Surgical ablation for atrial fibrillation for two decades: are the results of new techniques equivalent to the Cox maze III procedure? J Thorac Cardiovasc Surg 2014 May;147(5):1478-86
Date
02/25/2014Pubmed ID
24560517DOI
10.1016/j.jtcvs.2013.10.084Scopus ID
2-s2.0-84899934501 (requires institutional sign-in at Scopus site) 51 CitationsAbstract
OBJECTIVES: A significant evolution has occurred in surgical ablation for atrial fibrillation (AF) toward alternate energy sources, lesion sets, and approaches, with the intent of simplifying the Cox maze III operation and maintaining similar outcomes. Because no large comparative studies with long-term follow-up exist, we have reviewed our experience.
METHODS: From January 1993 to January 2011, 1540 patients underwent surgical ablation for AF. The operations were performed in conjunction with repair of congenital heart disease in 351 (30%) and adult-acquired disease in 1189 patients (70%). In the 1189 patients, preoperative AF was paroxysmal in 598 (50%) and persistent in 591 (50%). The energy sources included cut and sew in 521 (44%), cryothermy in 267 (22%), radiofrequency in 262 (22%), and a combination in 139 patients (12%). The lesion sets included biatrial in 810 (68%), isolated pulmonary vein isolation in 269 (23%), and isolated left atrial in 110 (9%). AF ablation was performed during isolated mitral valve surgery in 516 patients (43%).
RESULTS: The median follow-up was 33 months (maximum, 20.3 years), and late rhythm follow-up was available for 80%. The cut and sew Cox maze III procedure was superior at each follow-up interval (P = .01, P = .03, and P < .001). On multivariate analysis, the cut and sew maze procedure was independently associated with less risk of recurrent AF at a follow-up period of 1 to 5 years (hazard ratio, 0.4; 95% confidence interval, 0.24-0.69; P < .001) and >5 years (hazard ratio, 0.23; 95% confidence interval, 0.12-0.42; P < .001) for all patients. When performed during isolated mitral valve surgery, the cut and sew Cox maze III was also independently associated with less risk of recurrent AF at >5 years (hazard ratio, 0.23; 95% confidence interval, 0.08-0.66; P = .007).
CONCLUSIONS: The cut and sew Cox maze III procedure appears to offer significantly greater freedom from AF without antiarrhythmic medications compared with alternate energy sources and lesion sets. Although alternate energy sources offer the advantage of quicker application and the possibility of minimally invasive applications, the Cox maze III operation arguably remains the reference standard for the surgical treatment of AF and should still be considered, especially for patients for whom AF ablation is of critical importance.
Author List
Stulak JM, Suri RM, Burkhart HM, Daly RC, Dearani JA, Greason KL, Joyce LD, Park SJ, Schaff HVMESH terms used to index this publication - Major topics in bold
AgedAnti-Arrhythmia Agents
Atrial Fibrillation
Catheter Ablation
Female
Humans
Male
Middle Aged
Multivariate Analysis
Patient Selection
Recurrence
Retrospective Studies
Risk Factors
Time Factors
Treatment Outcome