J Korean Med Sci.  2024 Apr;39(15):e143. 10.3346/jkms.2024.39.e143.

Outcomes of Concomitant Maze Procedure in Tricuspid Repair for Severe Tricuspid Regurgitation

• Park I
• Chung S
• Cho YH
• Sung K
• Kim WS
• Song K
• Ahn JH
• Jeon CS
• Park PW
• Jeong DS

• KMID: 2555473
• DOI: http://doi.org/10.3346/jkms.2024.39.e143

Abstract

Background
We aimed to analyze the impact of concomitant Maze procedure on the clinical and rhythm outcomes, and echocardiographic parameters in tricuspid repair for patients with severe tricuspid regurgitation (TR) and persistent atrial fibrillation (AF).
Methods
Patients who had severe TR and persistent AF and underwent tricuspid valve (TV) repair were included in the study. Both primary TR and secondary TR were included in the current study. The study population was stratified according to Maze procedure. The primary outcome was major adverse cardiovascular and cerebrovascular event (MACCE) at 15 years postsurgery. Propensity-score matching analyses was performed to adjust baseline differences.
Results
Three hundred seventy-one patients who underwent tricuspid repair for severe TR and persistent AF from 1994 to 2021 were included, and 198 patients (53.4%) underwent concomitant Maze procedure. The maze group showed 10-year sinus rhythm (SR) restoration rate of 55%. In the matched cohort, the maze group showed a lower cumulative incidence of cardiac death (4.6% vs. 14.4%, P = 0.131), readmission for heart failure (8.1% vs. 22.2%, P = 0.073), and MACCE (21.1% vs. 42.1%, P = 0.029) at 15 years compared to the non-maze group. Left atrial (LA) diameter significantly decreased in the maze group at 5 years (53.3 vs. 59.6 mm, P < 0.001) after surgery compared to preoperative level, and there was a significant difference in the change of LA diameter over time between the two groups (P = 0.013).
Conclusion
The Maze procedure during TV repair in patients with severe TR and persistent AF showed acceptable SR rates and lower MACCE rates compared to those without the procedure, while also promoting LA reverse remodeling.

Keyword

Tricuspid Regurgitation; Maze Procedure; Sinus Rhythm Restoration; Left Atrial Reverse Remodeling

Figure

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  Fig. 1 Study flow diagram. A total of 371 patients who underwent TV repair for severe TR and persistent atrial fibrillation were enrolled. Patients were divided into maze and non-maze groups. After propensity score matching, 117 pairs of maze and non-maze group were matched.TV = tricuspid valve, TR = tricuspid regurgitation.

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  Fig. 2 Cumulative incidence curves for MACCE (A), cardiac death (B), rehospitalization for HF (C), and PPM insertion (D) according to Maze procedure in the propensity-score matched cohort. All-cause death or non-cardiac death was accounted as a competing event in the Fine-Gray model.MACCE = major adverse cardiovascular and cerebrovascular events, HF = heart failure, PPM = permanent pacemaker.

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  Fig. 3 Sinus rhythm restoration rate between the maze and the non-maze groups in the total patients.

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  Fig. 4 Serial changes in LV end-diastolic diameter (A), LV end-systolic diameter (B), LV ejection fraction (C), TAPSE (D), and LAD (E) according to the Maze procedure. The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively; and the top and bottom ends of the whiskers extend from the box to the furthest data points within 1.5 times the interquartile range from the quartiles, encompassing the range of the data excluding outliers. Linear mixed model was used to assess interaction between time and group.LV = left ventricle, TAPSE = tricuspid annular plane systolic excursion, LAD = left atrium diameter.

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