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Clinical benefits of concomitant surgical ablation for atrial fibrillation in patients undergoing mitral valve surgery

  • Author Footnotes
    1 Dr Hee Jung Kim and Dr Hyung-Do Han contributed equally to this work as first author.
    Hee Jung Kim
    Footnotes
    1 Dr Hee Jung Kim and Dr Hyung-Do Han contributed equally to this work as first author.
    Affiliations
    Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Korea University, Seoul, Korea
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  • Author Footnotes
    1 Dr Hee Jung Kim and Dr Hyung-Do Han contributed equally to this work as first author.
    Kyung-Do Han
    Footnotes
    1 Dr Hee Jung Kim and Dr Hyung-Do Han contributed equally to this work as first author.
    Affiliations
    Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
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  • Wan Kee Kim
    Affiliations
    Department of Thoracic and Cardiovascular Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Korea
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  • Yang Hyun Cho
    Affiliations
    Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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  • Seung-Hyun Lee
    Correspondence
    Address reprint requests and correspondence: Dr Seung-Hyun Lee, Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno, Seodaemun-gu, Seoul 03722, Korea.
    Affiliations
    Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
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  • Hyung Gon Je
    Affiliations
    Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan University College of Medicine, Yangsan, Korea
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  • Author Footnotes
    1 Dr Hee Jung Kim and Dr Hyung-Do Han contributed equally to this work as first author.
Published:September 21, 2022DOI:https://doi.org/10.1016/j.hrthm.2022.09.014

      Background

      The maze procedure is the dominant concomitant surgery performed with mitral valve (MV) surgery in patients with atrial fibrillation (AF). Most clinical recommendations regarding the maze procedure depend on the individual maze expert centers.

      Objective

      The purpose of this study was to evaluate the clinical benefits of the maze procedure during MV surgery in a national cohort.

      Methods

      Using the national health claims database established by the National Health Insurance Service of South Korea, data on subjects with AF who had undergone MV surgery from 2009 to 2017 were reviewed. The outcomes of interest were mortality; occurrence of ischemic or hemorrhagic stroke; hospitalization for bleeding events; and the composite of death, cerebrovascular accident, and major bleeding. Propensity score (PS) matching was performed for baseline adjustment.

      Results

      Among 9501 subjects, the maze procedure was performed in 5508 (58.0%). In the PS-matched cohort (3376 pairs), the risk of the composite event was significantly lower in the maze group (hazard ratio [HR] 0.799; 95% confidence interval [CI] 0.731–0.873) than in the nonmaze group. The superiority of the maze procedure was similar for individual clinical events, including death (HR 0.795; 95% CI 0.711–0.889); ischemic stroke (HR 0.788; 95% CI 0.67–0.926); and major bleeding (HR 0.749; 95% CI 0.627–0.895), but not for hemorrhagic stroke (HR 0.984; 95% CI 0.768–1.262). In subgroup analyses of the composite events, these benefits were consistent among subjects aged ≥70 years or <70 years, surgery type (replacement vs repair), MV pathologies, and subjects with CHA2DS2-VASc score ≥4 or <4.

      Conclusion

      The addition of the maze procedure during MV surgery provided protective effects in the composite outcome of interest.

      Keywords

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      Linked Article

      • Cheating death in a maze of surgical ablation data
        Heart Rhythm
        • Preview
          Atrial fibrillation (AF) is encountered in 16%–50% of patients with mitral valve disease and is associated with greater disease severity and mortality with either medical or surgical management of the valve disease.1 In addition to being a marker for disease severity, AF could contribute to adverse outcomes due to systemic emboli, impaired cardiac performance, and risks of AF therapies. Surgical treatment of mitral valve disease combined with a Maze procedure to restore sinus rhythm and removal or occlusion of the left atrial appendage (LAA) can address some of these risks.
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