Re: 8 weeks post maze,palpitations en anticoagulant.

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Posted by steve giddings on August 06, 2001 at 11:58:09:

In Reply to: Re: 8 weeks post maze,palpitations en anticoagulant. posted by hans koster on August 06, 2001 at 04:12:26:

Sorry, for some reason the last part of my note got cut off (maybe it was like the guy with the hook at the Apollo Theatre).
The remainder was... the empiric observation has been that there have been virtually no stroke events in patients who have undergone the maze after the immediate recovery period, when anticoagulation could not be done in any event for risk of bleeding. Some would argue that this isn't because of a return to sinus rhythm, but because the right and left atrial appendages are removed as part of the procedure, and these long, skinny sacks (that look somewhat like uniflated ears on a Mickey Mouse balloon) are where the vast majority of atrial clots form.

Concerning lack of effective atrial contractions post maze, this is a somewhat contentious issue. Atrial contractions, particulalry those of the left atrium, are less effective, primarily because a ring is cut (or frozen or rfa'd) around they site for the pulmonary veins' collective entry into the left atrium. This isolates about 25% of the left atrium from any electrical signal, and so this portion of the LA never "beats" after surgery. The studies that show a significant fraction of patients with no effective atrial contraction used transthoracic echocardiography as the evaluating tool and were done relatively soon post op (3 mo) Studies done at longer intervals and studies using transesophageal echo (which gets a better view of the LA) show a much higher proportion of patients with beating atria. There is probably some argument as to what constitutes "effective" as well, 50% emptying, 30%, etc (this is referred to as interobserver error or discordance).

I don't think the coumadin for 6 months post op advocates have a bad idea or are doing this because they doubt the benefits of the surgery, or are misinformed, quite the opposite. The short term risks of well monitored anticoagulation are quite small. The potential consequences of an embolic event post op, regardless of how small the risk, are very large.

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