Background The Cox-Maze procedure (CMP) has achieved high success rates in the therapy of atrial fibrillation (AF) while becoming progressively less invasive. This report evaluates our experience with the CMP in the treatment of lone AF over two decades and compares the original cut-and-sew CMP-III to the ablation-assisted CMP-IV, which uses bipolar radiofrequency and cryoenergy to create the original lesion pattern. Methods and Results Data were collected prospectively on 212 consecutive patients (mean age: 53.5±10.4, 78% males), who underwent a stand-alone CMP from 1992 through 2010. Median duration of preoperative AF was 6 (IQR 2.9–11.5) years, with 48% paroxysmal and 52% persistent or longstanding persistent AF. Univariate analysis with preoperative and perioperative variables used as covariates for the CMP-III (n=112) and the CMP-IV (n=100) was performed. Overall, 30-day mortality was 1.4% with no intraoperative deaths. Freedom from AF was 93% and freedom from AF off antiarrhythmics was 82% at a mean follow-up time of 3.6 ± 3.1 years. Freedom from symptomatic AF at 10 years was 85%. Only one late stroke occurred with 80% of patients being off anticoagulation. The less invasive CMP-IV had significantly shorter cross-clamp times (41±13 vs. 92±26 minutes, p<0.001) while achieving high success rates with 90% freedom from AF and 84% freedom from AF off antiarrhythmics at 2 years. Conclusions The CMP, while simplified and shortened by alternative energy sources, has excellent results even with improved follow-up and stricter definition of failure.

Purpose The Cox-maze III procedure (CMP) has achieved high success rates for the surgical treatment of atrial fibrillation (AF). In 2002, our group introduced a simplified CMP, in which most incisions were replaced with linear lines of ablation using bipolar radiofrequency and cryoenergy. This operation, termed the CMP-IV, has significantly shortened operative times and allowed for a minimally invasive approach. This report evaluates our results in 100 consecutive patients undergoing a stand-alone CMP-IV. Methods Data were collected prospectively on 100 patients (mean age, 56±10 years) who underwent a CMP-IV from January 2002 through May 2010. All patients were available for follow-up with a mean follow-up of 17±10 months. Electrocardiograms or 24-h Holter monitorings were obtained at 6, 12, and 24 months. Data were analyzed using a longitudinal database containing over 380 variables. Results Thirty-one percent of patients had paroxysmal AF, with the remainder having persistent (6%) or longstanding persistent AF (63%). The mean preoperative duration of AF was 7.4±6.7 years. The mean left atrial diameter was 4.7±1.1 cm. In this group, 40 patients had failed with a mean of 2.6±1.3 catheter ablations. Mean aortic cross-clamp time was 41±13 min. There was one postoperative mortality. Postoperative freedom from AF was 93%, 90%, and 90% at 6, 12, and 24 months, respectively. Freedom from AF off antiarrhythmic medication was 82%, 82%, and 84% at 6, 12, and 24 months, respectively. Conclusion The less invasive CMP-IV has a high single procedure success rate, even with improved follow-up and stricter definitions of failure.

Valve-sparing autograft reoperations after the Ross procedure carry a low operative risk, with acceptable reintervention rates in the first postoperative decade. Patients with isolated and/or severe autograft regurgitation have an increased hazard of reintervention after valve-sparing reoperation; for these patients, careful preoperative weighing of surgical options is required.

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The Ross operation is a complex procedure for aortic valve replacement in which the pulmonary autograft is replaced by a homograft. However, homograft availability is becoming limited. This report evaluates the performance of porcine stentless prostheses as alternative pulmonary substitutes. Echocardiographic results from two patient cohorts were compared at time of discharge and 1 year after a Ross procedure. Thirty-three patients (median age 42 years, range 17-62 years, 76% male) received a stentless prosthesis (median size 25.6 mm, range 25-29 mm) for right ventricular outflow tract reconstruction. Clinical data were not significantly different from 106 patients (median age 47 years, range 2-68 years, 75% male) who received cryopreserved homografts (median size 26 mm, range 20-33 mm). At time of discharge, peak pressure gradients (ΔPmax ) across the stentless valve (median ΔPmax 13 mmHg, range 2-26 mmHg) were higher compared to homografts (median ΔPmax 7 mmHg, range 1-32 mmHg, p<0.001). At 1 year, gradients increased in both groups, but were significantly higher across stentless valves (median ΔPmax 23 mmHg, range 10-81 mmHg vs. median ΔPmax 13 mmHg, range 2-74 mmHg, p<0.001). Eleven patients (33%) in the stentless-valve group were classified "at risk" with a ΔPmax of ≥30 mmHg. Four of them (12%) had to be re-operated. In conclusion, stentless valves showed higher pressure gradients and their performance was inferior to cryopreserved homografts. See accompanying commentary by Ulrich Stock DOI: 10.1002/biot.201200341.