The Cox maze IV procedure: Predictors of late recurrence

Abstract

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.

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…A number of groups have reported excellent results with ablation-assisted Cox-Maze procedures. 1301,1302,1303,1304,1305,1306 …”

“…1301 A total of 124 patients (44%) underwent surgery only for AF treatment, and 158 patients (56%) had other cardiac surgery performed, which included mitral valve surgery in approximately 50% of patients. Among the entire patient cohort, 89% of the patients were in sinus rhythm with or without AAD therapy, and 78% were in sinus rhythm and free of AAD therapy at 12 months of follow-up.…”

“…Importantly, the cross-clamp times are shorter with the Cox-Maze IV procedure. 1301 The advantage of these approaches includes the ability to reliably create the endocardial lesions of the Maze, down to the mitral annulus. Late evaluation of this procedure in 146 stand-alone patients has shown a 72% freedom from AF at 5 years of follow-up and a 59% freedom from AF off antiarrhythmic medications.…”

Ablation of long-standing persistent atrial fibrillation

“…As per current guidelines, stand-alone surgical ablation is a Class IIb recommendation in highly symptomatic AF patients intolerant of other approaches (3). James Cox's original "cut-and-sew" surgical maze procedure (82) which was developed to treat this specific population now has evolved into the Cox-maze IV surgery (83). The basis of the maze procedure is to create lines using RFA, cryoablation, and surgical incisions in order to partition atrial tissue to prevent the maintenance of re-entrant wavelets.…”

Surgical Management of Atrial Fibrillation

“…Several studies have demonstrated that addition of left atrial plication to mitral valve surgery improved restoration of sinus rhythm compared to mitral valve surgery alone (45,46). However, others have shown greater than 50% recurrent arrhythmias in patients post-Cox Maze IV with LA size greater than 8cm even with a LA plasty (47). The surgical approaches for LA plasty include excision of either inferior or inferior and superior walls as well as the autotransplant approach.…”