Cox Maze Procedure For Atrial Fibrillation Research Articles

Are There Gender Differences in Outcomes after the Cox-Maze Procedure for Atrial Fibrillation?

Atrial fibrillation (AF) management suggests that women do not tolerate medication rhythm control strategies as well as men do; however, AF percutaneous catheter ablation has been found to be favorable. The study purpose was to compare the sex-based outcomes for patients who undergo the Cox-Maze procedure for AF. Data were collected through our AF surgical ablation registry. Rhythm was verified by electrocardiogram and 24-hour holter at 6 and 12 months. General health-related quality of life (Short-Form 12) and specific AF symptom burden (Atrial Fibrillation Symptom Checklist: Frequency and Severity, version 3) were obtained at baseline and 12 months. Since 2005, a total of 540 patients have undergone a Cox-Maze procedure (34% were women). The women presented with higher operative risk [additive European System for Cardiac Operative Risk Evaluation (EuroSCORE), 6.71 ± 2.61 vs 5.25 ± 2.80, t = 5.85, P < 0.001], higher rates of congestive heart failure (49% vs 32%, P < 0.001), and more concomitant mitral valve procedures (32% vs 19%, P = 0.001). Perioperative outcomes were similar. Return to sinus rhythm off antiarrhythmics were not different at 6 and 12 months (78% vs 75%, P = 0.53, and 81% vs 80%, P = 1.00, respectively). Cumulative 2-year survival (93.9% for the men and 89.3% for the women) was not different for all-cause mortality (hazard ratio, 1.47; confidence interval, 0.68-3.21; P = 0.33) and cardiac-related mortality [women: 10/14 (71%) vs men 7/11 (64%), P = 1.00]. Health-related quality of life showed significant improvement; AF symptoms significantly decreased across the sexes. Outcomes after the Cox-Maze procedure are similar across sex. Atrial fibrillation surgical ablation should be considered a treatment option for women-it is safe and effective, improves general health-related quality of life, and reduces AF symptom burden.

Are There Gender Differences in Outcomes after the Cox-Maze Procedure for Atrial Fibrillation?

Are There Gender Differences in Outcomes after the Cox-Maze Procedure for Atrial Fibrillation?

Bacterial Pericarditis due to Providencia stuartii

A 58-year-old man was admitted for relapsing pericarditis. His past medical history included a transient ischemic attack when he was 47 years old, radical right nephrectomy for neoplasia 8 years earlier, and hypertension. One year earlier, a diagnosis of pleuropericarditis was made in another hospital. The patient was febrile and complained of chest pain; an echocardiogram showed thickening of parietal pericardium, hyperechoic matter on visceral pericardium, and the presence of pericardial and pleural effusion, without hemodynamic impairment. Concomitantly, the patient had a dental abscess; cultures from this abscess were negative during antibiotic therapy. He was treated empirically with piperacillin/tazobactam for 15 days and then with amoxicillin/clavulanate for ≈1 month and …

Normal Quality of Life after the Cox-Maze Procedure for Atrial Fibrillation

BACKGROUND/OBJECTIVE: Atrial fibrillation(AF) has been shown in numerous studies to significantly decrease patient quality of life. The Cox-Maze procedure has excellent long-term efficacy in curing AF. However, it is unknown whether this procedure improves long-term quality of life in these patients. The purpose of this study was to examine late quality of life in patients that underwent a lone Cox-Maze procedure. METHODS: Between 1987 and 2003, 163 patients underwent a Cox-Maze procedure for lone AF at our institution. Of these, 68 patients agreed and completed the Medical Outcomes Study Short Form 36 Health Survey. Scores from the age-matched general US population were normalized to a mean of 50 and standard deviation of 10 to facilitate comparison. Collected data were compared to the norm-based score for each domain using a one-sample t-test. Four patients were removed from analysis because of AF recurrence. RESULTS: There were 52 males(81%). Mean age was 52.6±9.5 years. Preoperatively, 37 patients(58%) had paroxysmal and 25 patients(39%) had persistent or permanent AF. The mean duration of AF before surgery was 9.8±8.2 years. There was no statistical difference in norm-based scores between the Cox-Maze procedure group and the age-matched general US population in any of the eight health domains at a mean follow-up of 8.7±3.7 years. CONCLUSION: Our results suggest that the Cox-Maze procedure cures atrial fibrillation in the majority of patients, and that those patients that are cured obtain a normal quality of life as compared to the general population at late follow-up.

Normal Quality of Life after the Cox-Maze Procedure for Atrial Fibrillation

Normal Quality of Life after the Cox-Maze Procedure for Atrial Fibrillation

Invited commentary

Invited commentary

Ten-year Experience With the Cox-Maze Procedure for Atrial Fibrillation: How Do We Define Success?

The Cox-maze procedure is the standard to which other surgical treatments of atrial fibrillation (AF) are compared. However, evaluation of new devices and lesion sets is difficult because of variable methods of reporting success in eliminating AF. We analyzed 10-year outcome with the "cut and sew" Cox-maze procedure and present rhythm at last follow-up, interval contact, and actuarial AF freedom. Between March 1993 and December 2002, 335 patients (211 men) underwent the Cox-maze procedure (age, 22 to 83 years; median, 62 years). Atrial fibrillation was chronic (CAF) in 175 patients and paroxysmal (PAF) in 160. Concomitant mitral valve procedures were performed in 59%, coronary artery bypass grafting in 19%, and tricuspid valve repairs in 7%. Early mortality was 0.9%. During hospitalization, transient AF occurred in 29% of patients and 10% required implantation of a new permanent pacemaker (PPM). Dismissal electrocardiogram was normal sinus rhythm in 64%, junctional rhythm in 18%, AF in 11%, and PPM in 7%. At last follow-up (mean 42 +/- 6 months), 88% of patients were free of AF. However, when analyzed by the Kaplan-Meier method, freedom from AF was lower for patients with preoperative lone PAF (5 years, 90%; 10 years, 64%), preoperative lone CAF (5 years, 80%; 10 years, 62%), and patients undergoing combined maze-mitral valve surgery (5 years, 68%; 10 years, 41%). Ten-year results with the standard Cox-maze procedure confirm high effectiveness, but reporting methods should be standardized to account for patients who have transient atrial arrhythmias during long-term follow-up.

The effect of ablation technology on surgical outcomes after the Cox-maze procedure: A propensity analysis

Since its introduction in 1987, the Cox-maze procedure has been the gold standard for the surgical treatment of atrial fibrillation. At our institution, this procedure has evolved from the cut-and-sew technique (Cox-maze III procedure) to one using bipolar radiofrequency energy and cryoablation as ablative sources to replace most incisions (Cox-maze IV procedure). This study compared surgical outcomes of patients undergoing the Cox-maze III procedure versus those of patients undergoing the Cox-maze IV procedure by using propensity analysis. From April 1992 through July 2005, 242 patients underwent the Cox-maze procedure for atrial fibrillation. Of these, 154 patients had the Cox-maze III procedure, and 88 had the Cox-maze IV procedure. Logistic regression analysis was used to identify covariates among 7 baseline patient variables. Using the significant regression coefficients, each patient's propensity score was calculated, allowing selectively matched subgroups of 58 patients each. Operative outcomes were analyzed for differences. Late follow-up was available for 112 (97%) patients. Freedom from atrial fibrillation recurrence and survival was calculated at 1 year by using Kaplan-Meier analysis. The Cox-maze III procedure had significantly longer crossclamp times. There was no significant difference in intensive care unit and hospital stay, 30-day mortality, permanent pacemaker placement, early atrial tachyarrhythmias, late stroke, and survival. Freedom from atrial fibrillation recurrence was greater than 90% in both groups at 1 year. The use of bipolar radiofrequency ablation has simplified the Cox-maze procedure, making it applicable to virtually all patients with atrial fibrillation undergoing concomitant cardiac surgery. The Cox-maze IV procedure produces similar surgical outcomes to the Cox-maze III procedure at 1 year of follow-up.

Atrial reduction plasty Cox maze procedure: extended indications for atrial fibrillation surgery

Background The Cox maze procedure yields good results for atrial fibrillation (AF). However, patients with predictors of failure—chronic long-standing AF, low amplitude fibrillatory waves, and large left atriums—are generally thought not to benefit from a maze procedure. We report an aggressive approach for these patients, utilizing biatrial reduction plasty concomitantly with the Cox maze procedure for AF. Methods A complete Cox maze procedure utilizing supplemental RF ablation was performed in 36 patients. All underwent resection of both atrial appendages and biatrial reduction plasty encompassing resection of the left atrial posterior wall from left to right pulmonary veins and from inferior pulmonary veins to the mitral annulus, as well as removal of the right atrial lateral wall. Mitral or tricuspid valve repair, or both, was performed on 32 patients. Results These patients had a mean AF duration of 45 ± 89 months. Their preoperative left atria measured 66 ± 16 mm, with mean AF waves of 0.74 ± 0.3 mm. Mean preoperative New York Heart Association class was 2.7 ± 0.7 and left ventricular ejection fraction was 48 ± 9. Cross clamp and bypass times were 91 ± 35 minutes and 124 ± 33 minutes, respectively. The average posterior left atrial tissue resected was 5.4 × 2.1 cm, and mean resected atrial weight was 10.3 ± 2 g. There were no deaths and length of stay was 5.5 ± 2 days. At a follow-up time of 19 ± 16 months, 32 of the 36 patients were in normal sinus rhythm and New York Heart Association class I. Conclusions Aggressive biatrial reduction plasty Cox maze procedure was effective in 89% of these “low success” AF patients. This simple procedure can extend utilization of the Cox maze procedure to more patients with chronic AF.

Cox-Maze procedure for atrial fibrillation: Mayo Clinic experience.

The Cox-Maze procedure corrects atrial fibrillation in 90% of patients, and successful operation restores sinus rhythm, thereby reducing risks of thromboembolism and anticoagulant-associated hemorrhage. Symptoms such as palpitation and fatigability also improve with restoration of atrioventricular synchrony. At the Mayo Clinic, 221 Cox-Maze procedures were performed from March 1993 through March 1999. Over 75% of patients had associated cardiac disease and concomitant operations. Overall, early mortality was 1.4%, and the incidence of postoperative pacemaker implantation was 3.2%. Limiting incisions to the right atrium simplifies the operation for patients who primarily have tricuspid valve disease, and in early follow-up, outcome appeared to be as good as that achieved with biatrial incisions. The Cox-Maze procedure has proved particularly useful for patients with preoperative atrial fibrillation who require valvuloplasty for acquired mitral valve regurgitation; 87 patients have had this combined procedure, and there have been no early deaths. Further, our experience indicates that ventricular dysfunction is not a contraindication for operation and that restoration of sinus rhythm after the Cox-Maze procedure improves left ventricular ejection fraction in most patients.