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J Thorac Cardiovasc Surg 1998;115:139-147
© 1998 Mosby, Inc.

SURGERY FOR CONGENITAL HEART DISEASE

Effect of the Cox maze procedure on the secretion of atrial natriuretic peptide

From the Department of Thoracic and Cardiovascular Surgery and InternalMedicine, Seoul National University College of Medicine,^a and Departmentof Clinical Pathology, Chung Ang University,^b Seoul, Korea. Supportedby grant No. 05-95-004 from the Seoul National University Hospital ResearchFund.

Read at the Seventy-seventh Annual Meeting of The American Associationfor Thoracic Surgery, Washington, D.C., May 4-7, 1997.

Received for publication May 7, 1997; revisions requested June 24,1997; revisions received July 24, 1997. Accepted for publication July 25, 1997. Reprints: Ki-Bong Kim, MD, Department of Thoracic and CardiovascularSurgery, Seoul National University Hospital, 28 Yeunkun-Dong, Chongro-Ku,Seoul 110-744, Korea.

Objectives:TheCox maze procedure has been confirmed to be effective in curing atrial fibrillation.Some authors have reported severe fluid retention after the Cox maze procedureand have suggested decreased secretion of atrial natriuretic peptide as apossible mechanism. This study was designed (1) to examine the serial changesin atrial natriuretic peptide after the Cox maze procedure as compared withchanges occurring after coronary artery bypass grafting and (2) to elucidateany differences in atrial natriuretic peptide levels between patients withtransient recurrence of atrial fibrillation after the Cox maze procedure andthose without recurrence of atrial fibrillation.
Methods:Blood samples were drawn from theright and left atria in patients undergoing the Cox maze procedure (n = 19) and from the rightatrium in patients undergoing coronary artery bypass grafting (n = 6) before and 1, 2, and 3 daysafter the operation. In six patients undergoing the Cox maze procedure, sampleswere also drawn from the radial artery before and 1, 2, 3, 5, and 7 days afterthe operation. The plasma samples were prepared by refrigerated centrifugationand stored until radioimmunoassay. In the Cox maze procedure group, atrialnatriuretic peptide levels in the right atrium were 629 ± 366,154 ± 112, 162 ± 112, and 183 ± 97 pg/mland those in the left atrium were 276 ± 168, 152 ±91, 162 ± 111, and 145 ± 80 pg/ml before and 1, 2,and 3 days after the operation, respectively. A marked decrease in atrialnatriuretic peptide levels was evident after the Cox maze procedure (p < 0.001). There was nosignificant correlation between atrial natriuretic peptide levels and atrialpressures after the Cox maze procedure, which suggests that secretion of atrialnatriuretic peptide by the atria was impaired. There was a significant correlationbetween the atrial natriuretic peptide levels in the left atrium and thosein the peripheral radial artery, and the decreased levels of atrial natriureticpeptide in the radial artery continued for 7 days after the Cox maze procedure.There were no differences in the atrial natriuretic peptide levels betweenthe patients with transient recurrence of atrial fibrillation (n = 6) and those without recurrence(n = 13) afterthe Cox maze procedure. In the coronary artery bypass grafting group, theatrial natriuretic peptide levels in the right atrium were 115 ±37, 124 ± 48, 154 ± 54, and 156 ± 36 pg/mlbefore and 1, 2, and 3 days after the operation, respectively. No change wasseen after the operation.
Conclusions: We observed a significant decrease in atrial natriuretic peptidelevels after the Cox maze procedure. This may be one of the possible causesof fluid retention after this procedure. These decreased atrial natriureticpeptide levels after the Cox maze procedure may result from the multiple atriotomyincisions and excision of both atrial auricles performed during the procedure,rather than from the conversion of atrial fibrillation to normal sinus rhythm.(J Thorac Cardiovasc Surg 1998;115:139–47

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