The long-term safety and efficacy of concomitant Cox maze procedures for atrial fibrillation in patients without mitral valve disease

Abstract

Objective: Newly published guidelines made the highest level recommendation for surgical treatment for atrial fibrillation. However, the number of patients without a mitral valve procedure with atrial fibrillation who are treated with concomitant surgical ablation is still low (15%-25%), because surgeons are reluctant to perform procedures in patients who would not otherwise require left atriotomy. The purpose of this study was to compare the outcomes of concomitant Cox maze with and without mitral valve procedures.Methods: Patients who underwent concomitant Cox maze procedures were prospectively followed since September 2005. Of the 711 patients, 238 did not receive mitral valve surgery. Propensity score matching was conducted to balance preoperative characteristics between patients with and without mitral valve procedures (164/group after matching).Results: Before matching, patients in the mitral valve group were younger (65 vs 67 years, P ¼ .047) and had higher euroSCORE II (European System for Cardiac Operative Risk Evaluation; 3.2% vs 2.6%, P ¼ .002), larger mean left atrial size (5.3 vs 4.8 cm, P <.001), and shorter median atrial fibrillation duration (19 vs 25 months, P ¼ .064). Early outcomes were similar for the matched groups. Cumulative 5-year freedom from stroke did not differ between matched mitral valve and non-mitral valve groups (96.1% vs 96.6%, P ¼ .667). At each time point, the proportion in sinus rhythm off antiarrhythmic medications was similar for the matched groups, including 5 years after surgery (68% vs 63%, P ¼ .492). Conclusions:The Cox maze procedure is safe and effective with comparable outcomes when performed concomitant to mitral valve or non-mitral valve surgery. Surgeons should base the decision to perform surgical ablation procedures on atrial fibrillation pathophysiology and the benefit to patients, not on the type of concomitant procedure.

Surgery and Catheter Ablation for Atrial Fibrillation: History, Current Practice, and Future Directions

“…In 2006, Itoh et al reported a marked decrease in long-term stroke at 12 years following surgery in which the AF was ablated [ 65 ]. In 2019, Ad et al, showed that the long-term freedom from stroke following AF ablation was independent of whether or not mitral valve surgery was also performed [ 66 ]. Moreover, in 2019, Malaisrie et al, from our group reported on the 6-year follow-up of 24,069 patients in the STS database undergoing CABG [ 67 ].…”

The role of personalized atrial modeling in understanding atrial fibrillation mechanisms and improving treatment

“…Typically, these strategies are adjuvant to pulmonary vein isolation and include empirical lines in the left atrium, entire posterior wall electrical isolation, and ablation of complex fractionated atrial electrograms, but have limited clinical efficiency. 8 Surgical Maze procedures 62 or hybrid approaches 63 are alternative rhythm control strategies, particularly suitable for patients with persistent AF, but are more invasive than catheter-based ablation. Atrial models have been used to optimize different surgical Maze procedures, and this has been previously reviewed.…”

“…69,70 5. Future perspectives 62 Current atrial modeling approaches have some limitations that need to be addressed in future studies. First, different fibrosis representation methodologies should be validated in clinical studies.…”

Commentary: Judgment day: Should you add atrial fibrillation ablation?

“…Ad and coworkers 8 have demonstrated that the 5-year freedom from AF of patients treated with AF ablation with a mitral valve procedure is similar when compared with AF ablation with coronary artery bypass (CAB) or aortic valve replacement (AVR), procedures that do not otherwise require a left atriotomy. Historically, only 15% to 30% of preoperative nonmitral surgery AF cases are treated with concomitant AF ablation.…”