A minimally invasive Cox maze IV procedure is as effective as sternotomy while decreasing major morbidity and hospital stay

Abstract

Objectives The Cox-Maze IV has the best results for the surgical treatment of atrial fibrillation. It has been traditionally performed through sternotomy with excellent outcomes, but this has been felt to be too invasive. An alternative approach is to perform a less invasive right anterolateral minithoracotomy. This series compared these approaches at a single center in consecutive patients. Methods Patients receiving Cox-Maze IV (n=356) were retrospectively reviewed from January 2002 to February 2014. Patients were stratified into two groups: right mini-thoracotomy (RMT: n=104) and sternotomy (ST: n=252). Preoperative and perioperative variables were compared as well as long term outcomes. Patients were followed for up two years and rhythm was confirmed with electrocardiogram or prolonged monitoring. Results Freedom from atrial tachyarrhythmias off antiarrhythmic drugs was 81% and 74% at 1 and 2 year respectively using a RMT approach and was not significantly different from the ST group at these same time points. Overall complication rate was lower in the RMT group (6% vs. 13%, p=0.044) as was 30 day morality (0% vs. 4%, p=0.039). Median ICU length of stay was lower in the RMT group (2 days [range 0-21] vs. 3 days [range 1-61], p=0.004) as was median hospital length of stay (7 days [range 4-35] vs. 9 days [range 1-111], p<0.001). Conclusions The Cox-Maze IV performed through a right mini-thoracotomy is as effective as sternotomy in the treatment of atrial fibrillation. This approach was associated with fewer complications and decreased mortality and decreased ICU and hospital length of stays.

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…dwubiegunowa ablacja RF lub kriotermia) sprawia, że zabiegi labiryntowania Cox-Maze są łatwiejsze, bardziej powtarzalne i możliwe z dostępu przez minitorakotomię [786,807,808]. Torakoskopowa PVI za pomocą dwubiegunowej ablacji RF zapobiega nawrotom AF (odsetek pacjentów bez arytmii w rocznej obserwacji 69-91%, układ wykonywanych uszkodzeń -patrz ryc.…”

“…leczenia AF IIa B [468,812,819,823] Operacja labiryntowania, najlepiej z dostępu minimalnie inwazyjnego, wykonywana w doświadczo-nym ośrodku przez odpowiednio wyszkolonego operatora, powinna być rozważana przez kardiogrupę (Heart Team) ds. leczenia AF jako metoda terapii pacjentów z objawowym, opornym na leczenie przetrwałym AF lub AF po ablacji w celu zmniejszenia objawów IIa C [808,832] Operacja labiryntowania, najlepiej obejmująca oba przedsionki, powinna być rozważana w celu zmniejszenia objawów przypisywanych AF u pacjentów poddawanych operacji kardiochirurgicznej, z uwzględnieniem dodatkowego ryzyka zabiegowego i korzyści z leczenia w celu kontroli rytmu serca [362] prób klinicznych z użyciem NOAC [39] oraz analiz przeprowadzonych u starszych Amerykanów (Medicare) [396]. Pacjenci w podeszłym wieku z AF są bardziej zagrożeni udarem mózgu, a wiec prawdopodobieństwo korzyści z OAC jest u nich większe niż u młodszych pacjentów [841], a mimo to OAC jest wciąż niedostatecznie wykorzystywane u osób w podeszłym wieku [220,842].…”

Surgical ablation for atrial fibrillation

“…Our group has shown that freedom from atrial fibrillation off antiarrhythmic drugs (AADs) was not significantly different between the two groups at 3, 6, 12, and 24 months [20]. Furthermore, the patients who underwent RMT had fewer complications, decreased ICU stays, and decreased median length of hospital stays when compared with those patients who underwent sternotomy [21 ▪▪ ]. These promising results demonstrate that the CMP IV performed through an RMT approach is as effective as sternotomy in the treatment of atrial fibrillation.…”

Minimally invasive surgery for atrial fibrillation

“…invasive RMT approach to the CMIV, compared to other minimally invasive techniques for AF ablation, is that it may be used in patients with concomitant mitral and tricuspid valve disease. In our series discussed above, MV repair or replacement was performed in 52% of patients undergoing the minimally invasive RMT CMIV procedure (2). We have further shown that the addition of concomitant MV surgery did not alter rates of freedom from ATAs after the CMIV procedure, although patients with concomitant MV disease can be expected to have more preoperative comorbidities and a higher complication rate following surgery (25).…”

“…This has made the operation more accessible to cardiac surgeons and patients, while achieving comparable results with less morbidity (2). Surgical innovation has also led to the development of other minimally invasive surgical approaches to AF ablation, including minimally invasive pulmonary vein isolation (PVI), extended left atrial lesion sets, and hybrid procedures.…”