Bipolar radiofrequency ablation can be used to replace the surgical incisions of the Cox maze procedure. This energy source did not result in pulmonary vein stenosis. The modification of the Cox maze III procedure to use bipolar radiofrequency ablation simplified and shortened this procedure without sacrificing short-term efficacy.

Objectives The Cox-Maze III procedure(CMP) achieved high cure rates and became the surgical gold standard for the treatment of atrial fibrillation(AF). Due to its invasiveness, a more simplified ablation-assisted procedure(CMP-IV) has been performed at our institution since January, 2002. The study examined multiple preoperative and perioperative variables to determine predictors of late recurrence. Methods Data were collected prospectively on 282 patients who underwent the CMP-IV from January 2002 through December 2009. Forty-two percent of patients had paroxysmal and 58% had either persistent or long-standing persistent AF. All patients were available for follow-up. Follow-up included ECGs in all patients. Since 2006, 24 hour holter monitoring was obtained in 94% of patients at 3, 6 and 12 months. Data were analyzed by logistic regression analysis at 12 months with 13 preoperative and perioperative variables used as co-variants. Results Sixty-six percent of patients had a concomitant procedure. Following an ablation-assisted CMP, the freedom from AF was 89%, 93%, and 89% at 3, 6, and 12 months, respectively. The freedom from both AF and antiarrhythmic drugs was 63%, 79%, and 78% at 3, 6, and 12 months. The risk factors for AF recurrence at one year were enlarged left atrial(LA) diameter(p=0.027), failure to isolate the entire posterior left atrium(p=0.022), and early atrial tachyarrhythmias (ATAs)(p=0.010). Conclusions The CMP-IV has a high success rate at one year, even with improved follow-up and stricter definitions of failure. In patients with large LA, there may be a need for more extensive size reduction or expanded lesion sets.

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Objective The presence of pulmonary hypertension (PH) historically has been considered a significant risk factor affecting early and late outcomes following valve replacement. Given the number of recent advances in the management of PH following cardiac surgery a better understanding of the impact of PH on outcomes may assist in the clinical management of these patients. The purpose of this study was to determine if pulmonary hypertension remains a risk factor in the modern era for adverse outcomes following aortic valve replacement (AVR) for aortic valve stenosis. Methods From January 1996 to June 2009, 1,080 patients underwent AVR for primary aortic valve stenosis, of which 574 (53%) had normal systolic pulmonary artery pressures (sPAP) and 506 (47%) had PH. PH was defined as mild (sPAP 35-44 mmHg), moderate (45-59mmHg), or severe (≥ 60mmHg). In the group of patients with PH, 204 had postoperative echocardiograms. Results Operative mortality was significantly higher in patients with PH (47/506, 9% versus 31/574, 5%; p=0.02). The incidence of postoperative stroke was similar (p=0.14), but patients with PH had an increased median hospital LOS (8 versus 7 days, p=0.001) and an increased incidence of prolonged ventilation (26% versus 17%, p<0.001). Preoperative PH was an independent risk factor for decreased long term survival (RR 1.7, p=0.02). Those with persistent PH postoperatively had decreased survival. Five-year survival (Kaplan-Meier) was 78 ± 6% with normal sPAP and 77 ± 7% with mild PH postoperatively, compared to 64 ± 8% with moderate PH and 45 ± 12% with severe PH (p<0.001). Conclusion In patients undergoing AVR, preoperative PH increased operative mortality and decreased long-term survival. Patients with persistent moderate or severe PH after AVR had decreased long-term survival. These data suggest that PH had a significant impact on outcomes in patients undergoing AVR and should be considered in preoperative risk assessment.