The Cox-maze IV procedure in its second decade: still the gold standard?

Abstract

Atrial fibrillation (AF) is the most common cardiac arrhythmia and the treatment options include medical treatment and catheter-based or surgical interventions. AF is a major cause of stroke, and its prevalence is increasing. The surgical treatment of AF has been revolutionized over the past 2 decades through surgical innovation and improvements in endoscopic imaging, ablation technology and surgical instrumentation. The Cox-maze (CM) procedure, which was developed by James Cox and introduced clinically in 1987, is a procedure in which multiple incisions are created in both the left and the right atria to eliminate AF while allowing the sinus impulse to reach the atrioventricular node. This procedure became the gold standard for the surgical treatment of AF. Its latest iteration is termed the CM IV and was introduced in 2002. The CM IV replaced the previous cut-and-sew method (CM III) by replacing most of the incisions with a combination of bipolar radiofrequency and cryoablation. The use of ablation technologies, made the CM IV technically easier, faster and more amenable to minimally invasive approaches. The aims of this article are to review the indications and preoperative planning for the CM IV, to describe the operative technique and to review the literature including comparisons of the CM IV with the previous cut-and-sew method. Finally, this review explores future directions for the surgical treatment of patients with AF.

Convergent epicardial‐endocardial ablation for treatment of long‐standing persistent atrial fibrillation: A review of literature

“…The complication rate of CM IV for general AF ranges from 1% as reported by Weimar et al (n = 100) to 6% in a study by Ruanengsri et al (n = 365) 6,20 . CM IV consequently has a relatively low periprocedural complication rate with high efficacy in eliminating AF recurrence.…”

“…The Cox‐Maze procedures have been associated with low rates of AF recurrence for patients with npAF 15‐17 . As new SA technologies have developed with different energy sources—including bipolar radiofrequency and cryoablation—the Cox Maze IV (CM IV) procedure developed, significantly lowering the complication rate of the previous cut‐and‐sew Cox Maze III procedure while maintaining similar rates of AF elimination 6,18 . However, CM IV does have several disadvantages when compared to both CVP and CA.…”

The electrophysiologic basis for lesions of the contemporary Maze operation

“…The literature has consistently shown that elimination of the RA lesions results in poorer outcomes than can be attained with biatrial lesions. 16,17,19 The only exceptions to that observation have occurred in patients in whom the left atrial lesions, FIGURE 4. A, The mitral line is created in combination with the CS lesion to block conduction across the LA isthmus, thereby preventing the possibility of developing peri-mitral flutter postoperatively.…”

Beyond pulmonary veins… The new horizon remains atrial anatomy

“…A sensible anatomical ablation for persistent AF ablation will target the first and respect the others (Figure ) . This approach is not drawn from a blank canvas: surgeons already outlined a very solid strategy with the Cox‐maze . The succession of its different iteration for safety purposes perfectly illustrates the importance of sparing the atrial conduction system.…”