The Maze Procedure and Postoperative Pacemakers

Abstract

There are numerous reasons why patients need new pacemakers after a maze procedure, but the right atrial lesions of the procedure rarely, if ever, are the cause.

Cox-maze III procedure for atrial fibrillation during valve surgery: a single institution experience

“…A cumulative meta-analysis of randomized controlled trials (RCT) on clinical outcomes of surgical ablation versus no ablative treatment in all patients with cardiac surgery demonstrated that there were no significant differences between surgical ablation versus no ablation in terms of pacemaker implantations [15]. One reason that new permanent pacemakers are required following a maze procedure is premature pacemaker implantation for a temporary junctional rhythm immediately postoperatively [16]. In the present study, the rate of junctional rhythm in the immediate postoperative period following maze procedure was 7.9% (5/64) overall.…”

The electrophysiologic basis for lesions of the contemporary Maze operation

“…16,17 Adding the RA lesions in the correct manner eliminates that obligatory failure rate and does not cause the patient to need permanent pacemakers more often postoperatively except by curing the AF and unmasking a sick sinus syndrome (SSS). 18…”

“…Concern that the RA lesions cause an increased need for permanent pacemakers is the result of improperly placed RA lesions or misinterpretation of data. [17][18][19][20] In our own series of patients from the 1980s and 1990s, [21][22][23] 114 patients were documented to have normal sinus node function preoperatively and not one of them required a pacemaker after the Maze procedure. Approximately 5% of patients with paroxysmal AF have SSS preoperatively and will require a pacemaker after a Maze procedure.…”

“…Thus, the more successful AF ablation is, the higher the postoperative pacemaker requirements will be. 17,18 In 2009, Santucci and colleagues 24 showed the 3 circuits that are responsible for typical atrial flutter in the RA. Typical atrial flutter results from a single macro-reentrant circuit that always uses the cavo-tricuspid isthmus (CTI) (Figure 4, C).…”

“…The only important caveat is that this lesion must be placed as anteriorly as possible on the RA free-wall to avoid injury to the atrial pacemaker complex. 18,27 These 3 RA lesions are safe and simple to perform and can be completed in 10 to 15 minutes. All of them can be created after the aortic crossclamp has been released during the warm reperfusion period before weaning from cardiopulmonary bypass.…”