Minimally Invasive Stand-Alone Cox-Maze Procedure for Patients With Nonparoxysmal Atrial Fibrillation

Abstract

Catheter-based ablation for atrial fibrillation (AF) performed percutaneously is shown to be limited in patients with nonparoxysmal AF (non-PAF). The full Cox-Maze surgical procedure demonstrated good success with non-PAF, but concerns were raised regarding increased morbidity eliminating the effect of the success rate. This study assessed the safety and efficacy of a stand-alone on-pump Cox-Maze procedure for non-PAF. Since 2005, 104 stand-alone Cox-Maze procedures for non-PAF were performed through a right minithoracotomy (6 cm) with femoral cannulation. Patients were monitored prospectively through our AF registry. Rhythm was verified by electrocardiogram and 24-hour Holter monitoring. Health-related quality of life (SF-12 Health Survey, Quality Metric, Lincoln, RI) and AF symptoms were assessed. Patients were a mean age of 55.9±9.0 years, and 78% had long-standing persistent AF. Patient outcomes included no operative (30 days) deaths or renal failure, 1 pacemaker, and 1 transient ischemic attack. The return to sinus rhythm at 6, 12, 24, 36 months was 94%, 94%, 92%, 92%, and off antiarrhythmic drugs was 87%, 87%, 79%, 80%, respectively. The success rate at 6 months after the initial 20 patients improved from 89% to 94%. Multivariate analysis found duration of AF predicted rhythm at 6 months (odds ratio, 1.15; 95% confidence interval, 1.01 to 1.31; p=0.04). Significant improvement was noted for health-related quality of life and decreased AF symptoms at 1 year. The long-term success rate after the Cox-Maze III procedure in a challenging group of non-PAF patients is acceptable. Our experience suggests the development of educational strategies to overcome the initial learning curve and patient selection criteria for AF surgical ablation.