The Cox-Maze procedure: What lesions and why
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ABSTRACT:
SUBMITTER: McGilvray M
PROVIDER: S-EPMC9938393 | biostudies-literature | 2022 Dec
REPOSITORIES: biostudies-literature
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Project description:ObjectiveThe effects of the Cox maze procedure on atrial function remain poorly defined. The purpose of this study was to investigate the effects of a modified Cox maze procedure on left and right atrial function in a porcine model.MethodsAfter cardiac magnetic resonance imaging, 6 pigs underwent pericardiotomy (sham group), and 6 pigs underwent a modified Cox maze procedure (maze group) with bipolar radiofrequency ablation. The maze group had preablation and immediate postablation left and right atrial pressure-volume relations measured with conductance catheters. All pigs survived for 30 days. Magnetic resonance imaging was then repeated for both groups, and conductance catheter measurements were repeated for the right atrium in the maze group.ResultsBoth groups had significantly higher left atrial volumes postoperatively. Magnetic resonance imaging-derived reservoir and booster pump functional parameters were reduced postoperatively for both groups, but there was no difference in these parameters between the groups. The maze group had significantly higher reduction in the medial and lateral left atrial wall contraction postoperatively. There was no change in immediate left atrial elastance or in the early and 30-day right atrial elastance after the Cox maze procedure. Although the initial left atrial stiffness increased after ablation, right atrial diastolic stiffness did not change initially or at 30 days.ConclusionsPerforming a pericardiotomy alone had a significant effect on atrial function that can be quantified by means of magnetic resonance imaging. The effects of the Cox maze procedure on left atrial function could only be detected by analyzing segmental wall motion. Understanding the precise physiologic effects of the Cox maze procedure on atrial function will help in developing less-damaging lesion sets for the surgical treatment of atrial fibrillation.
| S-EPMC2868590 | biostudies-literature
Project description:ObjectiveThe Cox maze IV procedure (CMPIV) has been established as the gold standard for surgical ablation; however, late outcomes using current consensus definitions of treatment failure have not been well described. To compare to reported outcomes of catheter-based ablation, we report our institutional outcomes of patients who underwent a left-sided or biatrial CMPIV at 5 years of follow-up.MethodsBetween January 2002 and September 2014, data were collected prospectively on 576 patients with AF who underwent a CMPIV (n = 532) or left-sided CMPIV (n = 44). Perioperative variables and long-term freedom from AF, with and without AADs, were compared in multiple subgroups.ResultsFollow-up at any time point was 89%. At 5 years, overall freedom from AF was 93 of 119 (78%), and freedom from AF off AADs was 77 of 177 (66%). No differences were found in freedom from AF, with or without AADs, at 1, 2, 3, 4, and 5 years for patients with paroxysmal AF (n = 204) versus with persistent/longstanding persistent AF (n = 305), or for those who underwent standalone versus a concomitant CMP. Duration of preoperative AF and hospital length of stay were the best predictors of failure at 5 years.ConclusionsThe outcomes of the CMPIV remain good at late follow-up. The type of preoperative AF or the addition of a concomitant procedure did not affect late success. The results of the CMPIV remain superior to those reported for catheter ablation and other forms of surgical AF ablation, especially for patients with persistent or longstanding AF.
| S-EPMC4637220 | biostudies-literature
Project description:The Cox-Maze procedure (CMP) for the surgical treatment of atrial fibrillation (AF) traditionally has required a median sternotomy and cardiopulmonary bypass. This study describes a method using ablation technologies to create the full Cox-Maze lesion set through a 5- to 6-cm right minithoracotomy.Twenty-two consecutive patients underwent a CMP through a right mini-thoracotomy and cardiopulmonary bypass. All patients were followed prospectively with electrocardiogram and 24-hour Holter monitoring at 3, 6, and 12 months. The CMP lesion set was created using bipolar radiofrequency energy and cryotherapy.There was no operative mortality or major complications.Two patients required a permanent pacemaker. Five patients (23%) had early atrial tachyarrhythmias. At last follow-up(mean, 18 ± 12 months), all the patients (n=22) were free from atrial dysrhythmias. At 3 months (n=19), 84% of patients were off antiarrhythmic drugs. At 6 months (n=18), 94% of patients were free from AF and off antiarrhythmic medications. At 12 months (n=16), 81% of patients were free from AF and off antiarrhythmic drugs and three patients remained on warfarin for a mechanical mitral valve.A full CMP can be performed through a right mini-thoracotomy with outstanding short-term results. This less invasive procedure can be offered to patients without compromising efficacy.
| S-EPMC2967773 | biostudies-other
Project description:ObjectiveObesity is a strong and independent factor for the development of atrial fibrillation (AF), and adversely impacts the success of catheter ablation procedures for AF. This study evaluated the impact of body mass index (BMI) on the outcomes following surgical ablation of AF.MethodsBetween 2003 and 2019, 236 patients underwent a stand-alone biatrial Cox maze IV procedure (CMP-IV) for refractory AF. Obesity was defined as BMI ≥30 kg/m2. Patients were divided into two groups: BMI <30 kg/m2 (n = 100) and BMI ≥30 kg/m2 (n = 136). Freedom from atrial tachyarrhythmia (ATA) was determined using electrocardiography, Holter, or pacemaker interrogation at 1 year and annually thereafter. Recurrence was defined as any documented ATA lasting ≥30 s. Predictors of recurrence were determined using multivariable logistic regression. Preoperative and procedural outcomes were compared between groups.ResultsObese patients had a higher rate of diabetes (16% vs 7%, P = 0.044) and larger left atrial diameter (4.9 ± 1.1 cm vs 4.6 ± 1.0 cm, P = 0.021) when compared to non-obese patients. There was no difference in major complication rate between the groups (4% vs 7%, P = 0.389). There was no operative mortality in either group. During 4.1 ± 2.4 years of follow-up, there was no significant difference in freedom from ATA with or without antiarrhythmic drugs in obese patients when compared to the non-obese group (P > 0.05). Absence of sinus rhythm at discharge predicted AF recurrence up to 7 years postoperatively.ConclusionsAs opposed to catheter ablation, obesity did not adversely impact the short and long-term outcomes of stand-alone surgical ablation with CMP-IV, and BMI was not a predictor of AF recurrence. Additionally, there was no significant increase in major complications in obese patients.
| S-EPMC9062928 | biostudies-literature
Project description:Cardiac adipose tissue is a well-known risk factor for the recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation, but its correlation with maze surgery remains unknown. The aim of this study was to investigate the correlation between the recurrence of AF and the adipose component of the left atrium (LA) in patients who underwent a modified Cox maze (CM) III procedure. We reviewed the pathology data of resected LA tissues from 115 patients, including the adipose tissue from CM-III procedures. The mean follow-up duration was 30.05 ± 23.96 months. The mean adipose tissue component in the AF recurrence group was 16.17% ± 14.32%, while in the non-recurrence group, it was 9.48% ± 10.79% (p = 0.021), and the cut-off value for the adipose component for AF recurrence was 10% (p = 0.010). The rates of freedom from AF recurrence at 1, 3, and 5 years were 84.8%, 68.8%, and 38.6%, respectively, in the high-adipose group (≥10%), and 96.3%, 89.7%, and 80.3%, respectively, in the low-adipose group (<10%; p = 0.002). A high adipose component (≥10%) in the LA is a significant risk factor for AF recurrence after CM-III procedures. Thus, it may be necessary to attempt to reduce the perioperative adipose portion of the cardiac tissue using a statin in a randomized study.
| S-EPMC8837174 | biostudies-literature
Project description:ObjectiveMost patients with atrial fibrillation (AF) undergoing cardiac surgery do not receive concomitant ablation. This study reviewed outcomes of patients with AF undergoing Cox-maze IV (CMIV) procedure with radiofrequency and cryoablation and coronary artery bypass grafting (CABG) at our institution.MethodsBetween the introduction of radiofrequency ablation in 2002 and 2015, 135 patients underwent left- or biatrial CMIV with CABG. Patients undergoing other cardiac procedures, except mitral valve repair, or who had emergent, reoperative, or off-pump procedures were excluded. Eighty-three patients remained in the study group after exclusion criteria were applied. Freedom from atrial tachyarrhythmias (ATAs) was ascertained using electrocardiogram, Holter monitor, or pacemaker interrogation at 1 to 5 years postoperatively.ResultsOperative mortality was 3%. Freedom from ATAs at 1 year in the CMIV group was 98%, with 88% off antiarrhythmia drugs. Freedom from ATAs and antiarrhythmia drugs was 70% at 5 years.ConclusionsThe addition of CMIV to CABG resulted in excellent freedom from ATAs at 1 to 5 years. These patients are at increased risk for nonfatal complications compared with others undergoing concomitant surgical ablation.
| S-EPMC5398092 | biostudies-literature
Project description:Objective: Atrial fibrillation is the most prevalent persistent arrhythmia in patients with hypertrophic obstructive cardiomyopathy. Comparative analyses of the safety and effectiveness of septal myectomy with and without surgical ablation are limited. This study aimed to compare the outcomes of septal myectomy with and without the Cox-maze IV procedure in patients with hypertrophic obstructive cardiomyopathy and atrial fibrillation. Methods: Ninety-four patients with hypertrophic obstructive cardiomyopathy and atrial fibrillation who underwent septal myectomy were analyzed, we divided it into concomitant Cox maze surgery (Cox-maze group) and no concomitant Cox maze operation (no Cox-maze group). Freedom from atrial fibrillation recurrence and all-cause mortality after surgery were assessed. Results: Freedom from all-cause mortality after septal myectomy at 1, 3, and 5 years was 98.5 ± 1.5% each in the Cox-maze group and 90.8 ± 6.3%, 85.1 ± 8.1%, and 85.1 ± 8.1%, respectively, in the no Cox-maze group. Patients in the no Cox-maze group had lower survival, freedom from atrial fibrillation recurrence off antiarrhythmic drugs, and arrhythmia control rate (including patients with successful antiarrhythmic drug conversion) than those in the Cox-maze group (P = 0.046, P = 0.040, and P = 0.012, respectively). Patients who underwent the Cox-maze IV procedure had lower atrial fibrillation recurrence rate than those who did not (hazard ratio, 0.141; 95% confidence interval, 0.042-0.479; P = 0.002). Post-operative increases in left atrial diameters (hazard ratio, 1.099; 95% confidence interval, 1.024-1.179; P = 0.009) were associated with atrial fibrillation recurrence. Conclusions: The Cox-maze IV procedure combined with septal myectomy improved mid-term survival and reduced mid-term atrial fibrillation recurrence in patients with hypertrophic obstructive cardiomyopathy and atrial fibrillation. The concomitant Cox-maze IV procedure was associated with a lower atrial fibrillation recurrence in patients with surgical hypertrophic obstructive cardiomyopathy and atrial fibrillation.
| S-EPMC8365245 | biostudies-literature
Project description:BackgroundThere was limited evidence on the clinical benefits of the concomitant Cox-Maze procedure with aortic valve replacement (AVR) in patients with atrial fibrillation. This study aimed to evaluate the early and long-term results of the concomitant Cox-Maze procedure in patients undergoing AVR for aortic valve disease.MethodsWe enrolled 101 patients who underwent AVR and had preoperative atrial fibrillation between January 1994 and December 2020. The early- and long-term clinical outcomes were compared between patients who underwent the concomitant Cox-Maze III procedures and those who did not undergo surgical ablation. Inverse probability of treatment weighting (IPTW) was used to adjust for differences in preoperative characteristics.ResultsForty-seven patients underwent the concomitant Cox-Maze III procedure (CM group), and 54 patients did not undergo surgical ablation for atrial fibrillation (non-CM group). There were no significant differences in early surgical outcomes between the two groups, except for a higher occurrence of acute kidney injury (AKI) in the CM group (P<0.001). The median follow-up duration was 70.7 months (interquartile range 36.2-118.8 months), and there were no significant differences in overall survival, thromboembolic complications, and anticoagulation-related bleeding between the two groups. Atrial fibrillation occurrence was significantly lower (P<0.001) in the CM group, and a greater number of patients discontinued anticoagulation in the CM group compared to the non-CM group (P=0.001).ConclusionsThe concomitant Cox-Maze procedure in patients with atrial fibrillation undergoing AVR did not increase early mortality or morbidity, except for AKI, and showed favorable long-term results in terms of rhythm outcome and anticoagulation discontinuation.
| S-EPMC11833580 | biostudies-literature
Project description:BackgroundAtrial tachycardias (ATs) frequently develop after a surgical Maze procedure. We aimed to elucidate the electrophysiologic mechanisms and their arrhythmogenic substrates of these ATs.Methods and resultsWe retrospectively reviewed 20 patients (14 females, mean age of 55.5 ± 8.6 years) with post-Maze ATs who underwent high-resolution mapping at three institutions. The slow conduction areas, reentry circuits, voltage signals, complex electrograms, and their correlation with the surgical incisions and lesions placed in the surgical Maze procedures were analyzed. Thirty-six ATs with a mean cycle length of 260.0 ± 67.6 ms were mapped in these patients. Among them, 22 (61.1%) were anatomical macro-reentrant ATs (AMAT), 12 (33.3%) non-AMATs (localized ATs), and 2 (5.6%) focal ATs, respectively. Epicardial conduction bridges were observed in 6/20 (30.0%) patients and 7/36 (19.4%) ATs. Different arrhythmogenic substrates were identified in these ATs, including slow conduction regions within the previous lesion areas or between the incisions and anatomical structures, the prolonged activation pathways caused by the short lesions connecting the tricuspid annulus, and the circuits around the long incisions and/or lesions.ConclusionsReentry is the main mechanism of the post-Maze ATs. The pro-arrhythmic substrates are most likely caused by surgical incisions and lesions. The slow conduction regions and the protected channels yielded from these areas are the major arrhythmogenic factors.
| S-EPMC10112846 | biostudies-literature
Project description:BackgroundCox-Maze procedure is currently the gold standard treatment for atrial fibrillation (AF). However, data on the effectiveness of the Cox-Maze procedure after concomitant mitral valve surgery (MVS) are not well established. The aim of this study was to assess the safety and efficacy of Cox-Maze procedure versus no-maze procedure n in AF patients undergoing mitral valve surgery through a systematic review of the literature and meta-analysis.MethodsA systematic search on PubMed/MEDLINE, EMBASE, and Cochrane Central Register of Clinical Trials (Cochrane Library, Issue 02, 2017) databases were performed using three databases from their inception to March 2023, identifying all relevant randomized controlled trials (RCTs) comparing Cox-Maze procedure versus no procedure in AF patients undergoing mitral valve surgery. Data were extracted and analyzed according to predefined clinical endpoints.ResultsNine RCTs meeting the inclusion criteria were included in this systematic review with 663 patients in total (341 concomitant Cox-Maze with MVS and 322 MVS alone). Across all studies with included AF patients undergoing MV surgery, the concomitant Cox-Maze procedure was associated with significantly higher sinus rhythm rate at discharge, 6 months, and 12 months follow-up when compared with the no-Maze group. Results indicated that there was no significant difference between the Cox-Maze and no-Maze groups in terms of 1 year all-cause mortality, pacemaker implantation, stroke, and thromboembolism.ConclusionsOur systematic review suggested that RCTs have demonstrated the addition of the Cox-Maze procedure for AF leads to a significantly higher rate of sinus rhythm in mitral valve surgical patients, with no increase in the rates of mortality, pacemaker implantation, stroke, and thromboembolism.
| S-EPMC10949564 | biostudies-literature