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J Thorac Cardiovasc Surg 2005;130:1653-1660
© 2005 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

The Cox maze procedure in mitral valve disease: Predictors of recurrent atrial fibrillation

A. Marc Gillinov, MD a , * , Jon Sirak, MD a , Eugene H. Blackstone, MD a , b , Patrick M. McCarthy, MD a , Jeevanantham Rajeswaran, MSc b , Gosta Pettersson, MD, PhD a , F. Joseph Sabik, III, MD a , Lars G. Svensson, MD, PhD a , Jose L. Navia, MD a , Delos M. Cosgrove, MD a , Nassir Marrouche, MD c , Andrea Natale, MD c

a Center for Atrial Fibrillation and the Departments of Thoracic and Cardiovascular Surgery,
b Quantitative Health Sciences,
c Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio

Read at the Eighty-fifth Annual Meeting of The American Association for Thoracic Surgery, San Francisco, Calif, April 10-13, 2005.

Received for publication April 1, 2005; revisions received July 7, 2005; accepted for publication July 26, 2005.

* Address for reprints: A. Marc Gillinov, MD, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation/F24, 9500 Euclid Ave, Cleveland, OH 44195 (Email: gillinom{at}ccf.org).

OBJECTIVES: The Cox maze procedure is the gold standard for ablation of atrial fibrillation in patients undergoing mitral valve surgery, and new approaches to atrial fibrillation ablation must be compared with it. Therefore, we sought to determine the time-related prevalence of atrial fibrillation and its risk factors after combined Cox maze and mitral valve surgery.

METHODS: From November 1991 through January 2004, 263 patients (mean left atrial diameter, 5.8 ± 1.2 cm) underwent combined mitral valve surgery (repair in 71%) and a cut-and-sew Cox maze procedure for atrial fibrillation (permanent, 74%; persistent, 7%; paroxysmal, 16%). Rhythm documented on 2367 postoperative electrocardiograms was used to estimate the prevalence of atrial fibrillation across time.

RESULTS: Hospital mortality was 1.9%. Postoperative atrial fibrillation prevalence peaked at 36% at 2 weeks, decreasing to 21% at 5 years. Risk factors for higher postoperative atrial fibrillation prevalence varied with time and included longer duration of preoperative atrial fibrillation (P = .003), larger left atrial diameter (P = .01), older age (P = .0002), and higher left ventricular mass index (P = .02).

CONCLUSIONS: In some patients undergoing mitral valve surgery and a Cox maze procedure, atrial fibrillation recurs over time, mandating close, long-term follow-up of heart rhythm. Earlier operation and left atrial size reduction should be considered to improve results in selected patients.

Abbreviations and Acronyms AF = atrial fibrillation; CL = confidence limit; ECG = electrocardiogram




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