Long-Term Outcomes of Mechanical Valve Replacement in Patients With Atrial Fibrillation Impact of the Maze Procedure

• Published in: Circulation (New York, N.Y.) Vol. 125; no. 17; pp. 2071 - 2080
• Main Authors: JOON BUM KIM, JOON SUK MOON, YUN, Sung-Cheol, WAN KEE KIM, JUNG, Sung-Ho, SUK JUNG CHOO, SONG, Hyun, CHEOL HYUN CHUNG, JAE WON LEE
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins 01.05.2012
• Subjects: Adult; Aged; Anticoagulants - adverse effects; Anticoagulants - therapeutic use; Atrial Appendage - surgery; Atrial Fibrillation - drug therapy; Atrial Fibrillation - etiology; Atrial Fibrillation - surgery; Biological and medical sciences; Blood and lymphatic vessels; Cardiology. Vascular system; Cardiovascular Agents - therapeutic use; Catheter Ablation; Combined Modality Therapy; Cryosurgery; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Endocarditis - epidemiology; Endocarditis - etiology; Female; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Kaplan-Meier Estimate; Male; Medical sciences; Microwaves - therapeutic use; Middle Aged; Mitral Valve Insufficiency - complications; Mitral Valve Insufficiency - surgery; Postoperative Complications - epidemiology; Postoperative Complications - etiology; Postoperative Complications - prevention & control; Postoperative Hemorrhage - epidemiology; Postoperative Hemorrhage - etiology; Prospective Studies; Sarcoidosis. Granulomatous diseases of unproved etiology. Connective tissue diseases. Elastic tissue diseases. Vasculitis; Thromboembolism - epidemiology; Thromboembolism - etiology; Thromboembolism - prevention & control; Treatment Outcome; Tricuspid Valve Insufficiency - diagnostic imaging; Tricuspid Valve Insufficiency - etiology; Tricuspid Valve Insufficiency - physiopathology; Tricuspid Valve Insufficiency - prevention & control; Ultrasonography; Ventricular Dysfunction, Left - complications; Ventricular Dysfunction, Left - diagnostic imaging; Ventricular Dysfunction, Left - physiopathology; Human; heart valve prosthesis; Prognosis; Arrhythmia; Prosthesis; Atrial fibrillation; Cardiovascular disease; Heart valve; Ablation; Excitability disorder; valve replacement; Heart disease; Surgery; heart valve prosthesis implantation
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.111.082347

The long-term benefits of the maze procedure in patients with chronic atrial fibrillation undergoing mechanical valve replacement who already require lifelong anticoagulation remain unclear. We evaluated adverse outcomes (death; thromboembolic events; composite of death, heart failure, or valve-related complications) in 569 patients with atrial fibrillation-associated valvular heart disease who underwent mechanical valve replacement with (n=317) or without (n=252) a concomitant maze procedure between 1999 and 2010. After adjustment for differences in baseline risk profiles, patients who had undergone the maze procedure were at similar risks of death (hazard ratio, 1.15; 95% confidence interval, 0.65-2.03; P=0.63) and the composite outcomes (hazard ratio, 0.82; 95% confidence interval, 0.50-1.34; P=0.42) but a significantly lower risk of thromboembolic events (hazard ratio, 0.29; 95% confidence interval, 0.12-0.73; P=0.008) compared with those who underwent valve replacement alone at a median follow-up of 63.6 months (range, 0.2-149.9 months). The effect of superior event-free survival by the concomitant maze procedure was notable in a low-risk EuroSCORE (0-3) subgroup (P=0.049), but it was insignificant in a high-risk EuroSCORE (≥4) subgroup (P=0.65). Furthermore, the combination of the maze procedure resulted in superior left ventricular (P<0.001) and tricuspid valvular functions (P<0.001) compared with valve replacement alone on echocardiographic assessments performed at a median of 52.7 months (range, 6.0-146.8 months) after surgery. Compared with valve replacement alone, the addition of the maze procedure was associated with a reduction in thromboembolic complications and improvements in hemodynamic performance in patients undergoing mechanical valve replacement, particularly in those with low risk of surgery.