Skip to main content
Download PDF
Download ePub
  • Research article
  • Open access
  • Published:

The occurrence and risk factors of bradycardia after the Maze procedure in patients with atrial fibrillation and tricuspid regurgitation

Journal of Cardiothoracic Surgery volume 16, Article number: 270 (2021) Cite this article

Abstract

Objective

To evaluate the occurrence and risk factors of bradycardia after the Maze procedure in patients with atrial fibrillation and tricuspid regurgitation.

Methods

All patients underwent mitral valve (MV) replacement and concomitant bi-atrial cut-and-sew Maze procedure along with other cardiac surgical procedures were recruited from the Department of Cardiovascular Surgery at the First Affiliated Hospital of Medical College of Xi'an Jiaotong University. According to the severity of tricuspid regurgitation, all patients were divided into mild tricuspid regurgitation group and moderate-to-severe tricuspid regurgitation group. The general clinical data, biochemical indexes, intraoperative and postoperative data were collected. The relationship between tricuspid regurgitation and sinus bradycardia after the Maze procedure was analyzed by multivariate logistic regression model.

Results

We enrolled 82 patients, including 24 males and 58 females. The patients had an average age of 56 ± 10 years old. There were 50 cases in mild tricuspid regurgitation group and 32 cases in moderate-to-severe tricuspid regurgitation group. Compared with the mild tricuspid regurgitation group, postoperative bradyarrhythmia (41% vs. 14%), pre-discharge bradyarrhythmia (63% vs. 14%), postoperative sinus bradycardia (34% vs. 10%) and pre-discharge sinus bradycardia (63% vs. 10%) in moderate-to-severe tricuspid regurgitation group were significantly increased (P < 0.01). In moderate-to-severe tricuspid regurgitation, the risk of sinus bradycardia increased after the Maze procedure (OR = 1.453, 95% CI 1.127–1.874), area under ROC curve was 0.81, the Jordan index was 0.665.

Conclusion

The severity of tricuspid regurgitation may be an important factor affecting sinus bradycardia after the Maze procedure. It can be considered as a factor to predict sinus bradycardia after the Maze procedure.

Peer Review reports

Introduction

Atrial fibrillation (AF) is one of the most common arrhythmias clinical practice. The incidence of AF increases with age. Atrial fibrillation is common in patients with valvular disease, which could further cause thromboembolism or even heart failure, seriously affecting the patient's quality of life, leading to high disability and mortality rates [1]. The Cox-Maze procedure (MP) is a well-established method of rhythm control in patients with AF, which has shown similar efficacy in patients with AF associated with valvular disease, coronary disease, or congenital heart disease compared with that in patients with AF alone [2,3,4]. In recent years, bipolar radiofrequency ablation, also known as Cox-Maze IV procedure (CM-IV), is widely used in the surgical treatment of AF [5,6,7]. However, the development of symptomatic bradyarrhythmia is a major complication of Cox-Maze IV procedure, which can lead to fatal or necessitate pacemaker implantation. Previous studies have reported a wide incidence of bradyarrhythmia with 2 to 21% during short-term follow-up after surgery [8,9,10]. Age, extended lesion set, and microwave energy source were identified as predictors of sinus node dysfunction or bradyarrhythmia. Sinus bradycardia (SB) has been shown to be the main type of bradyarrhythmia [8, 11,12,13].

Tricuspid regurgitation (TR) may be present in 10 to 50% of patients with mitral valve regurgitation or stenosis, or both, as well as other left-sided valve lesions [14,15,16]. It remains unknown that whether TR severity affects the incidence of SB after the Maze procedure. Therefore, we conducted this study to investigate the effect of the severity of TR on the incidence of SB in patients with atrial fibrillation after the Maze procedure.

Methods

Patients

All patients underwent the Cox-Maze IV procedure for persistent AF combined with TR between January 2015 and November 2020 were included. Patients with previous history of surgical cardiac surgery, paroxysmal atrial fibrillation along with sinus bradycardia, permanent pacemaker (PPM) implantation before the Cox-Maze IV procedure, malignant tumors, hematological diseases, severe liver and kidney diseases, children and pregnant women were excluded. All patients in this study had persistent AF, which was defined as continuous AF with more than 1 month duration before the Cox-Maze IV procedure and not self-terminating, in which cardioversion had not been indicated. Twelve-lead electrocardiographic (ECG) evidence of AF was checked at two or more separate visits at least 1 month after the operation date. This retrospective study was approved by our institutional review board, and the informed consent requirement could be avoided (No. XJTU1AF2020LSK-078).

Surgical treatment

All patients underwent mitral valve (MV) replacement and concomitant bi-atrial cut-and-sew Maze procedure along with other cardiac surgical procedures at the discretion of cardiac surgery specialist. The decision on performing a tricuspid valve (TV) surgical intervention was made by cardiac surgery team, on the basis of the preoperative echocardiographic findings as well as on-site findings in the operation room.

Study outcomes and definition

The outcome of this study was bradycardia development, the primary outcome was SB, defined as symptomatic sinus bradycardia associated with documented sinus exit block, pause, or arrest in any type of electrocardiographic data, including Twelve-lead ECG, Holter monitoring, or telemetry record. Transient asymptomatic postoperative junctional rhythm was not counted as a clinical event. The rate of high-degree atrioventricular block (AVB) and PPM implantation were defined as secondary outcomes.

The general clinical data, biochemical indexes, intraoperative and postoperative data were collected. According to the severity of TR, patients were divided into mild TR group and moderate-to-severe TR group. The occurrence of bradycardia including SB after the Cox-Maze IV procedure and the effect of TR and other effect factors on SB were evaluated.

Definition of tricuspid regurgitation

The severity of TR was graded following previous study (Table 1) [2, 17]. The left ventricular ejection fraction (LVEF) was determined by simplified Simpson method, and the left ventricular end-diastolic diameter (LVEDD) was measured by M type ultrasound (Table 1).

Table 1 Recommendations for the echocardiographic assessment of tricuspid regurgitation: a summary from review of Arsalan M and the European Association of Cardiovascular Imaging
Full size table

Postoperative follow-up

Postoperative ECG was used to determine the presence of AF. ECG was continuously monitored during the patient’s stay in the intensive care unit, and the standard twelve-lead ECG was checked daily during the postoperative hospital stay. To evaluate cardiac function and the recovery of the atrial contraction, transthoracic echocardiography (TTE) was performed before discharge.

Statistical analysis

All data were presented as frequencies and percent ages or mean ± standard deviant (SD). Differences between two groups were compared using unpaired Student’s t tests or Mann–Whitney U test for continuous variables and χ2 test for categorical variables. For laboratory results, we also assessed whether measurements were outside the normal range. All statistical analyses were performed using IBM Statistics 26. A two-tailed value of P < 0.05 was considered as statistically significant.

Results

Basic characteristics

Between January 2015 and November 2020, a total of 82 patients, including 24 men and 58 women were enrolled and had an average age of 56 ± 10 years old. All patients were divided into mild TR group and moderate-to-severe TR group, there were 50 cases in mild TR group and 32 cases in moderate-to-severe TR group.

Furthermore, according to whether SB occurs after the Maze procedure. The patients were divided into the patients with SB group and patients without SB group, there were 26 cases in the patients with SB group and 56 cases in patients without SB group. All patients underwent mitral valve (MV) replacement. The bi-atrial MP was performed in 82 patients. AV replacement was performed in 15 patients (18.3%), and left atrial volume reduction was performed in 28 patients (34.1%). Concomitant TV surgery was performed in 64 patients (78.0%), most of whom underwent TV repair (n = 60, 75.6%).

SB after the Maze procedure

Within 1 h after operation, SB and AVB occurred in 16 (19.5%) and 1 (1.2%) patient, respectively. PPM was implanted in 3 patients (3.7%) with SB and in 1 patient (1.2%) with AVB. Compared with the mild TR group, moderate-to-severe TR group had a higher incidence of bradyarrhythmia (41% vs. 14%) and SB (34% vs. 10%) after the Maze procedure. Moreover, these patients also had a higher incidence of bradyarrhythmia (63% vs. 14%) and SB (63% vs. 10%) development before discharge compared with the mild TR group (P < 0.01, Table 2). The pulmonary systolic blood pressure of the patients with moderate-to-severe TR were significantly higher than those with the mild TR (41.75 ± 12.39 mmHg vs. 35.76 ± 9.04 mmHg) (P < 0.05, Table 3).

Table 2 Comparison of clinical characteristics according to the severity of TR in patients
Full size table
Table 3 Comparison of intraoperative and postoperative characteristics according to the severity of TR in patients
Full size table

Comparison of clinical date between patients with SB and without SB

The clinical data of patients with SB (n = 26) were compared with those of patients without SB (n = 56). Patients with SB were characterized by higher prevalence of hypertension (23% vs. 7%) and pulmonary systolic blood pressure (42.23 ± 11.08 mmHg vs. 36.57 ± 9.17 mmHg), larger tricuspid regurgitation area [6.2 (5.38–8.68) cm2 vs. 2.55 (1.5–4.5) cm2], longer hospital stay [22 (17.8–28) d vs. 19.5 (15–23) d], shorter operation time [240 (198–260) min vs. 255 (199–309) min] and ventilator assisted time (0.9 ± 0.5 d vs. 1.2 ± 0.7 d), lower the total amount of amiodarone before discharge [4.75 (2–6.28) g vs. 5.85(4.6–7.58) g] than those without SB (P < 0.05, Tables 4 and 5).

Table 4 Comparison of clinical characteristics according to whether SB development in patients
Full size table
Table 5 Comparison of intraoperative and postoperative characteristics according to whether SB development in patients
Full size table

The association of TR and SB after the Maze procedure

We analyzed the relationship between tricuspid regurgitation and SB after the Maze procedure by multivariate logistic regression model. In moderate-to-severe TR group, risk of SB increased after the Maze procedure (OR = 1.453, 95% CI 1.127–1.874, Table 6). Area under ROC curve was 0.81, the predictive sensitivity was 80.8%, the specificity was 85.7% (Fig. 1), the accuracy was 84.1%, the Jordan index was 0.665, the positive predictive value was 78.8% and the negative predictive value was 87.8%.

Table 6 Predictors of recurrent SB after MP
Full size table
Fig. 1
figure 1

Roc curve of tricuspid regurgitation area in predicting sinus bradycardia after operation

Full size image

Discussion

Cox-Maze IV is considered as an effective treatment on the control of AF. SB is a major complication of Cox-Maze IV. Most previous studies have focused on the efficacy of the MP. However, data about safety outcomes, especially the natural course from a chronological viewpoint, are lacking, and there are few studies on the occurrence rate and risk factors of SB after the Maze procedure [18, 19]. Whether TR was associated with the occurring of SB after MP is still unknown. Cho et al. [8] has evaluate the incidence of sick sinus syndrome (SSS) after the Maze procedure with mitral valve surgery, and showed only that the proportion of moderate-to-severe TR were different between patients with SSS and patients without SSS.

This retrospective analysis focused on the evaluation on the occurrence of bradycardia after the Maze procedure in patients with AF and TR. The effect of TR and other factors on bradycardia was also investigated. Firstly, according to severity of TR, We found that patients with moderate-to-severe TR had a higher incidence of bradyarrhythmia than those with the mild TR after the Maze procedure, and had a higher incidence of bradyarrhythmia and SB than those with the mild TR before discharge. The pulmonary systolic blood pressure of the patients with moderate-to-severe TR was significantly higher than those with the mild TR. Thus, we suspect that the possible mechanism is that AF causes the atrial muscle to lose normal electrophysiological conduction, atrial activity disorder, blood inability to fill and expel, blood stasis in the atrium, leading to atrial enlargement, tricuspid annulus retraction and dilatation, and right ventricular enlargement. With further expansion of the right ventricle, tricuspid leaflets are incompatibility and regurgitation also aggravate [20,21,22,23,24]. With the progress of the disease, pulmonary hypertension was induced, the level of 5-HT increased in the pulmonary circulation, which caused pulmonary vasoconstriction, exacerbation of fibrosis and remodeling of the right heart system, resulting in sinus node dysfunction, autonomic nervous tension imbalance, jugular vein irritation, gastrointestinal dysfunction and other complications, while jugular vein irritation, gastrointestinal dysfunction could cause autonomic nervous dysfunction, and these further decrease sinus node function [25, 26].

Most previous studies thought that age, extended lesion, and microwave energy source were identified as predictors of sinus node dysfunction or SB, however, these observations are insufficient to change the clinical practice [8, 11,12,13]. Our study has used a fixed microwave energy source, excluded the confounding factors including age and cardiac enlargement, to investigate other factors affecting the incidence of SB after the Maze procedure. According to whether SB occurred after the Maze procedure, the patients were divided into the patients with SB and patients without SB. Interestingly, comparing with the patients without SB, pulmonary systolic blood pressure and tricuspid regurgitation area significantly increased in the patients with SB. Furthermore, the multivariate logistic regression showed that the severity of TR is an important factor affecting the incidence of SB after the Maze procedure.

Because it was a retrospective study, all patients underwent preoperative ultrasound evaluation. Patients with mild tricuspid regurgitation underwent left ventricular valve replacement during operation. Tricuspid valvuloplasty was performed in patients with high-risk factors such as atrial fibrillation or tricuspid valve ring diameter greater than 40 mm.

There were some limitations in this study. The sample size is too small. The study groups are not matched or adjusted. There are unaccountable selection biases without precising detailed rhythm status and preoperative rhythm medication of the patients. Whether TV repair in the setting of MAZE procedure could decrease the occurrence of SB, AVB or PPI is worth to be further investigated.

Conclusion

In conclusion, severity of TR was considered as an indicator for the incidence of SB after the Maze procedure.

Availability of data and materials

Not applicable.

Abbreviations

AF:

Atrial fibrillation

MP:

Maze procedure

CM-IV:

Cox-Maze IV

SB:

Sinus bradycardia

TR:

Tricuspid regurgitation

PPM:

Permanent pacemaker

ECG:

Electrocardiographic

MV:

Mitral valve

TV:

Tricuspid valve

AVB:

Atrioventricular block

LVEF:

Left ventricular ejection fraction

LVEDD:

Left ventricular end-diastolic diameter

TTE:

Transthoracic echocardiography

SD:

Standard deviant

MV:

Mitral valve

SSS:

Sick sinus syndrome

References

  1. O’Neill J, Jegodzinski L, Tayebjee MH. Incidence of subclinical atrial fibrillation in a South Asian population. Pacing Clin Electrophysiol. 2018;41:1600–5.

    Article  Google Scholar 

  2. Arsalan M, Walther T, Smith RL, Grayburn PA. Tricuspid regurgitation diagnosis and treatment. Eur Heart J. 2017;38:634–8.

    PubMed  Google Scholar 

  3. Brennan AP, Martin W, Adams H, Yii M. Impact of the Cox-Maze IV procedure on left atrial mechanical function. Heart Lung Circ. 2019;28:1835–40.

    Article  Google Scholar 

  4. Ruaengsri C, Schill MR, Khiabani AJ, Schuessler RB, Melby SJ, Damiano RJ Jr. The Cox-Maze IV procedure in its second decade: still the gold standard? Eur J Cardiothorac Surg. 2018;53:i19–25.

    Article  Google Scholar 

  5. Jiang Z, Tang M, Ma N, et al. Right minithoracotomy versus conventional median sternotomy for patients undergoing mitral valve surgery and Cox-Maze IV ablation with entirely bipolar radiofrequency clamp. Heart Vessels. 2018;33:901–7.

    Article  Google Scholar 

  6. Boll G, Rowin EJ, Maron BJ, Wang W, Rastegar H, Maron MS. Efficacy of combined Cox-Maze IV and ventricular septal myectomy for treatment of atrial fibrillation in patients with obstructive hypertrophic cardiomyopathy. Am J Cardiol. 2020;125:120–6.

    Article  Google Scholar 

  7. Labin JE, Haque N, Sinn LA, et al. The Cox-Maze IV procedure for atrial fibrillation is equally efficacious in patients with rheumatic and degenerative mitral valve disease. J Thorac Cardiovasc Surg. 2017;154:835–44.

    Article  Google Scholar 

  8. Cho MS, Heo R, Jin X, et al. Sick sinus syndrome after the Maze procedure performed concomitantly with mitral valve surgery. J Am Heart Assoc. 2018;7:e009629.

    Article  Google Scholar 

  9. Jeon CS, Shim MS, Park SJ, et al. The absence of atrial contraction as a predictor of permanent pacemaker implantation after Maze procedure with cryoablation. Korean J Thorac Cardiovasc Surg. 2017;50:163–70.

    Article  Google Scholar 

  10. Ad N, Holmes SD, Ali R, Pritchard G, Lamont D. A single center’s experience with pacemaker implantation after the Cox Maze procedure for atrial fibrillation. J Thorac Cardiovasc Surg. 2017;154:139-46.e131.

    Article  Google Scholar 

  11. Takagaki M, Yamaguchi H, Ikeda N, et al. Risk factors for atrial fibrillation recurrence after Cox Maze IV performed without pre-exclusion. Ann Thorac Surg. 2020;109:771–9.

    Article  Google Scholar 

  12. Masaki N, Kawamoto S, Motoyoshi N, et al. Predictors of the need for pacemaker implantation after the Cox Maze IV procedure for atrial fibrillation. Surg Today. 2018;48:495–501.

    Article  CAS  Google Scholar 

  13. Henn MC, Lancaster TS, Miller JR, et al. Late outcomes after the Cox Maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg. 2015;150:1168–1176, 1178.e1161–2.

    Google Scholar 

  14. Czer LS, Maurer G, Bolger A, et al. Tricuspid valve repair. Operative and follow-up evaluation by Doppler color flow mapping. J Thorac Cardiovasc Surg. 1989;98:101–10 (discussion 110–101).

    Article  CAS  Google Scholar 

  15. Goldman ME, Guarino T, Fuster V, Mindich B. The necessity for tricuspid valve repair can be determined intraoperatively by two-dimensional echocardiography. J Thorac Cardiovasc Surg. 1987;94:542–50.

    Article  CAS  Google Scholar 

  16. Cohen SR, Sell JE, McIntosh CL, Clark RE. Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement. J Thorac Cardiovasc Surg. 1987;94:488–97.

    Article  CAS  Google Scholar 

  17. Simon R, Oelert H, Borst HG, Lichtlen PR. Influence of mitral valve surgery on tricuspid incompetence concomitant with mitral valve disease. Circulation. 1980;62:I152-157.

    CAS  PubMed  Google Scholar 

  18. McGilvray MMO, Bakir NH, Kelly MO, et al. Efficacy of the stand-alone Cox-Maze IV procedure in patients with longstanding persistent atrial fibrillation. J Cardiovasc Electrophysiol. 2021. https://doi.org/10.1111/jce.15113.

    Article  PubMed  Google Scholar 

  19. Khiabani AJ, MacGregor RM, Bakir NH, et al. The long-term outcomes and durability of the Cox-Maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg. 2020;5:S0022-5223(20)31065-5.

    Google Scholar 

  20. Liu Y, Tian H, Yan X, Fan F, Wang W, Han J. Serotonin inhibits apoptosis of pulmonary artery smooth muscle cells through 5-HT2A receptors involved in the pulmonary artery remodeling of pulmonary artery hypertension. Exp Lung Res. 2013;39:70–9.

    Article  Google Scholar 

  21. West JD, Carrier EJ, Bloodworth NC, et al. Serotonin 2B receptor antagonism prevents heritable pulmonary arterial hypertension. PLoS ONE. 2016;11:e0148657.

    Article  Google Scholar 

  22. Morecroft I, Pang L, Baranowska M, et al. In vivo effects of a combined 5-HT1B receptor/SERT antagonist in experimental pulmonary hypertension. Cardiovasc Res. 2010;85:593–603.

    Article  CAS  Google Scholar 

  23. Hood KY, Mair KM, Harvey AP, Montezano AC, Touyz RM, MacLean MR. Serotonin signaling through the 5-HT(1B) receptor and NADPH oxidase 1 in pulmonary arterial hypertension. Arterioscler Thromb Vasc Biol. 2017;37:1361–70.

    Article  CAS  Google Scholar 

  24. Janssen W, Schymura Y, Novoyatleva T, et al. 5-HT2B receptor antagonists inhibit fibrosis and protect from RV heart failure. Biomed Res Int. 2015;2015:438403.

    PubMed  PubMed Central  Google Scholar 

  25. Kanemoto N, Sasamoto H. Arrhythmias in primary pulmonary hypertension. Jpn Heart J. 1979;20:765–75.

    Article  CAS  Google Scholar 

  26. Nakao S, Hirakawa A, Fukushima R, Kobayashi M, Machida N. The anatomical basis of bradycardia-tachycardia syndrome in elderly dogs with chronic degenerative valvular disease. J Comp Pathol. 2012;146:175–82.

    Article  CAS  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

Not applicable.

Author information

Author notes

  1. Xue Wang and Heng Gao are co-first authors.

Authors and Affiliations

  1. Department of Cardiovascular Surgery, First Affiliated Hospital of Xi’an Jiaotong University, No. 277 Yanta West Road, Xi’an, 710061, People’s Republic of China

    Xue Wang, Chao Deng, Miaomiao Liu & Yang Yan

  2. Department of Emergency Internal Medicine, Shaanxi Provincial People’s Hospital, 256 Youyi West Road, Xi’an, 710068, People’s Republic of China

    Heng Gao

Authors
  1. Xue Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Heng Gao
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Chao Deng
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Miaomiao Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yang Yan
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

XW was dedicated to the study design, data analysis, manuscript preparation and manuscript editing; XW and HG carried out the literature research and clinical studies; HG and CD were involved in the experimental studies; ML focused on the data acquisition; XW and ML were contributed to the statistical analysis; YY handled the study concepts, definition of intellectual content and manuscript review. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Yang Yan.

Ethics declarations

Ethical approval and consent to participate

This retrospective study was approved by our institutional review board, and the informed consent requirement could be avoided (No. XJTU1AF2020LSK-078).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wang, X., Gao, H., Deng, C. et al. The occurrence and risk factors of bradycardia after the Maze procedure in patients with atrial fibrillation and tricuspid regurgitation. J Cardiothorac Surg 16, 270 (2021). https://doi.org/10.1186/s13019-021-01653-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13019-021-01653-1

Keywords

Journal of Cardiothoracic Surgery

ISSN: 1749-8090

Contact us