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ARTIGO ORIGINAL

Evolução tardia da operação de Cox para fibrilação atrial em valvopatia mitral

Marcelo B JateneI; Eduardo SosaII; Fábio B JateneI; Flávio TarasoutchiII; Ana Cristina MonteiroII; Pedro R SalernoIII; Luiz Carlos Bento de SouzaIII; José Carlos PachónIII; Adib D JateneI

DOI: 10.1590/S0102-76381995000100003

RESUMO

A operação de Cox para fibrilação atrial (FA), descrita inicialmente para os casos de FA crônica e ou paroxística, vem tendo, em nosso meio, emprego freqüente em pacientes (pts) valvopatas mitrais portadores de FA, com controle da arritmia a médio e longo prazo. Entre julho 91 e outubro 94, 32 pts (25 femininos) portadores de FA crônica e valvopatia mitral foram operados. A idade média foi de 50,2 anos (35 a 68), sendo a valvopatia de origem reumática em 30 pts e mixomatosa em 2; 81,2% dos pacientes encontravam-se em CF IV (NYHA), sendo que 9 haviam sido previamente operados e 4 tiveram episódio prévio de embolia sistêmica. O diâmetro médio do AE era de 5,5 cm e a PSAP de 55 mmHg. Todos os pts foram operados por esternotomia mediana, seguindo a técnica original descrita por Cox (Cox I) em 18 pts e a técnica modificada (Cox 111) em 14 pts. Crioablação dos anéis mitral, tricúspide e seio coronário foi utilizada em 25 pts. Em 17 pts a valva mitral foi substituída por bioprótese de PB e conservada em 15 pts. Foram observados 2 óbitos hospitalares (baixo débito e insuficiência hepática); 14 pts fizeram uso de MP temporário no pósoperatório imediato e 4 apresentaram insuficiência respiratória com boa evolução. Um paciente apresentou morte súbita domiciliar, uma semana após a alta. Em 25 pts com evolução superior a 6 meses (média 25 m), 24 encontram-se em ritmo regular (sinusal em 19 e juncional em 5), assintomáticos e com FC média de 71,5 bpm. Contração atrial foi demonstrada pelo ECO, sendo menos efetiva no AE. Um paciente foi submetido a implante de MP definitivo por bradicardia sinusal no 2 mês de PO. Em conclusão, a operação de Cox vem mostrando resultados reprodutíveis na FA associada à doença mitral, com obtenção de ritmo regular e contração atrial presente. Não houve recorrência de FA no período avaliado.

ABSTRACT

The "Maze" procedure for surgical treatment of chronic atrial fibrillation (AF) described by Cox was performed in 34 patients (pts) from July 91 to October 94; 26 were female and the ages ranged from 35 to 68y (50.2y). All pts had mitral valve disease (MVD) and chronic AF (> 1 year). Thirty one pts had surgical rheumatic MVD (mitral stenosis in 21; mitral double disfunction in 9) and 3 had mixomatous MVD with severe regurgitation. Twenty eight pts were in FC (NYHA) IV and 6 in FC III preoperatively. Left atrium diameter varied from 4.4 to 6.5 cm (5.5 cm). In 21 pts the surgical treatment was performed following the original "Maze" technique and in 13 pts with the modifications proposed by Cox. The surgery was completed with 17 mitral conservative procedures and 17 mitral valve replacements (bovine pericardium bioprostheses). Eight pts had left atrial thrombosis. There were 2 (5.8%) immediate deaths (low cardiac output and severe liver disfunction) and 1 patient died in the 48th day with infeccious complications. The first patient required reoperation for bleeding review. Atrial arrhythmias were observed in 6 pts and 14 required temporary pace-maker. Regular "sinus" rhythm was observed in all pts. No other major complications were observed. In 30 pts with more than 6 months of follow up, 27 (90%) were in regular rhythm (heart rate from 55 to 87bpm), with no antiarrhythmic drugs and atrial contraction demonstrated by ECHO. In conclusion, the "Maze" procedure showed effective to treat AF even in pts with big atrium and MVD, with acceptable immediate and late results. Longer observation is required to a definitive conclusion.
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REFERÊNCIAS

1. BONCHEK, L. I.; BURLINGAME, M. W.; WORLEY, S. J.; VAZALES, B. E.; LUNDY, E. F. - Cox/maze procedure for atrial septal defects with atrial fibrillation: management strategies. Ann. Thorac. Surg., 55: 607-610, 1993. [MedLine]

2. CAMERON, A.; SCHWARTZ, M. J.; KRONMAL, R. A.; KOSINSKI, A. S. - Prevalence and significance of atrial fibrillation in coronary artery disease (CASS Registry). Am. J. Cardiol., 61: 714-747, 1988.

3. COBLER, J. L.; WILLIAMS, M. E.; GREENLAND, P. - Thyrotoxicosis in institutionalized elderly patients with atrial fibrillation. Arch. Intern. Med., 144: 1758-1760, 1984. [MedLine]

4. COX, J. L. - Evolving applications of the maze procedure for atrial fibrillation. Ann. Thorac. Surg., 55: 578-580, 1993. [MedLine]

5. COX, J. L. - A perspective of postoperative atrial fibrillation in cardiac operations. Ann. Thorac. Surg., 56: 405-409, 1993. [MedLine]

6. COX, J. L. - The surgical treatment of atrial fibrillation. IV: Surgical technique. J. Thorac. Cardiovasc. Surg., 101: 584-592, 1991. [MedLine]

7. COX, J. L.; BOINEAU, J. P.; SCHUESSLER, R. B.; KATER, K. M.; LAPPAS, D. G. - Five-year experience with the maze procedure for atrial fibrillation. Ann. Thorac. Surg., 56: 814-824, 1993.

8. COX, J. L.; BOINEAU, J. P.; SCHUESSLER, R. B.; KATER, K. M.; LAPPAS, D. G. - From fisherman to fibrillation: an unbroken line of progress. Ann. Thorac. Surg., 58: 1269-1273, 1994. [MedLine]

9. COX, J. L.; BOINEAU, J. P.; SCHUESSLER, R. B.; JAQUISS, R. D. B.; LAPPAS, D. G. - Modification of the maze procedure for atrial flutter and atrial fibrillation. I: Rationale and surgical results. (No prelo. J. Thorac. Cardiovasc. Surg., 1995). [MedLine]

10. COX, J. L.; CANAVAN, T. E.; SCHUESSLER, R. B.; CAIN, M. E.; LINDSAY, B. D.; STONE, C; SMITH, P. K.; CORR, P. B.; BOINEAU, J. P. - The surgical treatment of atrial fibrillation. II: Intraoperative electrophysiologic mapping and description of the electrophysiologic basis of atrial flutter and atrial fibrillation. J. Thorac. Cardiovasc. Surg., 101: 406-426, 1991. [MedLine]

11. COX, J. L.; JAQUISS, R. D. B.; SCHUESSLER, R. B.; BOINEAU, J. P. - Modification of the maze procedure for atrial flutter and atrial fibrillation. II: Surgical technique of the Maze III procedure. (No prelo, J. Thorac. Cardiovasc. Surg. 1995). [MedLine]

12. COX, J. L.; SCHUESSLER, R. B.; BOINEAU, J. P. - The surgical treatment of atrial fibrillation. I: Summary of the current concepts of the mechanism of atrial flutter and atrial fibrillation. J. Thorac. Cardiovasc. Surg., 101: 402-405, 1991. [MedLine]

13. COX, J. L.; SCHUESSLER, R. B.; D'AGOSTINO Jr., H. J.; STONE, C. M.; CHANG, B. C; CAIN, M. E.; CORR, P. B.; BOINEAU, J. P. - The surgical treatment of atrial fibrillation. III: Development of definitive surgical procedure. J. Thorac. cardiovasc. Surg., 101: 569-583, 1991. [MedLine]

14. CRESWELL, L. L.; SCHUESSLER, R. B.; ROSENBLOOM, M.; COX, J. L.; Hazards of postoperative atrial arrhythmias. Ann. Thorac. Surg., 56: 539-549, 1993. [MedLine]

15. DIAMONTOPOULOS, E. J.; ANTHOPOULOS, L.; NANAS, S.; MALIARAS, G.; CHRISOS, D.; MOULOPOULOS, S. D. - Detection of arrhythmias in a representative sample of the Athens population. Eur. Heart. J., 8 (Supl. D): 17-19, 1987. [MedLine]

16. FISHER, C. M. - Embolism in atrial fibrillation. In: KULBERTUS, H. E.; OLSSON, S. B.; SCHLEPPER, M. (eds.) - Atrial fibrillation. Molndal, Sweden, A.B. Hassle, 1982, p. 192-210.

17. GREGORI Jr, F.; CORDEIRO, C; COUTO, W.; SILVA, S.; AQUINO, W.; NECHAR, A. - The Cox operation without cryoablation for the treatment of chronic atrial fibrillation. (Aceito para publicação em 1994. Ann. Thorac. Surg). [MedLine]

18. GUIRAUDON, G. M.; CAMPBELL, C. S.; JONES, D. L.; McLELLAN, J. L.; McDONALD, J. L. - Combined sino-atrial node atrioventricular node isolation: a surgical alternative to Hiss bundle ablation in patients with atrial fibrillation. Circulation, 72 (Parte 2): 220, 1985 (Resumo). [MedLine]

19. HIROSAWA, K.; SEKIGUCHI, M.; KASANUKI, H. - Natural history of atrial fibrillation. Heart Vessels, 10: (Supl. 2) 14-23, 1987.

20. JATENE, A. D.; SOSA, E.; TARASOUTCHI, F.; JATENE, M. B.; POMERANTZEFF, P. M. A. - Tratamento cirúrgico da fibrilação atrial. Procedimento do "labirinto": experiência inicial. Rev. Bras. Cir. Cardiovasc., 7: 107-111, 1992.

21. KOSAKAI, Y.; KAWAGUCHI, A. T.; ISOBE, F.; SASAKO, Y.; NAKANO, K.; EISHI, K.; TANAKA, N.; KITO, Y.; KAWASHIMA, Y. - Cox maze procedure for chronic atrial fibrillation associated with mitral valve disease. J. Thorac. Cardiovasc. Surg., 108 : 1049-1055, 1994.

22. McCARTHY, P. M.; CASTLE, L. W.; MALONEY, J. D.; THOHMAN, R. G.; SIMMONS, T. W.; WHITE, R. D.; KLEIN, A. L.; COSGROVE III, D. M. - Initial experience with the maze procedure for atrial fibrillation. J. Thorac. Cardiovasc Surg., 105 : 1077-1087, 1993. [MedLine]

23. MARTIN, A.; BENBOW, L. J.; BUTROUS, G. G. S.; LEACH, C; CAMM, A. J. - Five-year follow-up of 101 elderly subjects by means of long-term ambulatory cardiac monitoring. Eur. Heart J., 5: 592-596, 1984. [MedLine]

24. ONUNDARSON, P. T.; THORGEIRSSON, G.; JONMUNDSSON, E.; SIGFUSSON, N.; HARDARSON, T. - Chronic atrial fibrillation: epidemiologic features and 14 year follow-up: a case control study. Eur. Heart J., 8: 521-527, 1987. [MedLine]

25. SAVAGE, D. D.; GARRISON, R. J.; CASTELLI, W. P. - Prevalence of submitral (annular) calcium and its correlates in a general population - based sample (the Framingham Study). Am J. Cardiol, 51: 1375-1378, 1983. [MedLine]

26. SCHEINMAN, M. M. & EVANS-BELL, T. - Catheter ablation of the atrioventricular junction: a report of the percutaneous mapping and ablation registry. Circulation, 70: 1024-929, 1984.

27. SCHEINMAN, M.; MORADY, F.; HESS, D. S. - Catheter induced ablation of the atrioventricular junction to control refractory supraventricular arrhythmias. JAMA, 248: 851, 1981.

28. TAMMARO, A. E.; RONZONI, D.; BONACCORSO, O. - Le aritmie nell'anziano. Minerva Med., 74: 1313-1318, 1983. [MedLine]

29. TRESEDER, A. S.; SASTRY, B. S.; THOMAS, T. P.; YATES, M. A.; PATHY, M. S. - Atrial fibrillation and stroke in elderly hospitalized patients. Age Aging, 15: 89-92, 1986.

30. WILLIAMS, J. M.; UNGERLEIDER, R. M.; LOFLAND, G. K.; COX, J. L. - Left atrial isolation: a new technique for the treatment of supraventricular arrhythmias. J. Thorac. Cardiovasc. Surg., 80: 373-380, 1980. [MedLine]

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