The long-term outcomes and durability of the Cox-Maze IV procedure for atrial fibrillation

Khiabani, Ali J.; MacGregor, Robert M.; Bakir, Nadia H.; Manghelli, Joshua L.; Sinn, Laurie A.; Maniar, Hersh S.; Moon, Marc R.; Schuessler, Richard B.; Melby, Spencer J.; Damiano, Ralph J.

doi:10.1016/j.jtcvs.2020.04.100

Cited by 69 publications

(71 citation statements)

References 39 publications

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“…Given the evidence for the posterior wall as an AF substrate, both in triggering and sustaining AF, the posterior wall has been explored as a target of radiofrequency and cryoablation to improve clinical outcomes in AF, particularly PersAF and LSPersAF. This is evident from the Cox-Maze IV surgical ablation lesion set, which isolates the posterior wall of the left atrium with epicardial ablation lines on the right and left pulmonary vein antrum followed by roof and floor ablations anchored to the left atriotomy [ 34 ]. However, Cox-Maze IV is typically performed concomitantly with open cardiac surgeries, limiting its reach to patients who do not need or want an open procedure.…”

Section: The Posterior Wall Of the Left Atrium In Non-paroxysmal Atrial Fibrillationmentioning

confidence: 99%

Persistent Atrial Fibrillation: The Role of Left Atrial Posterior Wall Isolation and Ablation Strategies

Kaba

Momin

Camm

2021

JCM

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Atrial fibrillation (AF) is a global disease with rapidly rising incidence and prevalence. It is associated with a higher risk of stroke, dementia, cognitive decline, sudden and cardiovascular death, heart failure and impairment in quality of life. The disease is a major burden on the healthcare system. Paroxysmal AF is typically managed with medications or endocardial catheter ablation to good effect. However, a large proportion of patients with AF have persistent or long-standing persistent AF, which are more complex forms of the condition and thus more difficult to treat. This is in part due to the progressive electro-anatomical changes that occur with AF persistence and the spread of arrhythmogenic triggers and substrates outside of the pulmonary veins. The posterior wall of the left atrium is a common site for these changes and has become a target of ablation strategies to treat these more resistant forms of AF. In this review, we discuss the role of the posterior left atrial wall in persistent and long-standing persistent AF, the limitations of current endocardial-focused treatment strategies, and future perspectives on hybrid epicardial–endocardial approaches to posterior wall isolation or ablation.

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Section: The Posterior Wall Of the Left Atrium In Non-paroxysmal Atrial Fibrillationmentioning

confidence: 99%

Persistent Atrial Fibrillation: The Role of Left Atrial Posterior Wall Isolation and Ablation Strategies

Kaba

Momin

Camm

2021

JCM

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“…[12] This has led to the development of the Cox-Maze IV procedure (CMP-IV). [13,14] The CMP-IV has excellent efficacy as shown by our group and others [15][16][17], with 77% freedom from ATAs at 10 years [18]. The late survival benefit associated with concomitant CMP-IV has also been well-established.…”

Section: Introductionmentioning

confidence: 62%

“…The CMP-IV remains the most effective treatment for AF, and has been shown to be effective for both paroxysmal and non-paroxysmal AF. [13][14][15]18] There have been few published reports on the late results of the CMP-IV in patients with longstanding persistent AF, who composed the most common subgroup of patients referred for surgical ablation. [12] Our results showed excellent and durable success with the CMP-IV for longstanding persistent AF from early through late follow-up amongst 174 consecutive patients.…”

Section: Discussionmentioning

confidence: 99%

“…Postoperative AADs and anticoagulants were administered to all patients unless contraindicated. [18] Patients who experienced postoperative ATAs unresponsive to AADs were cardioverted prior to discharge unless contraindicated (primary contraindication was documented left atrial [LA] clot). AADs were discontinued in patients in SR at 2-3 months postoperatively.…”

Section: Perioperative Carementioning

confidence: 99%

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Efficacy of the Stand-Alone Cox-Maze IV Procedure in Patients with Longstanding Persistent Atrial Fibrillation

McGilvray

Bakir

Kelly

et al. 2021

Preprint

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Introduction: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and results in significant morbidity and mortality. The Cox-Maze IV procedure (CMP-IV) has been shown to have excellent efficacy in returning patients to sinus rhythm, but there have been few reports of late follow-up in sizable cohorts of patients with longstanding persistent AF, the most difficult type of AF to treat. Methods & Results: Between May 2003 and March 2020, 174 consecutive patients underwent a stand-alone CMP-IV for longstanding persistent AF. Rhythm outcome was assessed postoperatively for up to 10 years, primarily via prolonged monitoring (Holter monitor, pacemaker interrogation, or implantable loop recorder). Fine-Gray regression was used to investigate factors associated with atrial tachyarrhythmia (ATA) recurrence, with death as a competing risk. Median duration of preoperative AF was 7.8 years (interquartile range [IQR] 4.0-12.0 years), with 71% (124/174) having failed at least one prior catheter-based ablation. There were no 30-day mortalities. Freedom from ATAs was 94% (120/128), 83% (53/64), and 88% (35/40) at 1, 5, and 7 years, respectively. On regression analysis, preoperative AF duration and early postoperative ATAs were associated with late ATAs recurrence. Conclusion: Despite the majority of patients having a long-duration of preoperative AF and having failed at least one catheter-based ablation, the stand-alone CMP-IV had excellent late efficacy in patients with longstanding persistent AF, with low morbidity and no mortality. We recommend consideration of stand-alone CMP-IV for patients with longstanding persistent AF who have failed or are poor candidates for catheter ablation.

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“…If a stable sinus rhythm (SR) is maintained for several months, the drugs are removed. However, in the case of AF recurrence, electrical cardioversion is applied to restore SR [6]. Given this context, a preoperative prediction of patient's rhythm at one year post-surgery could be very useful to plan a tailored follow-up of each patient, thus scheduling in advance electrical cardioversion for those patients with a low probability of SR maintenance and avoiding aggressive drug treatments in the remaining patients [9].…”

Section: Introductionmentioning

confidence: 99%

Time Variability of Fibrillatory Waves Energy Predicts Long-Term Outcome of Atrial Fibrillation Concomitant Surgical Ablation

Rodenas¹,

Escribano²,

Martinez-Iniesta³

et al. 2020

2020 Computing in Cardiology Conference (CinC)

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Surgical ablation (SA) is the most effective procedure to terminate atrial fibrillation (AF) in patients requiring concomitant open-heart surgery. However, considering the great stress provoked in the patient's heart, along with the benefits of anticipating antiarrhythmic therapeutical decisions, preoperative prediction of long-term failure of the procedure is an interesting clinical challenge. Hence, the present work introduces a novel algorithm to anticipate SA outcome after one year of follow-up by just analyzing the surface ECG. The method firstly extracts fibrillatory waves reflected on standard lead V1 using an adaptive QRST cancellation approach. The resulting signal is then segmented into 1 s-length intervals and wavelet energy is computed for all of them. Finally, the coefficient of variation of the time series obtained for the 7th scale is computed. Analyzing 20 second-length preoperative ECG excerpts from 53 persistent AF patients undergoing concomitant openheart surgery, only the proposed method reported statistically significant differences between the patients who relapsed to AF and those who maintained sinus rhythm during the follow-up. The algorithm also provided values of sensitivity, specificity, and accuracy between 10 and 20% better than the well-established dominant atrial frequency and fibrillatory waves amplitude, thus suggesting to be a promising predictor of AF recurrence after SA.

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The long-term outcomes and durability of the Cox-Maze IV procedure for atrial fibrillation

Cited by 69 publications

References 39 publications

Persistent Atrial Fibrillation: The Role of Left Atrial Posterior Wall Isolation and Ablation Strategies

Persistent Atrial Fibrillation: The Role of Left Atrial Posterior Wall Isolation and Ablation Strategies

Efficacy of the Stand-Alone Cox-Maze IV Procedure in Patients with Longstanding Persistent Atrial Fibrillation

Time Variability of Fibrillatory Waves Energy Predicts Long-Term Outcome of Atrial Fibrillation Concomitant Surgical Ablation

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