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J Thorac Cardiovasc Surg 2003;126:1822-1827
© 2003 The American Association for Thoracic Surgery
Cardiopulmonary support and physiology |
a Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Mo, USA
Read at the Eighty-second Annual Meeting of The American Association for Thoracic Surgery, Washington, DC, May 5-8, 2002.
Received for publication October 11, 2002; revisions received January 17, 2003; accepted for publication April 14, 2003.
* Address for reprints: Ralph J. Damiano, Jr, MD, Chief of Cardiac Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, One Barnes-Jewish Plaza, Queeny Tower Suite 3108, St Louis, MO 63110, USA
damiano{at}msnotes.wustl.edu
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Abstract |
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METHODS: From 1988 to 2001, 198 patients underwent a Cox maze III procedure; 112 were lone operations, and 86 were concomitant procedures. Major complications included renal failure, reoperation for bleeding, mediastinitis, stroke, and balloon pump insertion. Follow-up was performed by means of mail and telephone questionnaires with both the patients and their cardiologists. All patients who had any history of arrhythmia or who were taking medication had their rhythm documented by means of electrocardiography.
RESULTS: The lone operation group was significantly younger (51.3 ± 10.5 vs 58.8 ± 9.9 years) and had a higher male/female ratio (4:1 vs 2:1). There was no difference in operative mortality between groups (1.8% vs 1.2%). At a follow-up of 5.4 ± 2.9 years, 96.6% (172/178) of all patients were free of atrial fibrillation. There was no difference between the lone operation and concomitant procedure groups (95.9% vs 97.5%).
CONCLUSION: The Cox maze III procedure has equivalent operative risk and long-term efficacy in patients undergoing both lone operations and concomitant procedures. The Cox maze III procedure remains the standard against which alternative procedures for atrial fibrillation must be judged.
The first Cox maze III procedure was performed in 1988. The operation is based on the theory that AF results from multiple macroreentry circuits in the atria. The operation creates a maze-like series of incisions in both atria to prevent the formation of these macroreentrant circuits. During the operation, the pulmonary veins are completely isolated, and both appendages are removed.6,7 This was fortuitous because the importance of the pulmonary veins in the initiation of AF has become more appreciated in recent years.8 The procedure has been proved to be effective, with a high success rate and elimination of late strokes.9
The present indications for a Cox maze III operation include drug intolerance, arrhythmia intolerance, and recurrent embolic events. There are 2 major groups of patients who are referred for this procedure: those with symptomatic lone AF and those with AF associated with other organic cardiac disease. It is likely that the underlying pathophysiology responsible for the genesis of AF in these 2 groups of patients is different. Thus one can expect differences in the results of the Cox maze III procedure in these 2 populations. This study examined the long-term efficacy of the Cox maze procedure in patients undergoing the procedure either for lone AF or as an adjunct to another major cardiac operation.
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Methods |
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Follow-up and data analysis
The patients' clinical profiles and perioperative outcomes were recorded prospectively in a computerized database. Perioperative complications were considered to be reoperation for bleeding, renal failure requiring dialysis, mediastinitis, placement of an intra-aortic balloon pump, perioperative transient ischemic accident or stroke, and perioperative myocardial infarction. Follow-up was conducted by means of a mailed questionnaire or telephone interview with the patient. A review of both the referring cardiologist's office charts and recent electrocardiograms (ECGs) was performed for any patient who stated that they were in AF or were taking medication. Information on each patient who died during the follow-up period was obtained from relatives, family physicians, or county death certificates. Atrial tachyarrhythmias occurring in the first 3 months were not counted.
All of the patients in this series had chronic AF, which was defined as a documented duration of longer than 6 months. Paroxysmal AF was defined as patients who were intermittently in AF. Persistent AF was defined as patients who were continuously in AF. This study was approved by the Washington University School of Medicine/Barnes-Jewish Hospital Institutional Review Board. Informed consent and release of information was obtained from each participant. The closing date for enrolling patient data for this study was January 1, 2002. Thus all patients had a minimum of 3 months' follow-up. Late survival and outcomes were recorded and analyzed according to Society of Thoracic Surgeons database guidelines. Data were collected and managed in Microsoft Access 2000 and analyzed with SysStat version 10.0 software (SPSS Corp, Chicago, Ill). The clinical profiles of the 2 groups of patients were compared by using the 
2 test or the Fisher exact test. Continuous variables, such as age, were compared with the unpaired t test with a Dunn correction. Late survival and time-dependant morbidity were evaluated univariately by means of Kaplan-Meier analysis with the Mantel log-rank test and, a multivariate analysis was performed by using Cox regression.
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Results |
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In this group the indication for arrhythmia surgery was 19 (17%) of 112 patients with documented cerebral vascular accidents, 5 (4%) patients with medication intolerance, and the majority of patients (88 [79%]) with arrhythmia intolerance.
Concomitant maze procedure
The Cox maze procedure was performed as a concomitant procedure at our institution starting in April 1992. The most common concomitant procedures were mitral repair, mitral valve replacement, and coronary artery bypass grafting (Table 1). The mean age of patients in this group was 58.8 ± 9.9 years (range, 25-75 years), which was significantly higher than that in the lone operation group (P < .01, Table 2). In this group the indications for the procedure included documented cerebral vascular event (19/86 [22%]), failed medications (2/86 [2%]), and arrhythmia intolerance (65/86 [76%]). There was an approximately 2:1 ratio in favor of men (53:33), which was a significantly smaller ratio than in the lone operation group (P < .01). There were 45 (52.3%) patients with persistent AF and 41 (47.7%) with paroxysmal AF. The mean length of AF in the persistent AF group was 5.4 ± 4.9 years, and in the paroxysmal AF group it was 6.3 ± 5.1 years.
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There were 12 (10.7%) major complications: 3 (2.7%) reoperations for bleeding, 2 (1.8%) patients with renal failure, 4 (3.6%) patients with intra-aortic balloon pump placement, and 1 (0.9%) patient with mediastinitis. There were 2 (1.8%) perioperative strokes/transient ischemic accidents. There were no documented postoperative myocardial infarctions. A total of 9 (8.0%) patients required placement of a pacemaker postoperatively. Six (67%) patients who received postoperative pacemakers had been given a diagnosis of sick sinus syndrome preoperatively. The incidence of postoperative pacemaker placement with normal preoperative sinus node function was 3% (3/106).
Concomitant maze procedure
The mean cardiopulmonary bypass time in this group was 201 ± 42 minutes, with an average crossclamp time of 123 ± 35 minutes. The median ICU stay was 3 days (range, 1-78 days). The median total length of stay was 12 days (range, 5-78 days). There was 1 (1.2%) perioperative death among 86 patients. This patient died from respiratory failure caused by adult respiratory distress syndrome on postoperative day 22. There were 12 (13.9%) perioperative complications: 6 (7.0%) patients returned to the operating room for bleeding, 1 (1.2%) patient had renal failure, 3 (3.5%) patients required the placement of an intra-aortic balloon pump, and 1 (1.2%) patient had mediastinitis. There was 1 (1.2%) patient with a stroke. None of the patients had a postoperative myocardial infarction. Twenty (23.3%) of these patients required postoperative pacemakers (Table 3).
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Late Follow-up
There was no significant difference between the groups in mean duration of follow-up or percentage of patients lost to follow-up. The mean duration of follow up was 5.4 ± 3.0 and 5.4 ± 2.7 years in the lone operation and concomitant procedure groups, respectively. Late follow-up was achieved in 98 (87.5%) of 112 patients in the lone operation group and in 79 (91.9%) of 86 patients in the concomitant group.
Patient survival
In the lone Maze procedure there were 3 (3.1%) late deaths in the lone operation group among 98 patients. All patients were free of AF. In the concomitant procedure group there were 7 (8.9%) late deaths, and all patients were free of AF before death. Six patients died as a result of a noncardiac cause, such as cancer, ischemic colitis, and late renal failure. One patient died of chronic heart failure. Information on the other 3 patients is currently unavailable.
Thromboembolic events
There was only one late stroke in the entire series, and this was in the lone operation group. This patient had a cerebrovascular accident to the right temporal lobe with residual symptoms of hoarseness, loss of fine motor abilities, and difficulty concentrating.
Warfarin sodium
All patients discharged after a Cox maze III procedure were prescribed warfarin sodium (Coumadin) for 3 months. In the lone operation group the majority of our patients were referrals from other states (95/112 [84.8%]). After their postoperative clinic visit, their medications were managed by their cardiologists or family physicians. In our study 12 (12.2%) of the 98 responders were taking warfarin at late follow-up.
Similar to the lone operation group, the majority of patients were out of state in the concomitant procedure group (66/86 [76.7%]). In this study 18 (20.9%) of the 86 responders were taking warfarin. Eleven (61.1%) of these 18 required anticoagulation for their prosthetic valve. The overall use of warfarin, excluding these patients, was 9.3% (7/75).
Recurrence of AF
In the lone maze procedure group all patients who identified themselves as being in AF were considered failures unless their cardiologist and an ECG or Holter recording documented otherwise. Only 4 (4.1%) of 98 patients in the lone operation group were in AF at follow-up. Seventy-eight (79.6%) patients were not in AF and free of antiarrhythmic medications. Sixteen (16.3%) patients were in normal sinus rhythm but were taking antiarrhythmic drugs.
In the concomitant maze procedure group, of the 79 responders, 2 (2.5%) patients were in AF. Fifty-eight (73.4%) patients were in sinus rhythm and off all antiarrhythmic medication. An additional 19 (24%) patients were free of AF but were taking medications. There was no difference in freedom from AF between the 2 groups (Figure 1).
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Discussion |
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In this study this procedure had excellent results in curing AF in both groups. Despite the longer crossclamp and cardiopulmonary bypass times, there was no difference in the morbidity and mortality between these 2 populations. The incidence of postoperative complications was identical between groups, except for a trend toward more reoperations for bleeding in the concomitant procedure group. Late complications were rare in both groups. It was noteworthy that there was only one late stroke reported in both groups. The Cox maze III procedure reduced the risk of stroke in this high-risk population. The incidence of stroke in patients with AF has been reported by the American Heart Association and the American College of Cardiology to be 5% per year, and even with anticoagulation, the risk is 2% to 3% per year.10 One of the greatest benefits of this procedure was the reduction of stroke as a late complication at a follow-up period of 5.4 ± 2.9 years. Moreover, the majority of patients (148/178 [83.1%]) were able to discontinue warfarin, which carries its own long-term risk of morbidity. In patients without prosthetic valves, only 9% still required anticoagulation.
The overall freedom from AF at follow-up was 97%. The great majority of these patients also had stopped taking both antiarrhythmic drugs and warfarin. With a high long-term cure rate and the benefits of being able to stop all medications, why is the Cox maze procedure so seldom performed in patients with refractory AF?
First, the procedure has been viewed as invasive and entailing significant morbidity because of the prolonged period of cardiopulmonary bypass required to perform the operation. However, a close examination of the alternatives for many patients clearly favors a more aggressive surgical approach. In patients with lone AF, the arrhythmia itself, antiarrhythmic drugs, and anticoagulation all have well-documented and significant complications.11 This study demonstrated that the Cox maze III procedure has a low mortality in this population (2/112 [1.8%]) while offering the patient a greater than 95% chance of a cure, reducing the risk of stroke.
In patients who have preoperative AF and are undergoing primary cardiac surgery for other reasons, these data suggest that selected patients would benefit from a Cox maze III procedure. The mortality of the concomitant procedure was low (1/86 [1.2%]), which compares favorably with the national average for coronary and mitral valve surgery.12 At our institution, our comparative mortality over a similar time period for elective coronary artery bypass grafting was 2.6% and for mitral valve repair was 2.4%. Although the addition of the Cox maze III procedure did not increase perioperative mortality, it did lengthen hospital stay (median, 12 days). However, the long-term benefits of this procedure in preventing stroke and eliminating the need for anticoagulation, particularly in patients undergoing mitral valve repair, would appear to outweigh this short-term inconvenience.
The long-term success rates in these patients would argue strongly for a more widespread adoption of the Cox maze procedure. The success of this procedure in the concomitant procedure group might be due to the correction of physiologic abnormalities, such as ischemia or left atrial distension, which could predispose a patient to AF. Our results are supported by other studies that have reported the efficacy of the Cox maze III procedure in patients undergoing mitral valve surgery.13-15
In this series 15% (29/198) of patients required a postoperative pacemaker. This has been used by some physicians as a reason to discourage the wider use of this operation. However, it is instructive to closely look at this group of patients. First of all, there was a significant difference in postoperative pacemaker placement between the 2 groups, 8% in the lone operation group versus 23% in the concomitant procedure group. Second, many of these patients were given a preoperative diagnosis of sick sinus syndrome. In patients with normal preoperative sinus node function, our rate of pacemaker placement was only 8% (14/183 [7.7%]).
Left atrial dysfunction has been reported as a common late sequelae of the Cox maze III procedure, occurring as a result of the extensive surgical manipulation of the left atrium.16 In this study left atrial function was not quantified. Regardless of the precise incidence of left atrial dysfunction, our data would suggest that if it occurs, it is not of physiologic significance. The great majority of our patients (148/178 [83.1%]) were not receiving anticoagulation. If there had been a physiologically significant reduction in left atrial function, especially in a study that spanned 14 years, one would have expected a higher rate of stroke, mortality, or both caused by heart failure. Neither of these problems was observed in this patient population.
Another reason the procedure has not had widespread adoption is the impression that the long-term efficacy is not sufficient to warrant the risk. This study clearly supports the success of this procedure in both groups of patients for the treatment of paroxysmal and persistent AF. This misconception might be the result of many published reports that inappropriately use the term "Cox maze" or "maze" procedure. Many of these studies use a different lesion set and are based on the empiric elimination of one or more incisions to simplify the procedure.17 These "maze" procedures have had mixed results with short-term or immediate follow-up.18,19 Moreover, the inappropriate use of the term "catheter maze" by electrophysiologists has further confused the issue. The catheter-based procedures have not been able to fully replicate the entire set of surgical lesions described in the classic Cox maze III procedure. Any procedure less than a complete Cox maze III procedure must be considered a new operation for AF and be carefully evaluated as such both experimentally and clinically.
In summary, the Cox maze III procedure is effective in curing AF in the majority of patients for whom nonsurgical therapy has failed. The Cox maze III procedure is efficacious in patients with lone AF and should be offered to a larger population of symptomatic patients. In patients undergoing coronary or valve surgery, the Cox maze III procedure is successful in curing AF in virtually all patients and did not add significantly to the expected mortality or morbidity of this group of patients. These data support a policy of offering a curative Cox maze III procedure to patients with refractory AF undergoing open cardiac surgery.
The major strength of our study was the large number of patients and the high percentage and duration of the follow-up. The major limitation of this study was that it might have underestimated the failure rate. Electrocardiographic follow-up was not obtained on patients who stated that they were in normal sinus rhythm and had stopped all medications. However, our follow-up of all patients who identified themselves as having any atrial dysarrhythmia should have captured the majority of treatment failures. Another limitation of any long-term AF study is the possibility that the patient might have had asymptomatic episodes of AF. Our follow-up in many patients was only annual physician visit ECGs, and this might have missed asymptomatic intermittent rare episodes of AF. Unfortunately, the logistics of continuously monitoring patients for years is not possible. If patients were indeed in intermittent AF, one would have expected a higher incidence of late strokes.
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First is the issue of patient selection and the generalizability of your results to other practices. In this series of operations for AF, concomitant operations were performed in 43% of patients. In our experience with more than 400 maze operations, more than 80% of patients have had valve repair or replacement, and therefore the issue of incremental risk and long-term efficacy is important. And although you found little difference in operative mortality between these groups, I am sure you would agree with me that there is some incremental risk because of prolongation of the ischemic time and bypass time and the additional atrial incisions. What your report does show is that in properly selected patients, this risk might be small.
Can you tell us how many patients at your institution during this interval had AF and underwent a concomitant operation, including aortic valve replacement, mitral valve replacement, and coronary bypass, but did not have an adjunctive maze procedure?
Dr Damiano. That first question is excellent, Dr Schaff, and I thank you for your comments. I think you make an excellent point. These are highly selected patients, and I do not think they are necessarily generalizable to the entire universe of patients who present to cardiac surgeons with AF in association with either mitral or aortic valve disease; clearly that should be kept in mind when interpreting our results.
We have looked back, and approximately 33% of our patients who present for mitral valve surgery have concomitant AF, and the large majority of these patients over the time period of this study did not have a concomitant Cox maze procedure. Therefore we are looking at a very selected low-risk group of those patients. I do agree completely with you that clearly there is an incremental risk factor in performing a Cox maze procedure. We do believe that with some of the new technology that this procedure can be simplified to the point where it does not significantly add to the crossclamp time, and our own particular approach to these patients is, I think, much more aggressive in 2002 than it has been in the past.
Dr Schaff. Second, in your article you describe late tamponade as the cause of death in one patient, and I presume this was a patient who was anticoagulated with warfarin. A previous report of Dr Cox's experience at this association stated that temporary anticoagulation with warfarin was used only in patients who had a history of stroke or had resistant AF during the perioperative period. Do you follow that protocol, or what is your use of anticoagulation after operation?
Dr Damiano. That is an excellent question, and although I cannot comment for the entire historical study, our present policy is to anticoagulate all patients with warfarin for between 1 and 3 months. Usually it is dependent on the cardiologist, but at least it is my practice to use warfarin in all these patients.
Dr Schaff. Third, these operations were performed by 3 surgeons, one of whom developed the procedure and has the world's largest experience. Many in the audience who are not yet using the maze procedure will wonder to what extent the additional crossclamp time and bypass time can be reduced as one gains experience with the procedure. Have you analyzed these times according to the number of cases performed?
Dr Damiano. Excellent question, but we have not looked at that.
Dr D. Craig Miller. Give us a guess, Ralph.
Dr Damiano. There is no question there is a significant learning curve to doing a Cox maze III procedure, and this report included virtually the entire learning curve with this procedure. Also, you have to remember that virtually all of these patients were subject to intraoperative mapping and clinical investigation. Therefore I think that is perhaps one of the reasons that the bypass times might be a little longer than we are seeing at the present time.
I can only comment that being able to replace at least some of the incisions with linear lines of ablation in a very small series of approximately 10 patients on whom we have performed the procedure recently has cut the crossclamp time by 50%. With more aggressive use of either linear cryoablation, like Dr Cox has described, or linear radiofrequency, microwave, or laser ablation, it is possible to decrease the crossclamp time. We wanted to present these data because they present the results over a 14-year period of time using the traditional cut-and-sew approach.
Dr Schaff. I would appreciate your observation on 2 final points. One regards the indication for operation. We have encountered an additional group, other than what you described, who are referred for surgical intervention, and these are patients with AF whose symptoms of AF are pretty well controlled with medicines, but these patients have intolerable side effects. They are often young patients, and they are justifiably concerned about interference with lifestyle and the long-term consequences.
The second group in terms of indications are patients with left ventricular dysfunction. We have a group of approximately 25 patients who have had left ventricular dysfunction probably caused by tachycardia-induced cardiomyopathy, and these patients might have a resting heart rate of anywhere from 90 to 100 beats/min, but with exercise, it goes very much higher, and invariably the left ventricular ejection fraction is improved postoperatively. Have you encountered any of these?
Dr Damiano. The answer is yes on both counts. In this series arrhythmia intolerance and drug intolerance really go hand in hand, and it is a little hard to distinguish between these indications. Often, these patients have arrhythmia intolerance because they have been unable to tolerate antiarrhythmic drugs, which suppress their AF. Clearly I think in the present day that a Cox maze III procedure with its documented long-term efficacy and ability to prevent stroke represents a very good option for a younger patient, as opposed to looking at 50 to 60 years of taking warfarin. We have seen those patients with left ventricular dysfunction. It is interesting, in the early days of the maze procedure, left ventricular dysfunction was considered a contraindication. But I know Dr Cox believes, and I strongly agree, that right now that might be one of the better indications for a maze procedure.
We have had a similar experience in patients who presented with lone AF, with no other organic heart disease and ejection fractions in the 20% to 40% range. Virtually all of those patients returned to normal ventricular function over time after the Cox maze III procedure.
Dr Schaff. Finally, I would like to point out the difficulty we as surgeons have in comparing outcomes of operation for AF, even when the same procedure is used in a consistent manner. What constitutes a cure? It is appropriate to consider recurrences after the perioperative period, arbitrarily 6 weeks or 3 months, but analyzing patients for the presence or absence of AF only at the time of last follow-up will almost certainly overestimate true freedom from AF because interval recurrences that resolve spontaneously or respond to medical treatment will be missed. This is not unlike assessing thromboembolic events after valve replacement, and this problem will become much more apparent in the future as we hear outcome studies of different devices and procedures for AF.
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Footnotes |
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References |
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-year clinical experience with surgery for atrial fibrillation. Ann Surg. 1996;224(3):267–275[Medline]This article has been cited by other articles:
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N. Ad, S. D. Barnett, C. K. Haan, S. M. O'Brien, S. Milford-Beland, and A. M. Speir Does preoperative atrial fibrillation increase the risk for mortality and morbidity after coronary artery bypass grafting? J. Thorac. Cardiovasc. Surg., April 1, 2009; 137(4): 901 - 906. [Abstract] [Full Text] [PDF]
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C. Lundberg, A. Albage, C. Carnlof, and G. Kenneback Long-Term Health-Related Quality of Life After Maze Surgery for Atrial Fibrillation Ann. Thorac. Surg., December 1, 2008; 86(6): 1878 - 1882. [Abstract] [Full Text] [PDF]
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W. P. Beukema, H. T. Sie, A. R. Ramdat Misier, P. P. H.M. Delnoy, H. J.J. Wellens, and A. Elvan Intermediate to Long-Term Results of Radiofrequency Modified Maze Procedure as an Adjunct to Open-Heart Surgery Ann. Thorac. Surg., November 1, 2008; 86(5): 1409 - 1414. [Abstract] [Full Text] [PDF]
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J. Melo, T. Santiago, C. Aguiar, E. Berglin, M. Knaut, O. Alfieri, S. Benussi, H. Sie, M. Williams, F. Hornero, et al. Surgery for atrial fibrillation in patients with mitral valve disease: Results at five years from the International Registry of Atrial Fibrillation Surgery. J. Thorac. Cardiovasc. Surg., April 1, 2008; 135(4): 863 - 869. [Abstract] [Full Text] [PDF]
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R. K. Voeller, M. S. Bailey, A. Zierer, S. C. Lall, S.-i. Sakamoto, K. Aubuchon, J. S. Lawton, N. Moazami, C. B. Huddleston, N. A. Munfakh, et al. Isolating the entire posterior left atrium improves surgical outcomes after the Cox maze procedure. J. Thorac. Cardiovasc. Surg., April 1, 2008; 135(4): 870 - 877. [Abstract] [Full Text] [PDF]
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S. C. Lall, K. V. Foyil, S.-I. Sakamoto, R. K. Voeller, J. P. Boineau, R. J. Damiano Jr., and R. B. Schuessler Pulmonary vein isolation and the Cox maze procedure only partially denervate the atrium. J. Thorac. Cardiovasc. Surg., April 1, 2008; 135(4): 894 - 900. [Abstract] [Full Text] [PDF]
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Y. Q. Cui, L. B. Sun, Y. Li, C. L. Xu, J. Han, H. Li, and X. Meng Intraoperative Modified Cox Mini-Maze Procedure for Long-Standing Persistent Atrial Fibrillation Ann. Thorac. Surg., April 1, 2008; 85(4): 1283 - 1289. [Abstract] [Full Text] [PDF]
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M. Lamotte, L. Annemans, B. Bridgewater, S. Kendall, and M. Siebert A health economic evaluation of concomitant surgical ablation for atrial fibrillation Eur. J. Cardiothorac. Surg., November 1, 2007; 32(5): 702 - 710. [Abstract] [Full Text] [PDF]
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A. M. Gillinov Choice of Surgical Lesion Set: Answers From the Data Ann. Thorac. Surg., November 1, 2007; 84(5): 1786 - 1792. [Abstract] [Full Text] [PDF]
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N. Ad The multi purse string maze procedure: A new surgical technique to perform the full maze procedure without atriotomies J. Thorac. Cardiovasc. Surg., September 1, 2007; 134(3): 717 - 722. [Abstract] [Full Text] [PDF]
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 H. Calkins, J. Brugada, D. L. Packer, R. Cappato, S.-A. Chen, H. J.G. Crijns, R. J. Damiano Jr, D. W. Davies, D. E. Haines, M. Haissaguerre, et al. HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures and Follow-Up: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation Developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and Approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society. Europace, June 1, 2007; 9(6): 335 - 379. [Full Text] [PDF]
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D. Kim, K. Kim, Y.-H. Lee, and H. Ahn Detection of atrial arrhythmia in superconducting quantum interference device magnetocardiography; preliminary result of a totally-noninvasive localization method for atrial current mapping Interactive CardioVascular and Thoracic Surgery, June 1, 2007; 6(3): 274 - 279. [Abstract] [Full Text] [PDF]
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B. El Oumeiri, C. Stefanidis, A. Sabry, M. Antoine, J.-M. De Smet, D. De Canniere, and J.-L. Jansens Long-term follow-up after endocardial radiofrequency modified Nitta procedure for concomitant atrial fibrillation treatment Interactive CardioVascular and Thoracic Surgery, June 1, 2007; 6(3): 319 - 322. [Abstract] [Full Text] [PDF]
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J. Puskas, E. Lin, D. Bailey, and R. Guyton Thoracoscopic Radiofrequency Pulmonary Vein Isolation and Atrial Appendage Occlusion Ann. Thorac. Surg., May 1, 2007; 83(5): 1870 - 1872. [Abstract] [Full Text] [PDF]
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J. M. Stulak, T. M. Sundt III, J. A. Dearani, R. C. Daly, T. A. Orsulak, and H. V. Schaff Ten-year Experience With the Cox-Maze Procedure for Atrial Fibrillation: How Do We Define Success? Ann. Thorac. Surg., April 1, 2007; 83(4): 1319 - 1324. [Abstract] [Full Text] [PDF]
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J. R. Doty, D. B. Doty, K. W. Jones, J. H. Flores, M. Mensah, B. B. Reid, S. E. Clayson, G. Snow, E. Righter, and R. C. Millar Comparison of standard Maze III and radiofrequency Maze operations for treatment of atrial fibrillation J. Thorac. Cardiovasc. Surg., April 1, 2007; 133(4): 1037 - 1044. [Abstract] [Full Text] [PDF]
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R. J. Shemin, J. L. Cox, A. M. Gillinov, E. H. Blackstone, and C. R. Bridges Guidelines for Reporting Data and Outcomes for the Surgical Treatment of Atrial Fibrillation Ann. Thorac. Surg., March 1, 2007; 83(3): 1225 - 1230. [Abstract] [Full Text] [PDF]
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K. C. Kim, K. R. Cho, Y.-J. Kim, D.-W. Sohn, and K.-B. Kim Long-term results of the Cox-Maze III procedure for persistent atrial fibrillation associated with rheumatic mitral valve disease: 10-year experience Eur. J. Cardiothorac. Surg., February 1, 2007; 31(2): 261 - 266. [Abstract] [Full Text] [PDF]
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S. C. Lall, S. J. Melby, R. K. Voeller, A. Zierer, M. S. Bailey, T. J. Guthrie, M. R. Moon, N. Moazami, J. S. Lawton, and R. J. Damiano Jr The effect of ablation technology on surgical outcomes after the Cox-maze procedure: A propensity analysis J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 389 - 396. [Abstract] [Full Text] [PDF]
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S. Martin-Suarez, B. Claysset, L. Botta, M. Ferlito, D. Pacini, C. Savini, G. Marinelli, and R. DiBartolomeo Surgery for atrial fibrillation with radiofrequency ablation: four years experience Interactive CardioVascular and Thoracic Surgery, February 1, 2007; 6(1): 71 - 76. [Abstract] [Full Text] [PDF]
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P. K.E.W. Ballaux, G. S.C. Geuzebroek, N. M. van Hemel, J. C. Kelder, K. M.E. Dossche, J. M.P.G. Ernst, L. V.A. Boersma, E. F.D. Wever, A. B. de la Riviere, and J. J.A.M.T. Defauw Freedom from atrial arrhythmias after classic maze III surgery: A 10-year experience J. Thorac. Cardiovasc. Surg., December 1, 2006; 132(6): 1433 - 1440. [Abstract] [Full Text] [PDF]
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S. Fukunaga, K. Takagi, K. Arinaga, and S. Aoyagi Introduction of transesophageal electrocardiography to surgery for continuous atrial fibrillation Interactive CardioVascular and Thoracic Surgery, December 1, 2006; 5(6): 672 - 675. [Abstract] [Full Text] [PDF]
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M.-J. Baek, C.-Y. Na, S.-S. Oh, C.-H. Lee, J. H. Kim, H. J. Seo, S.-W. Park, and W. S. Kim Surgical treatment of chronic atrial fibrillation combined with rheumatic mitral valve disease: effects of the cryo-maze procedure and predictors for late recurrence Eur. J. Cardiothorac. Surg., November 1, 2006; 30(5): 728 - 736. [Abstract] [Full Text] [PDF]
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V. Badhwar, J. D. Rovin, G. Davenport, J. C. Pruitt, R. R. Lazzara, G. Ebra, and G. H. Dworkin Left Atrial Reduction Enhances Outcomes of Modified Maze Procedure for Permanent Atrial Fibrillation During Concomitant Mitral Surgery Ann. Thorac. Surg., November 1, 2006; 82(5): 1758 - 1764. [Abstract] [Full Text] [PDF]
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O. M. Wazni, W. Saliba, T. Fahmy, D. Lakkireddy, S. Thal, M. Kanj, D. O. Martin, J. D. Burkhardt, R. Schweikert, and A. Natale Atrial Arrhythmias After Surgical Maze: Findings During Catheter Ablation J. Am. Coll. Cardiol., October 3, 2006; 48(7): 1405 - 1409. [Abstract] [Full Text] [PDF]
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S. J. Melby, S. L. Gaynor, J. G. Lubahn, A. M. Lee, P. Rahgozar, S. D. Caruthers, T. A. Williams, R. B. Schuessler, and R. J. Damiano Jr Efficacy and safety of right and left atrial ablations on the beating heart with irrigated bipolar radiofrequency energy: A long-term animal study J. Thorac. Cardiovasc. Surg., October 1, 2006; 132(4): 853 - 860. [Abstract] [Full Text] [PDF]
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A. M. Gillinov, S. Bhavani, E. H. Blackstone, J. Rajeswaran, L. G. Svensson, J. L. Navia, B.G. Pettersson, J. F. Sabik III, N. G. Smedira, T. Mihaljevic, et al. Surgery for Permanent Atrial Fibrillation: Impact of Patient Factors and Lesion Set Ann. Thorac. Surg., August 1, 2006; 82(2): 502 - 514. [Abstract] [Full Text] [PDF]
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S. J. Melby, A. Zierer, S. P. Kaiser, R. B. Schuessler, and R. J. Damiano Jr Epicardial microwave ablation on the beating heart for atrial fibrillation: The dependency of lesion depth on cardiac output. J. Thorac. Cardiovasc. Surg., August 1, 2006; 132(2): 355 - 360. [Abstract] [Full Text] [PDF]
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M. Jahangiri, G. Weir, K. Mandal, I. Savelieva, and J. Camm Current strategies in the management of atrial fibrillation. Ann. Thorac. Surg., July 1, 2006; 82(1): 357 - 364. [Abstract] [Full Text] [PDF]
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A. Itoh, J. Kobayashi, K. Bando, K. Niwaya, O. Tagusari, H. Nakajima, S. Komori, and S. Kitamura The impact of mitral valve surgery combined with maze procedure. Eur. J. Cardiothorac. Surg., June 1, 2006; 29(6): 1030 - 1035. [Abstract] [Full Text] [PDF]
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J. Q. Melo Surgery for atrial fibrillation: Are we heading in the right direction? J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 949 - 951. [Full Text] [PDF]
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C. A. Rogers, G. D. Angelini, L. A. Culliford, R. Capoun, and R. Ascione Coronary surgery in patients with preexisting chronic atrial fibrillation: early and midterm clinical outcome. Ann. Thorac. Surg., May 1, 2006; 81(5): 1676 - 1682. [Abstract] [Full Text] [PDF]
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M. E.W. Hemels, Y. L. Gu, A. E. Tuinenburg, P. W. Boonstra, A. C.P. Wiesfeld, M. P. van den Berg, D. J. Van Veldhuisen, and I. C. Van Gelder Favorable long-term outcome of maze surgery in patients with lone atrial fibrillation. Ann. Thorac. Surg., May 1, 2006; 81(5): 1773 - 1779. [Abstract] [Full Text] [PDF]
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S. D. Barnett and N. Ad Surgical ablation as treatment for the elimination of atrial fibrillation: A meta-analysis J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 1029 - 1035. [Abstract] [Full Text] [PDF]
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N. Ad, S. Barnett, E. A. Lefrak, A. Korach, A. Pollak, D. Gilon, and A. Elami Impact of follow-up on the success rate of the cryosurgical maze procedure in patients with rheumatic heart disease and enlarged atria J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 1073 - 1079. [Abstract] [Full Text] [PDF]
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F. Milla, N. Skubas, W. M. Briggs, L. N. Girardi, L. Y. Lee, W. Ko, A. J. Tortolani, K. H. Krieger, O. W. Isom, and C. A. Mack Epicardial beating heart cryoablation using a novel argon-based cryoclamp and linear probe J. Thorac. Cardiovasc. Surg., February 1, 2006; 131(2): 403 - 411. [Abstract] [Full Text] [PDF]
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S. L. Gaynor, G. D. Byrd, M. D. Diodato, Y. Ishii, A. M. Lee, S. M. Prasad, J. Gopal, R. B. Schuessler, and R. J. Damiano Jr Microwave Ablation for Atrial Fibrillation: Dose-Response Curves in the Cardioplegia-Arrested and Beating Heart Ann. Thorac. Surg., January 1, 2006; 81(1): 72 - 76. [Abstract] [Full Text] [PDF]
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A. M. Gillinov, J. Sirak, E. H. Blackstone, P. M. McCarthy, J. Rajeswaran, G. Pettersson, F. J. Sabik III, L. G. Svensson, J. L. Navia, D. M. Cosgrove, et al. The Cox maze procedure in mitral valve disease: Predictors of recurrent atrial fibrillation J. Thorac. Cardiovasc. Surg., December 1, 2005; 130(6): 1653 - 1660. [Abstract] [Full Text] [PDF]
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 T. M. Sundt and B. J. Gersh Making Sense of the Maze: Which Patients With Atrial Fibrillation Will Benefit? JAMA, November 9, 2005; 294(18): 2357 - 2359. [Full Text] [PDF]
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G. M. Guiraudon, D. L. Jones, A. C. Skanes, D. Bainbridge, C. M. Guiraudon, S. M. Jensen, X. Yuan, M. Drangova, and T. M. Peters En Bloc Exclusion of the Pulmonary Vein Region in the Pig Using Off Pump, Beating, Intra-Cardiac Surgery: A Pilot Study of Minimally Invasive Surgery for Atrial Fibrillation Ann. Thorac. Surg., October 1, 2005; 80(4): 1417 - 1423. [Abstract] [Full Text] [PDF]
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 M.-C. Chen, J.-P. Chang, C.-J. Chen, C.-H. Yang, W. C. Hung, M. Fu, and K.-H. Yeh Atrial Pacemaker Complex Preserved Radiofrequency Maze Procedure Reducing the Incidence of Sick Sinus Syndrome in Patients With Atrial Fibrillation Chest, October 1, 2005; 128(4): 2571 - 2575. [Abstract] [Full Text] [PDF]
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J. S. Gammie, J. C. Laschinger, J. M. Brown, R. S. Poston, R. N. Pierson III, L. G. Romar, K. L. Schwartz, M. J. Santos, and B. P. Griffith A Multi-Institutional Experience With the CryoMaze Procedure Ann. Thorac. Surg., September 1, 2005; 80(3): 876 - 880. [Abstract] [Full Text] [PDF]
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J. Ninet, X. Roques, R. Seitelberger, C. Deville, J. L. Pomar, J. Robin, O. Jegaden, F. Wellens, E. Wolner, C. Vedrinne, et al. Surgical ablation of atrial fibrillation with off-pump, epicardial, high-intensity focused ultrasound: Results of a multicenter trial J. Thorac. Cardiovasc. Surg., September 1, 2005; 130(3): 803 - 803. [Abstract] [Full Text] [PDF]
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 C. A. Mack, F. Milla, W. Ko, L. N. Girardi, L. Y. Lee, A. J. Tortolani, J. Mascitelli, K. H. Krieger, and O. W. Isom Surgical Treatment of Atrial Fibrillation Using Argon-Based Cryoablation During Concomitant Cardiac Procedures Circulation, August 30, 2005; 112(9_suppl): I-1 - I-6. [Abstract] [Full Text] [PDF]
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G. D. Byrd, S. M. Prasad, C. M. Ripplinger, T. R. Cassilly, R. B. Schuessler, J. P. Boineau, and R. J. Damiano Jr Importance of Geometry and Refractory Period in Sustaining Atrial Fibrillation: Testing the Critical Mass Hypothesis Circulation, August 30, 2005; 112(9_suppl): I-7 - I-13. [Abstract] [Full Text] [PDF]
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S. Benussi, S. Nascimbene, G. Calori, P. Denti, Z. Ziskind, S. Kassem, G. La Canna, C. Pappone, and O. Alfieri Surgical ablation of atrial fibrillation with a novel bipolar radiofrequency device J. Thorac. Cardiovasc. Surg., August 1, 2005; 130(2): 491 - 497. [Abstract] [Full Text] [PDF]
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M. E. Halkos, J. M. Craver, V. H. Thourani, F. Kerendi, J. D. Puskas, W. A. Cooper, and R. A. Guyton Intraoperative Radiofrequency Ablation for the Treatment of Atrial Fibrillation During Concomitant Cardiac Surgery Ann. Thorac. Surg., July 1, 2005; 80(1): 210 - 216. [Abstract] [Full Text] [PDF]
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M. E. Goldman and L. B. Croft Atrial Fibrillation: The Ancient Conundrum Defies Simple Solution J. Am. Coll. Cardiol., June 7, 2005; 45(11): 1813 - 1814. [Full Text] [PDF]
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K. Bando, H. Kasegawa, Y. Okada, J. Kobayashi, A. Kada, T. Shimokawa, M. Nasu, S. Nakatani, K. Niwaya, O. Tagusari, et al. Impact of preoperative and postoperative atrial fibrillation on outcome after mitral valvuloplasty for nonischemic mitral regurgitation J. Thorac. Cardiovasc. Surg., May 1, 2005; 129(5): 1032 - 1040. [Abstract] [Full Text] [PDF]
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M.-J. Baek, S.-S. Oh, C.-H. Lee, and C.-Y. Na Outcome of the modified maze procedure for atrial fibrillation combined with rheumatic mitral valve disease using cryoablation Interactive CardioVascular and Thoracic Surgery, April 1, 2005; 4(2): 130 - 134. [Abstract] [Full Text] [PDF]
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C. C. Lang, V. Santinelli, G. Augello, A. Ferro, F. Gugliotta, S. Gulletta, G. Vicedomini, C. Mesas, G. Paglino, S. Sala, et al. Transcatheter radiofrequency ablation of atrial fibrillation in patients with mitral valve prostheses and enlarged atria: Safety, feasibility, and efficacy J. Am. Coll. Cardiol., March 15, 2005; 45(6): 868 - 872. [Abstract] [Full Text] [PDF]
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S. J. Hazel, H. S. Paterson, J. R.M. Edwards, and G. J. Maddern Surgical Treatment of Atrial Fibrillation via Energy Ablation Circulation, March 1, 2005; 111(8): e103 - e106. [Full Text] [PDF]
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T. Nitta, H. Ohmori, S.-i. Sakamoto, Y. Miyagi, S. Kanno, and K. Shimizu Map-guided surgery for atrial fibrillation J. Thorac. Cardiovasc. Surg., February 1, 2005; 129(2): 291 - 299. [Abstract] [Full Text] [PDF]
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S. L. Gaynor, R. B. Schuessler, M. S. Bailey, Y. Ishii, J. P. Boineau, M. J. Gleva, J. L. Cox, and R. J. Damiano Jr Surgical treatment of atrial fibrillation: Predictors of late recurrence J. Thorac. Cardiovasc. Surg., January 1, 2005; 129(1): 104 - 111. [Abstract] [Full Text] [PDF]
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J. L. Monro The next challenge--adapting to change Eur. J. Cardiothorac. Surg., December 1, 2004; 26(6): 1063 - 1072. [Full Text] [PDF]
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S. Benussi Treatment of atrial fibrillation Eur. J. Cardiothorac. Surg., December 1, 2004; 26(Suppl_1): S39 - S41. [Abstract] [Full Text] [PDF]
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N. A. Mokadam, P. M. McCarthy, A. M. Gillinov, W. H. Ryan, M. R. Moon, M. J. Mack, S. L. Gaynor, S. M. Prasad, S. A. Wickline, M. S. Bailey, et al. A Prospective Multicenter Trial of Bipolar Radiofrequency Ablation for Atrial Fibrillation: Early Results Ann. Thorac. Surg., November 1, 2004; 78(5): 1665 - 1670. [Abstract] [Full Text] [PDF]
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S. L. Gaynor, Y. Ishii, M. D. Diodato, S. M. Prasad, K. M. Barnett, N. R. Damiano, G. D. Byrd, S. A. Wickline, R. B. Schuessler, and R. J. Damiano Jr Successful Performance of Cox-Maze Procedure on Beating Heart Using Bipolar Radiofrequency Ablation: A Feasibility Study in Animals Ann. Thorac. Surg., November 1, 2004; 78(5): 1671 - 1677. [Abstract] [Full Text] [PDF]
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S. L. Gaynor, M. D. Diodato, S. M. Prasad, Y. Ishii, R. B. Schuessler, M. S. Bailey, N. R. Damiano, J. B. Bloch, M. R. Moon, and R. J. Damiano Jr A prospective, single-center clinical trial of a modified Cox maze procedure with bipolar radiofrequency ablation J. Thorac. Cardiovasc. Surg., October 1, 2004; 128(4): 535 - 542. [Abstract] [Full Text] [PDF]
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Y. Ishii, M. J. Gleva, M. C. Gamache, R. B. Schuessler, J. P. Boineau, M. S. Bailey, and R. J. Damiano Jr Atrial Tachyarrhythmias After the Maze Procedure: Incidence and Prognosis Circulation, September 14, 2004; 110(11_suppl_1): II-164 - II-168. [Abstract] [Full Text] [PDF]
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R. M. John and G. Michaud Atrial Fibrillation: Nonpharmacologic Therapies Coming of Age Chest, June 1, 2004; 125(6): 1977 - 1979. [Full Text] [PDF]
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R. B. Schuessler Do we need a map to get through the maze? J. Thorac. Cardiovasc. Surg., March 1, 2004; 127(3): 627 - 628. [Full Text] [PDF]
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