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J Thorac Cardiovasc Surg 2007;133:389-396
© 2007 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

The effect of ablation technology on surgical outcomes after the Cox-maze procedure: A propensity analysis

Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo.

Read at the Eighty-sixth Annual Meeting of The American Association for Thoracic Surgery, Philadelphia, Pa, April 29-May 3, 2006.

Received for publication April 27, 2006; revisions received September 22, 2006; accepted for publication October 9, 2006.

^_* Address for reprints: Ralph J. Damiano, Jr, MD, Washington University School of Medicine, Barnes-Jewish Hospital, Suite 3108 Queeny Tower, 1 Barnes-Jewish Hospital Plaza, Saint Louis, MO 63110. (Email: damianor{at}wustl.edu).

OBJECTIVES: Since its introduction in 1987, the Cox-maze procedure has been the gold standard for the surgical treatment of atrial fibrillation. At our institution, this procedure has evolved from the cut-and-sew technique (Cox-maze III procedure) to one using bipolar radiofrequency energy and cryoablation as ablative sources to replace most incisions (Cox-maze IV procedure). This study compared surgical outcomes of patients undergoing the Cox-maze III procedure versus those of patients undergoing the Cox-maze IV procedure by using propensity analysis.

METHODS: From April 1992 through July 2005, 242 patients underwent the Cox-maze procedure for atrial fibrillation. Of these, 154 patients had the Cox-maze III procedure, and 88 had the Cox-maze IV procedure. Logistic regression analysis was used to identify covariates among 7 baseline patient variables. Using the significant regression coefficients, each patient’s propensity score was calculated, allowing selectively matched subgroups of 58 patients each. Operative outcomes were analyzed for differences. Late follow-up was available for 112 (97%) patients. Freedom from atrial fibrillation recurrence and survival was calculated at 1 year by using Kaplan-Meier analysis.

RESULTS: The Cox-maze III procedure had significantly longer crossclamp times. There was no significant difference in intensive care unit and hospital stay, 30-day mortality, permanent pacemaker placement, early atrial tachyarrhythmias, late stroke, and survival. Freedom from atrial fibrillation recurrence was greater than 90% in both groups at 1 year.

CONCLUSIONS: The use of bipolar radiofrequency ablation has simplified the Cox-maze procedure, making it applicable to virtually all patients with atrial fibrillation undergoing concomitant cardiac surgery. The Cox-maze IV procedure produces similar surgical outcomes to the Cox-maze III procedure at 1 year of follow-up.

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Discussion
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