. 심 방세동에 대한 수술은 좌측 폐정맥 부위는 격리하지 않는 변형 Maze 수술을 시행하였다. 수술 후 동성 율동으로 회복여부, 심방세동의 재발에 미치는 요인과 장기 결과를 분석하였다. 결과: 수술 직후 2례를 제외한 33례(93.9%)에서 동성율동으로 돌아왔으나 수술 후 퇴원 전에 12례에서 심방세동이 재발되었다. 수술환자중 1례에서 수술 후 3일에 동성 정지에 따른 심정지가 발생하여 소생되었으나 뇌손상으로 수술 후 15일에 사망하였다. 심방세동이 재발된 경우 수술 후 약 2개월에서 6개월 사이에 항부정맥 약물(mquinidine)과 전기적 제세동으로 치료하여 12례중 10례에서 동성 율동으로 돌아온 환자는 항부정맥 약물을 모두 중단하 였으며, 수술 후 3년에서 9년(평균 71.1$\pm$17.5개월) 추적 관찰 중 9례에서 심방세동이 재발되어 장기간 동성 율동이 유지된 환자는 34명중 25명으로 73.5%이었다. 승모판 질환이 있던 환자에서 수술 후 심방세동의 재발에 미치는 요인들을 조사한 결과 수술전 심방세동의 기간(동성율동 유지군 : 재발군=6.3년 : 10.3년, P=0.008)과 수술 전 단순 흉부 X선상 심흉비율(0.58 : 0.72, p=0.009)은 통계학적으로 유의하게 나타났으나 심초음파 검사상 좌심방의 직경(57.2mm : 77.4mm, p=0.106)은 통계학적 유의성이 없었다. 결론: 심방세동이 있는 환자에서 동반 질환 수술시 병행하여 수술한다면 정상 동성 율동으로 회복될 기회를 증가시킬 수 있는 유용한 수술법으로 생각된다. 그러나 수술후 재발률을 감소시키기 위하여 적절한 술기의 변형에 대한 연구와 약물요법의 병행을 고려하여야 할 것으로 사료된다.

• Journal of Chest Surgery
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• v.29 no.6
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• pp.599-605
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• 1996

A total of 249 patients undergoing isolated coronary revascularization were studied for the occurrence of postoperative atrial fibrillation(AF). Possible associations of this arrhythmia with various preoperative, intraoperative and postoperative factors were studied by univariate and multivariate analysis. The overall incidence of postoperative AF was 15%, with the median time occurence of 48 hours(mean time : 59.1 $\pm$ 56.9 hours) after arrival to the intensive care unit. Cardiac index decreased significantly after occurence of AF(p=0.001). There were no in-hospital complications in those patients with AF. Univariate studies indicated preoperative ejection fract on(EF), triglyceride level, postoperative peak CKMB isoenzpme and atrial pacing to be the dominant factor promoting postoperative AF, with an increasing prevalence in lower EF(p=0.025), triglyceride(p=0.006) and peak CKMB isoenzyme(p=0.002), and in patients with atrial pacing(p=0.001). Hospital stay(p=0.001) and late mortality(p=0.003) were significantly increased in patients with postoperative AF Multivariate analysis showed that body weight and postoperative atrial pacing to be the dominant factor promoting postoperative AF, with an increasing prevalence in over- weight patients(p=0.011) and patients with atrial pacing(p=0.001). Both univariate and multivariate analy- sis showed that the age was not a significant factor but tended to promote postoperative AF respectively (p=0.053, 0.064). After 30.1 $\pm$ 11.4 months gfollow-up, those patients with AF had sinus rhythm. We think that we must try to prevent postoperative AF after ccoronary artery bypass grafting because of its deleterio s hemodynamic effect, prolonged hospital stay, and increased late mortality.

• Journal of Chest Surgery
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• v.41 no.3
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• pp.313-319
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• 2008

Background: The Cox maze-III procedure is considered as the most effective surgical treatment for atrial fibrillation. Because this procedure takes a long time and it complicates the concomitant cardiac surgery, some surgeons perform a left atrial maze procedure or pulmonary vein isolation only to reduce the operation time. This study was performed to evaluate how the modified procedures, with using cut-and-sew techniques, can influence the treatment of atrial fibrillation. Material and Method: Between Feb 1999 and June 2005, 40 patients (17 males and 23 females) with organic heart disease and atrial fibrillation underwent the Cox maze-III procedure (23), the left atrial maze procedure (10) or pulmonary vein isolation (7). The cut-an-sew technique was used to ablate the atrial wall, but cryoablation was used instead of the cut-and-sew technique for the coronary sinus and the inferior wall between the pulmonary vein and the mitral annulus. Result: After a mean follow-up period of $50.0{\pm}21.6$ months, all (100%) of the 23 patients who underwent the Cox maze-III procedure had regular sinus or atrial rhythm conversion, and 7(70%) of 10 with a left atrial maze procedure and 4(57.1%) of 7 with pulmonary vein isolation had regular sinus or atrial rhythm conversion (p=0.002). Conclusion: To obtain a high conversion rate from atrial fibrillation to a regular sinus rhythm or a regular atrial rhythm, the standard Cox maze-III procedure should be performed in both atria. The limited modified procedures like the left atrial maze procedure or pulmonary vein isolation may reduce the cure rate of atrial fibrillation.

• Journal of Chest Surgery
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• v.40 no.2 s.271
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• pp.90-96
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• 2007

Background: Postoperative atrial fibrillation is the most frequently arrhythmic complication associated with coronary artery bypass graft surgery. This study was designed to investigate the incidence of atrial fibrillation in patients undergoing OPCAB and on-pump CABG and to identify the risk factors associated with its development. Material and Method: 247 consecutive patients were evaluated among 306 patients who underwent the coronary artery bypass graft surgery between January, 2002 and December, 2005. 178 patients underwent OPCAB (OPCAB group) and 69 patients underwent On-pump CABG (On-pump CABG group). The incidence and the risk factors of atrial fibrillation in two groups were determined. Result: There were no significant differences between two groups with respect to the preoperative demographic characteristics of the patients. The incidences of postoperative atrial fibrillation were 25 cases (14%) in OPCAB group and 15 cases (21%) in On-pump CABG group. Age over 65 years, net positive fluid imbalance for postoperative 3 days, and chest tube bleeding for postoperative 3 days were independent predictive factors in OPCAB group. Age over 65 years and net positive fluid imbalance for postoperative 3 days were independent predictive factors in On-pump CABG group. In multivariate analysis, age over 65 years was the only risk factor of postoperative atrial fibrillation in both groups. Conclusion: Atrial fibrillation is a common complication after procedures of myocardial revascularization. There wasn't a low incidence of postoperative atrial fibrillation in OPCAB, compared with On-pump CABG. Age over 65 years was associated with postoperative atrial fibrillation irrespective of the use of cardiopulmonary bypass.

• Journal of Chest Surgery
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• v.37 no.7
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• pp.609-612
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• 2004

Even though the Cox-Maze III procedure is the gold standard in the therapy for atrial fibrillation (AF) and its outcome is excellent, the complexity of the operation, longer cardiopulmonary bypass time and the risk of bleeding have tended to dissuade cardiac surgeons from its application. The recent data of the pathogenesis of AF and the development of alternative energy sources have facilitated the development of the modified Cox-Maze procedure rapidly. We reported that atrial fibrillation was conversed to sinus rhythm by the epicardial microwave ablation without cardiopulmonary bypass and the normal sinus rhythm was observed during 33 months of follow-up period.

• Journal of Chest Surgery
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• v.31 no.1
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• pp.59-65
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• 1998

Atrial fibrillation is the most common of all cardiac arrhythmias. It is associated with significant morbidity and mortality and is frequently resistant to medical therapy. On the experimental and clinical study, the presence of macroreentrant circuits and the absence of either microreentrant circuits or evidence of atrial automaticity suggests that atrial fibrillation should be amenable to surgical ablation. The results of the maze III procedure are associated with a higher incidence of postoperative sinus rhythm, improved long-term sinus node function, fewer pacemaker requirements, less arrhythmia recurrence, and improved long-term atrial transport function. We had experienced 4 patients with chronic atrial fibrillation. For the first time, Hioki procedure had been performed in the first patient with ASD and atrial fibrillation, regular sinus rhythm showed on postoperative EKG, but junctional rhythm and bradycardia developed postoperative 3 years. The maze III procedure for the rest with mitral valvular disease and atrial fibrillation had been done, followed by regular sinus rhythm for 2 patients and atrial fibrillation for 1 patient, managed with amiodarone, on immediate postoperative state. Echocardiogram documented good contraction of right atrium and hardly contraction of left atrium for 2 patients with regular sinus rhythm postoperative 3 months.

• Journal of Chest Surgery
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• v.31 no.7
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• pp.668-673
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• 1998

During the past several years, the maze operation has become the most effective method of treatment for chronic atrial fibrillation. When the maze procedure is done concomittantly with other cardiac operations, surgeons, in their initial experiences, may be concerned about the additional operative risks and uncertainty of the results. We performed the Cox-maze III procedure in six cases of chronic atrial fibrillation associated with mitral, mitral & aortic, or coronary arterial disease. Maze III procedure was done with open mitral commissurotomy(3 cases), mitral valve replacement(1 case), aortic and mitral valve replacement(1 case), and two-vessel coronary bypass graft(1 case). In spite of rather prolonged aortic cross clamp time, cardiac recovery was uneventful in all cases. No cases required reexploration for postoperative bleeding. All patients showed regular sinus rhythms immediate or between 2 and 20 days postoperateratively. Transient postoperative supraventricular arrhythmarias were easily controlled by various antiarrhythmic agents. In follow up evaluations, all cases showed regular sinus rhythm on ECG and the right and left atrial transport function was confirmed by Doppler echocardiography in all except one. Though our experience was limited in case number, the Cox-maze III procedure was effective in controlling the chronic atrial fibrillation without serious additional operative risks.

• Journal of Chest Surgery
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• v.42 no.6
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• pp.710-718
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• 2009

Background: The Cox maze procedure has been used as a standard surgical treatment for atrial fibrillation for about 20 years. Recently, the creators have used a bipolar radiofrequency electrode (Cox maze IV procedure) instead of the incision and suture (cut-sew) technique to make atrial ablation lesions for persistent atrial fibrillation. We investigated clinical outcomes for the Cox maze procedure with a bipolar radiofrequency electrode and cryoablator in patients with persistent atrial fibrillation, and compared results with clinical outcomes of the cut-sew procedure. Material and Method: Between April 2005 and July 2007, 40 patients with persistent atrial fibrillation underwent Cox maze IV procedure with a bipolar radiofrequency electrode and cryoablator (bipolar radiofrequency group). Surgical outcomes were compared with those of 35 patients who had the cut-sew technique for the Cox maze III procedure. All patients had concomitant cardiac surgery. Postoperatively, the patients were followed up every 1 to 2 months. Result: At 6 months postoperatively, the conversion rate to regular sinus rhythm was not significantly different between the two groups: 95.0% for the bipolar radiofrequency ablation group; 97.1% for the cut-sew technique (p=1.0). At the end of the follow-up period, the conversion rate to regular sinus rhythm was also not significantly different (92.5% vs. 91.6%, p=1.0). In multivariate analysis using a Cox-regression model, the postoperative atrial dimension was an independent determinant of sinus conversion in the bipolar radiofrequency ablation group (hazard ratio 31, p=0.005). In the Cox-regression model for both groups, atrial fibrillation at 6 months postoperatively (hazard ratio 92.24, p=0.003) and the postoperative left atrial dimension (hazard ratio 16.05, p=0.019) were independent risk factors of continuance or recurrence of atrial fibrillation after Cox maze procedures. Aortic cross-clamp time and cardiopulmonary bypass time were significantly shorter in the radiofrequency group than in the cut-sew group. Conclusion: In the Cox maze procedure for patients with persistent atrial fibrillation, the use of bipolar radiofrequency ablation and a cryoablator is as good as the cut-sew technique for conversion to sinus rhythm. The postoperative left atrial dimension is an independent determinant of postoperative continuance and recurrence of atrial fibrillation.

• Journal of Chest Surgery
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• v.32 no.4
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• pp.347-352
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• 1999

Background: The atrial fibrillation in patients with mitral valvular heart disease is frequently converted to sinus rhythm after the mitral valve surgery. This sinus restoration implies an important meaning in that it not only helps postoperative convalescence in patients with unstable hemodynamics but also reduces the rate of postoperative thromboembolism. Material and Method: We retrospectively analyzed 184 patients who received mitral valve surgery from June 1986 to December 1996 to investigate the trend of rhythm change following mitral valve surgery and thus to clarify the predisposing factors of postoperative sinus rhythm conversion and its maintenance. Result: The sinus rhythm was restored after the operation in 54 out of 139 patients with atrial fibrillation preoperatively(38.8%). However, the atrial fibrillation recurred in 41 patients at the time of discharge showing a recurrence rate of 75.9 percent. The mean duration of sinus rhythm in patients with eventual atrial fibrillation recurrence was 8.2${\pm}$5.9 days. Only 15 patients were in sinus rhythm at the time of late follow-up with the mean follow-up period of 84.4${\pm}$34.7 months. While the age, duration of symptoms, duration of atrial fibrillation, left atral size, and pulmonary artery pressure were thought to be the predisposing factors for sinus conversion after the operation, only the duration of atrial fibrillation and ejection fraction were considered risk factors for the recurrence of the atrial fibrillation following sinus conversion. Conclusion: This study suggests that the early operation is mandatory for the satisfactory result regarding postoperative rhythm. Moreover, additional operative measure in adjunct to the intervention of mitral valve should be considered for the maintenance of restored sinus rhythm as reflected by high postoperative recurrence rate of atrial fibrillation.