Superiority of cut-and-sew technique for the Cox maze procedure: Comparison with radiofrequency ablation

Stulak, John M.; Dearani, Joseph A.; Sundt, Thoralf M.; Daly, Richard C.; McGregor, Christopher G.A.; Zehr, Kenton J.; Schaff, Hartzell V.

doi:10.1016/j.jtcvs.2006.09.115

Cited by 50 publications

(30 citation statements)

References 23 publications

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“…Surgical studies on the cut-and-sew maze technique 18 have shown that substrate modification at the time of (surgical) PVI almost always eliminates AF, including patients with persistent forms of AF. The difference between the surgical and the radiofrequency current ablation approach is that surgical PVI is permanent, whereas radiofrequency current-induced PVI at the index procedure is associated with a high likelihood of reconduction from the PVs to the LA through gaps in the circumferential ablation lines.…”

Section: The Substrate-modification Strategy Failed To Reduce Arrhythmentioning

confidence: 99%

Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Fink

Schlüter

Heeger

et al. 2017

Circ: Arrhythmia and Electrophysiology

150

105

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C atheter ablation has become a routine treatment option for patients experiencing symptomatic paroxysmal atrial fibrillation (AF). Long-term clinical success rates of ≤80% after 5 years have been reported for the treatment of paroxysmal AF by initial stand-alone pulmonary vein isolation (PVI) as the accepted cornerstone of all AF ablation strategies; however, to achieve permanent PVI, multiple procedures are often required. 1,2 In contrast, the results for ablation of persistent AF are less convincing. 3 The optimal strategy for persistent AF is not known, and previous studies investigating more extensive ablation strategies in addition to PVI demonstrated heterogeneous results. [4][5][6][7][8][9][10][11][12] The recently published STAR AF 2 trial (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial) compared initial stand-alone PVI to PVI with additional ablation of complex fractionated atrial electrograms (CFAEs) or additional linear ablation and could not demonstrate a superior outcome for the additional ablation strategies. 13 The prospective and randomized Alster-Lost-AF © 2017 American Heart Association, Inc. Original ArticleBackground-Pulmonary vein isolation (PVI) for persistent atrial fibrillation is associated with limited success rates and often requires multiple procedures to maintain stable sinus rhythm. In the prospective and randomized Alster-Lost-AF trial (Ablation at St. Georg Hospital for Long-Standing Persistent Atrial Fibrillation), we sought to assess, in patients with symptomatic persistent or long-standing persistent atrial fibrillation, the outcomes of initial ablative strategies comprising either stand-alone PVI (PVI-only approach) or a stepwise approach of PVI followed by complex fractionated atrial electrogram ablation and linear ablation (Substrate-modification approach). Methods and Results-Patients were randomized 1:1 to stand-alone PVI or PVI plus substrate modification. The primary study end point was freedom from recurrence of any atrial tachyarrhythmia, outside a 90-day blanking period, at 12 months. A total of 124 patients were enrolled, with 118 patients included in the analysis (61 in the PVI-only group, 57 in the Substrate-modification group). Atrial tachyarrhythmias recurred in 28 PVI-only group patients and 24 Substratemodification group patients, for 1-year freedom from tachyarrhythmia recurrence after a single ablation procedure of 54% (95% confidence interval, 43%-68%) in the PVI-only and 57% (95% confidence interval, 46%-72%) in the Substratemodification group (P=0.86). Twenty-four patients in the PVI-only group (39%) and 18 in the Substrate-modification group (32%) were without arrhythmia recurrence and off antiarrhythmic drug therapy at the end of the 12-month follow-up. Conclusions-In

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Section: The Substrate-modification Strategy Failed To Reduce Arrhythmentioning

confidence: 99%

Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Fink

Schlüter

Heeger

et al. 2017

Circ: Arrhythmia and Electrophysiology

150

105

View full text Add to dashboard Cite

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“…Raanani et al ( 2001) recorded sinus rhythm in only 75% of patients a mean of 26 months after Cox maze and mitral valve surgery, which is similar to the Mayo Clinic experience of 74% freedom from AF at 2 years ( Handa et al ,1999;Shaff et al 2000). The use of RF energy for the creation of the atrial lesions of the Cox maze procedure was associated with significantly less freedom from AF both at hospital discharge and at followup (Stulak et al 2007). The differences of the long-term success rate c o u l d b e i n f l u e n c e d o t h e r t h a n b y t h e differences among intraoperative v a r i a b l e s , m a i n l y b y p r e o p e r a t i v e v a r i a b l e s , s u c h a s concomitant valvular surgery and rheumatic valvular heart disease.…”

Section: Literature Reviewmentioning

confidence: 98%

Treatment of Atrial Fibrillation in Patients Undergoing Mitral Valve Surgery

Rostagno¹,

Berioli²,

Stefàno³

2012

Atrial Fibrillation - Basic Research and Clinical Applications

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“…However, ablation devices, such as traditional cryoablation, RF ablation, microwave, or ultrasonography, do not necessarily guarantee transmural, continuous necrosis. Although Lall et al 25 noted that AF surgery using an RF ablation device cured AF in >90% of the patients, which is the same as the traditional cut-and-sew maze procedure, Stulak et al 26 and Doty et al 27 reported that the traditional cut-and-sew maze procedure was superior to RF surgery for the treatment of AF. Ishii et al 28 pointed out the importance of complete ablation of the coronary sinus and pulmonary veins during AF surgery.…”

Section: Postoperative Atrial Tachycardiamentioning

confidence: 99%

Surgery for atrial fibrillation: recent progress and future perspective

Nitta

Ishii

Sakamoto

2012

Gen Thorac Cardiovasc Surg

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Development and introduction of radiofrequency ablation devices allowed the maze procedures to be performed safely and easily, further enabling off-pump pulmonary vein isolation through a mini-thoracotomy or thoracoscope. The effects of the maze procedure include prevention of stroke and other complications related to atrial fibrillation, improved cardiac performance, and relief of symptoms. Indications for the maze procedure have been discussed on the basis of the evidence. Pulmonary vein isolation has been shown to be effective in most patients with paroxysmal atrial fibrillation and can be performed with endocardial catheter ablation and minimally invasive epicardial ablation. These two modalities should be compared in terms of the success rate, occurrence of cerebral microembolic signals, capability of additional lesions indicated for persistent or long-standing persistent atrial fibrillation, and closure of the left atrial appendage. Noncontinuous or nontransmural lines of conduction block as a result of incomplete ablation can result in recurrence of atrial fibrillation and induction of atrial tachycardia. Intraoperative verification of conduction block across the ablation lines is recommended to prevent these complications. Volume reduction of the enlarged left atrium or a boxlesion to isolate the entire posterior left atrium may be effective in patients with a dilated left atrium, but the potentially impaired atrial transport function should be considered. Mapping of active ganglionated plexi and their ablation may improve the outcome of the procedure, but the long-term effect on atrial fibrillation and autonomic nerve activities should be examined.

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Superiority of cut-and-sew technique for the Cox maze procedure: Comparison with radiofrequency ablation

Cited by 50 publications

References 23 publications

Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Treatment of Atrial Fibrillation in Patients Undergoing Mitral Valve Surgery

Surgery for atrial fibrillation: recent progress and future perspective

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