Abstract
PurposeTo compare findings in patients undergoing atrial fibrillation(AF) and/or atrial flutter(AFl) ablation after failed cut and sew (CS) vs. non-cut and sew (NCS) surgical maze.MethodsWe compared 10 patients with prior CS to 25 with prior NCS maze undergoing catheter ablation after failed maze.ResultsPatient demographics: Age 68.3 ± 8.7 CS vs. 68.2 ± 9.2 NCS(P = 0.977), male 70% CS vs. 72% NCS(P = 1.000), LA size 5.11 ± 0.60 cm CS vs. 4.54 ± 0.92 cm NCS(P = 0.096), sternotomy 100% CS vs. 64% of NCS(P = 0.036). Concomitant heart surgery in 100% CS and 68% NCS(P = 0.073). NCS used radiofrequency 84%, cryoablation 8%, microwave 4%, and ultrasound 4%. All maze operations targeted pulmonary vein (PV) isolation. The maze also targeted the mitral isthmus 100% CS vs. 36% NCS(P = 0.001) and the tricuspid isthmus 90% CS vs. 40% NCS (P = 0.018). Maze failure arrhythmia mechanism was AF 0% CS and 56% NCS (P = 0.0006). Nine CS pts failed for AFl and 1 for RA tachycardia. For NCS pts, 11 failed for AFl. CS isolated 94% of PVs and NCS isolated only 26% of PVs (P < 0.0005). At EPS, clinical and induced arrhythmias were ablated and non-isolated PVs were isolated. After final ablation, arrhythmia-free rates were 60% for CS and 52% for NCS (P = 0.723) after 2.99 ± 2.35 years.ConclusionsAfter failed surgical maze, CS isolated nearly all PVs and NCS never isolated all PVs and the clinical rhythm was more frequently AF for NCS and AFl for CS. CS remains the surgical gold standard for durable PV isolation.
Highlights
James L Cox introduced the first surgical procedure for atrial fibrillation (AF) and the original Cox maze procedure has undergone several iterations [1]
In the original Cox maze IV, the right and left pulmonary vein (PV) were encircled as two circles and an inferior line leaving most of the posterior left atrial (LA) electrically connected to the remainder of the atrium
A cryoablation line was placed from the PV encircling incision to the mitral annulus on the endocardial surface, and the line was repeated on the epicardial surface including the coronary sinus to preclude a loop around the mitral valve or through the coronary sinus
Summary
James L Cox introduced the first surgical procedure for atrial fibrillation (AF) and the original Cox maze procedure has undergone several iterations [1]. The Cox maze III procedure achieved wide popularity as both a stand-alone procedure and as an add-on procedure for patients undergoing other types of open-heart surgery [3]. The Cox maze III procedure involved a box lesion consisting of a through and through surgical incision around all 4 PVs (PVs). In the original Cox maze IV, the right and left PVs were encircled as two circles and an inferior line leaving most of the posterior LA electrically connected to the remainder of the atrium. Variations of the Cox maze IV procedure have been done at the time of open-heart surgery via sternotomy or as stand-alone procedures through mini thoracotomies or ports, both as on-pump or off-pump procedures. Procedures have used focused ultrasound [6], and surgical and catheter-
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