JTCS Click here to go to SJM website.
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Niv Ad
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Barnett, S. D.
Right arrow Articles by Ad, N.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Barnett, S. D.
Right arrow Articles by Ad, N.
Related Collections
Right arrow Electrophysiology - arrhythmias
Right arrowRelated Article

J Thorac Cardiovasc Surg 2006;131:1029-1035
© 2006 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Surgical ablation as treatment for the elimination of atrial fibrillation: A meta-analysis

Scott D. Barnett, PhD * , Niv Ad, MD

Inova Heart and Vascular Institute, Falls Church, Va

Received for publication June 14, 2005; revisions received October 12, 2005; accepted for publication October 25, 2005.

* Address for reprints: Scott D. Barnett, PhD, Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042 (Email: scott.barnett{at}inova.com).


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
OBJECTIVE: The maze procedure is recognized as the most effective surgical treatment of atrial fibrillation. In the last few years, new surgical ablation techniques were developed involving the left atrium only and modifications of the maze procedure in ablating both atria. For this study, we evaluated the evidence regarding the effectiveness of the surgical ablation procedures (biatrial and left atrial) in reducing postoperative atrial fibrillation and subsequent survival.

METHODS: MEDLINE was searched for English-language studies using the terms "maze," "atrial fibrillation," and "surgical treatment" for 1995 through August 2005. Primary outcomes of interest were postoperative survival and postoperative freedom from atrial fibrillation. Survival data were collected at 1-, 2-, and 3-year intervals. Freedom from atrial fibrillation was collected at 3 months and at 1-, 2-, and 3-year intervals.

RESULTS: Sixty-nine studies were included in this analysis. Five thousand eight hundred eighty-five total patients were involved. Patients undergoing surgical ablation (range, 90.4-85.4) demonstrated significantly greater rates of freedom from atrial fibrillation compared with those seen in control patients (range, 47.2-60.9). Survival rates among patients with biatrial surgical procedures (range, 94.9-92.8) were similar to those who had left atrial procedures only (range, 93.9-89.4). However, patients undergoing biatrial ablation (range, 92.0-87.1 vs 86.1-73.4) demonstrated superior freedom from atrial fibrillation at all time points.

CONCLUSION: Biatrial ablation surgical procedures were more effective in controlling atrial fibrillation than procedures confined to the left atrium. To encourage the use of future meta-analysis within the surgical literature, we suggest the more frequent reporting of either through Kaplan-Meier survival analyses and the reporting of rates for specific time intervals.

Abbreviations and Acronyms AF = atrial fibrillation


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Go GoThe maze procedure is recognized as the most effective surgical treatment of atrial fibrillation (AF). Introduced in 1987 by J. L. Cox as a stand-alone procedure, the maze procedure has undergone 4 iterations, with each successfully replacing the previous one.

To our knowledge, there have been no systematic reviews or meta-analyses to estimate and compare the efficacy of the maze procedure and any other biatrial surgical procedure with that of procedures limited to the left atrium in the elimination of AF. The goal of this study is to assess the evidence regarding the effectiveness of the different surgical ablation techniques in eliminating postoperative recurrent AF. In addition, we report postoperative survival rates for 1, 2, and 3 years.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
Search Strategy
We searched MEDLINE for studies in English using the terms "maze," "atrial fibrillation," and "surgical treatment" for the period of 1995 through March 2005. We eliminated any case reports or articles focusing on electronic advances in the surgical treatment of AF. Four studies were eliminated because they represented the same patient group. Studies were then reviewed a final time by each author to ensure the search criteria were met and desired clinical data were included. 1-69 Go

Statistical Methods
Each author then reviewed each report to dichotomize every study into temporal categories of "retrospective" or "prospective" and to assign study sample sizes to one of 3 size categories on the basis of the sample of surgical patients in each study: small (<50), medium (51-100), or large (>100). The individual author results were then compared, and differences in interpretation were resolved. Included studies reflected surgeon preference for the use of different procedures: the use of some studies using the standard maze procedure lesion set and others using different protocols for biatrial and left atrial lesion sets only. Thus we defined included surgical ablation procedures as either biatrial or left atrial procedures only.

The primary outcomes of interest were postoperative survival and postoperative freedom from AF. Survival data were collected at 1-, 2-, and 3-year intervals. Freedom from AF was collected at 3 months and at 1-, 2-, and 3-year intervals. In the event that a study involved multiple control groups, control group survival and freedom from AF estimates were combined into one control group by using weighted averages, with the respective control group sample sizes serving as the weights.

Effect sizes for all end points were calculated by using the Cohen d statistic. 70 Go Variance estimates for all end points were calculated by using the method of Hunter and Schmidt. 71 Go Weighted postoperative survival and freedom from AF estimates were analyzed, with the respective study surgical group or control group sample sizes used as the weights. The Student t test was used to test for statistical significance. All statistical analyses were conducted with SAS (version 8.12; SAS, Cary, NC) software.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
Studies
Sixty-nine studies were included in this analysis. Biatrial surgical ablation procedures accounted for 67% of all studies, and 75% were retrospective in nature. Small studies (<50 subjects) comprised almost one half of all studies (42%). Only 14 (19%) studies involved control groups. Average patient follow-up was 22.9 months. Primary indication for surgical intervention was prolonged AF, usually defined as "chronic," generally presented in tabular format in the Results section or defined earlier as "chronic" or "persistent" AF lasting more than 6 or 12 months. Electrocardiography, Holter monitoring, echocardiography, or combinations of these were primarily used to define postoperative freedom from AF. Several reports relied on patient self-report during follow-up, but electrocardiographic confirmation was then obtained. Freedom from AF end points was primarily defined as a return to sinus rhythm.

Samples Size
Sample sizes for selected studies averaged 85.3 (74.9 for subjects undergoing surgical ablation and 51.3 for control subjects, Table 1). Studies with the biatrial ablation procedure averaged 73.3 subjects, and studies with left atrial procedures averaged 67.3 subjects. Sample sizes for which a control group was involved generally included more control subjects compared with surgical patients (average, 51.3 [range, 10-227] vs 37.1 [range, 5-103]).


View this table:
[in this window]
[in a new window]
  		TABLE 1. Average sample size
 
When stratified by lesion, studies involved more patients undergoing biatrial ablation (88.0 ± 60.1) compared with patients undergoing left atrial ablation (79.9 ± 67.1, Table 2). When stratified by temporal score, prospective studies enrolled fewer total subjects (57.8 ± 40.4) and almost one half as many surgical patients (45.0 ± 32.7) compared with retrospective studies (94.3 ± 65.6 and 84.7 ± 63.5, respectively; Table 2).


View this table:
[in this window]
[in a new window]
  		TABLE 2. Average sample size by lesion and temporal score
 
Patient Survival and Freedom from AF, All Patients
Patients undergoing surgical ablation demonstrated similar survival rates compared with those of control patients (Table 3). At 1, 2, and 3 years, control subjects demonstrated a 3% improvement in survival. However, at 3 months and 1, 2, and 3 years, patients undergoing surgical ablation (range, 90.4%-85.4%) demonstrated significantly greater rates of freedom from AF compared with those seen in control subjects (range, 47.2%-60.9%). With the exception of the 3-year end point, surgical patients nearly doubled the freedom from AF rate compared with that seen in control subjects.


View this table:
[in this window]
[in a new window]
  		TABLE 3. Average weighted reported postoperative survival and freedom from recurrent atrial fibrillation, all patients
 
Patient Survival and Freedom From AF by Lesion
When stratified by lesion (biatrial lesions vs left atrial lesions only), survival rates among biatrial surgical patients (range, 94.9%-92.8%) were similar to those among left atrial surgical patients (range, 93.9%-89.4%; Table 4). Biatrial surgical patients (range, 92.0%-87.1%) demonstrated superior freedom from AF at all time points compared with left atrial surgical patients (range, 86.1%-73.4%).


View this table:
[in this window]
[in a new window]
  		TABLE 4. Average weighted reported postoperative survival and freedom from recurrent atrial fibrillation by lesion
 
Patient Survival and Freedom From AF by Temporal Score
When stratified by temporal score, both prospective and retrospective studies demonstrated similar survival rates at 1, 2, and 3 years (Table 5), with prospective studies slightly better (range of 95.2%-96.1% vs range of 94.3%-91.9%). Retrospective studies, however, demonstrated increased rates of freedom from AF (range of 91.4%-87.3% vs range of 86.3%-79.4%).


View this table:
[in this window]
[in a new window]
  		TABLE 5. Average weighted reported postoperative survival and freedom from recurrent atrial fibrillation by temporal score
 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
The use of meta-analyses to summarize research is not a novel approach but is still a vastly underused research tool. Ideally, investigators would pool individual data from multiple studies under various hypotheses either similar or identical to those of their original respective study. Usually, however, results from published reports are abstracted through the use of statistics on the basis of sampling methods. 70,71 Go Results are pooled, and effect sizes can then be generated as if all studies were generated from one large hypothetical patient population, with each study acting as a unique sample from that hypothetical population. The literature addressing the surgical treatment for AF now has dozens of studies on various populations from various highly regarded surgical groups, all producing excellent results. In this report we present the results of what we believe to be the first large-scale meta-analysis designed to evaluate the efficacy of surgical ablation as a treatment for the elimination of AF.

Our results suggest that both surgical groups with and without ablation experience nearly identical postoperative survival rates and superior freedom from AF rates at 3 months and 1, 2, and 3 years. Furthermore, among surgical patients, biatrial ablation procedures were similar to left atrial ablation–only procedures in postoperative survival and superior in freedom from AF rates. The higher success rate in ablating AF by applying the maze procedure or any other biatrial surgical modification is not surprising. Review of the current literature that discusses the electrophysiology of AF reveals that there are quite a few different mechanism suggested, from simple mechanisms pointing to the pulmonary veins as the source of the arrhythmia to a more complex pattern showing that pathophysiology is more complex and biatrial. 72,73 Go

A better understanding for the possible reason for the differences in the mechanisms is important. Unfortunately, to some extent, our ability to do so is presently limited. In this study the results with the biatrial approach were superior to those achieved with left atrial ablation only. This might be related to the fact that the surgical patients usually presented with other cardiac pathologies, such as mitral valve and coronary artery disease, and with long duration of AF. As a result, the disease process in the surgical group of patients is much more advanced and diffuse when compared with that of patients treated with catheter pulmonary vein ablation for lone AF. Given that most mapping data for AF are based on nonsurgical patients with lone AF, it would be difficult to speculate about the exact mechanism among surgical patients to further support either surgical approach. Mapping during surgical intervention has the potential to guide surgeons to more specific ablation protocols. However, at this time, few clinical studies have assessed this strategy.

There are some reports documenting greater permanent pacemaker implantation after the maze procedure compared with that after left atrial ablation only. The indication for pacemaker use is sinus node dysfunction in most cases. The majority of patients with sinus node activity recover to the extent that patients are no longer pacemaker dependent. 74 Go However, except for among patients after the maze I procedure, sinus node dysfunction cannot be attributed to the surgical procedure. It might be due to the fact that there is a higher success rate in ablating AF and that more cases of sick sinus syndrome that are strongly associated with AF are discovered.

Our study has several strengths and limitations. To our knowledge, this is the first attempt to systematically analyze published data for the surgical treatment of AF. We have conducted an extensive search for all clinical studies meeting our search criteria. However, publication bias might have eliminated potential studies for whatever reason deemed important by various editorial boards, and although there is no formal way to test for this, we would be remiss if we did not caution the readers of this potential for bias. In addition, determining rates of survival and freedom from postoperative AF was sometimes accomplished by viewing actual Kaplan-Meier curves and extrapolating results. This might have led to some discrepancies from the true published results. However, given the ease of reading a Kaplan-Meier plot, we think this is a minimal concern. Furthermore, our study included all studies relevant to our search strategy.

We made no attempt to exclude studies on the basis of size, degree of follow-up, or definition of AF. This might have biased our findings, but we have attempted to portray as general and inclusive a review of the literature as possible. The inclusion of different study groups might have biased the effects of any subgroup analysis, but we believe this effect could be minimal because of the consistent profile of patients referred for a surgical ablation procedure. Studies involving shorter follow-up might have ended before a return to dysrhythmia, thereby indicating artificially high rates of freedom from AF. Unfortunately, the traditional strengths of meta-analyses involving clinical trials are potential limitations for our study. Those meta-analyses have very defined patient groups from which a meta-analysis can be performed. There are few clinical trials involving our subject matter, leaving us with retrospective trials from which patient groups were undoubtedly more heterogeneous. With this in mind, we have attempted to give the interested reader a composite view of the existing research regarding surgical treatment for AF.

We caution the reader that this is a summary of published results. We did not have access to original data, and thus errors might have occurred in our extrapolation of data from Kaplan-Meier tables, in the combination of multiple control groups into one group through weighting, and in the potential temporal bias of using data over an 11-year span. Surgical ablation expertise and technique have no doubt caused increases in both survival and freedom from AF rates. Furthermore, freedom from AF as a study end point was generally defined as a return to sinus rhythm, with no additional detail. It is possible that a different patient population would have provided different freedom from AF rates under different investigator protocols.

This summary review suggests the surgical treatment for AF offers similar postoperative survival rates and vastly superior freedom from AF rates compared with those of traditional therapies. In addition, the surgical treatment of AF involving biatrial status offers superior long-term survival and freedom from AF.


Earn CME credits at http://cme.ctsnetjournals.org

 

See related editorial on page 949.

 


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Halkos ME, Craver JM, Thourani VH, et al. Intraoperative radiofrequency ablation for the treatment of atrial fibrillation during concomitant cardiac surgery. Ann Thorac Surg 2005;80:210-215.[Abstract/Free Full Text]
  2. Sueda T, Imai K, Orihashi K, et al. Midterm results of pulmonary vein isolation for the elimination of chronic atrial fibrillation. Ann Thorac Surg 2005;79:521-525.[Abstract/Free Full Text]
  3. Gaynor SL, Schuessler RB, Baily MS, et al. Surgical treatment of atrial fibrillation. predictors of late recurrence. J Thorac Cardiovasc Surg 2005;129:104-111.[Abstract/Free Full Text]
  4. Damiano Jr RJ, Gaynor SL, Bailey M, et al. The long-term outcome of patients with coronary disease and atrial fibrillation undergoing the Cox maze procedure. J Thorac Cardiovasc Surg 2003;126:2016-2021.[Abstract/Free Full Text]
  5. Prasad SM, Maniar HS, Camillo CJ, et al. The Cox maze III procedure for atrial fibrillation. long-term efficacy in patients undergoing lone versus concomitant procedures. J Thorac Cardiovasc Surg 2003;126:1822-1828.[Abstract/Free Full Text]
  6. Fayad G, Le Tourneau T, Modine T, et al. Endocardial radiofrequency ablation during mitral valve surgery. effect on cardiac rhythm, atrial size, and function. Ann Thorac Surg 2005;79:1505-1511.[Abstract/Free Full Text]
  7. Ad N, Cox JL. The Maze procedure for the treatment of atrial fibrillation. a minimally invasive approach. J Card Surg 2004;19:196-200.[Medline]
  8. Chen MC, Chang JP, Chang HW. Preoperative atrial size predicts the success of radiofrequency maze procedure for permanent atrial fibrillation in patients undergoing concomitant valvular surgery. Chest 2004;125:2129-2134.[Abstract/Free Full Text]
  9. Chiappini B, tin-Suarez S, LoForte A, et al. Cox/Maze III operation versus radiofrequency ablation for the surgical treatment of atrial fibrillation. a comparative study. Ann Thorac Surg 2004;77:87-92.[Abstract/Free Full Text]
  10. de Lima GG, Kalil RA, Leiria TL, et al. Randomized study of surgery for patients with permanent atrial fibrillation as a result of mitral valve disease. Ann Thorac Surg 2004;77:2089-2094.[Abstract/Free Full Text]
  11. Knaut M, Tugtekin SM, Matschke K. Pulmonary vein isolation by microwave energy ablation in patients with permanent atrial fibrillation. J Card Surg 2004;19:211-215.[Medline]
  12. Mokadam NA, McCarthy PM, Gillinov AM, et al. A Prospective multicenter trial of bipolar radiofrequency ablation for atrial fibrillation. early results. Ann Thorac Surg 2004;78:1665-1670.[Abstract/Free Full Text]
  13. Romano MA, Bach DS, Pagani FD, et al. Atrial reduction plasty Cox maze procedure. extended indications for atrial fibrillation surgery. Ann Thorac Surg 2004;77:1282-1287.[Abstract/Free Full Text]
  14. Sie HT, Beukema WP, Elvan A, et al. Long-term results of irrigated radiofrequency modified maze procedure in 200 patients with concomitant cardiac surgery. six years experience. Ann Thorac Surg 2004;77:512-516.[Abstract/Free Full Text]
  15. Szalay ZA, Civelek A, Dill T, et al. Long-term follow-up after the mini-maze procedure. Ann Thorac Surg 2004;77:1277-1281.[Abstract/Free Full Text]
  16. Szalay ZA, Skwara W, Klovekorn WP, et al. Predictors of failure to cure atrial fibrillation with the mini-maze operation. J Card Surg 2004;19:1-6.[Medline]
  17. Wisser W, Khazen C, Deviatko E, et al. Microwave and radiofrequency ablation yield similar success rates for treatment of chronic atrial fibrillation. Eur J Cardiothorac Surg 2004;25:1011-1017.[Abstract/Free Full Text]
  18. Akpinar B, Guden M, Sagbas E, et al. Combined radiofrequency modified maze and mitral valve procedure through a port access approach. early and mid-term results. Eur J Cardiothorac Surg 2003;24:223-230.[Abstract/Free Full Text]
  19. Colangelo N, Benussi S, Nascimbene S, et al. Cardiopulmonary bypass strategy during concomitant surgical treatment of mitral valve disease and atrial fibrillation. Perfusion 2003;18:19-24.[Abstract/Free Full Text]
  20. Doll N, Kiaii BB, Fabricius AM, et al. Intraoperative left atrial ablation (for atrial fibrillation) using a new argon cryocatheter. early clinical experience. Ann Thorac Surg 2003;76:1711-1715.[Abstract/Free Full Text]
  21. Guden M, Akpinar B, Caynak B, et al. Left versus bi-atrial intraoperative saline-irrigated radiofrequency modified maze procedure for atrial fibrillation. Card Electrophysiol Rev 2003;7:252-258.[Medline]
  22. Guden M, Akpinar B, Sagbas E, et al. A radiofrequency modified maze and valve procedure through a port-access approach. Heart Surg Forum 2003;6:292-296.[Medline]
  23. Jessurun ER, van Hemel NM, Defauw JJ, et al. A randomized study of combining maze surgery for atrial fibrillation with mitral valve surgery. J Cardiovasc Surg (Torino) 2003;44:9-18.[Medline]
  24. Kondo N, Takahashi K, Minakawa M, et al. Left atrial maze procedure. a useful addition to other corrective operations. Ann Thorac Surg 2003;75:1490-1494.[Abstract/Free Full Text]
  25. Lee JW, Park NH, Choo SJ, et al. Surgical outcome of the maze procedure for atrial fibrillation in mitral valve disease. rheumatic versus degenerative. Ann Thorac Surg 2003;75:57-61.[Abstract/Free Full Text]
  26. Mantovan R, Raviele A, Buja G, et al. Left atrial radiofrequency ablation during cardiac surgery in patients with atrial fibrillation. J Cardiovasc Electrophysiol 2003;14:1289-1295.[Medline]
  27. Raman J, Ishikawa S, Storer MM, et al. Surgical radiofrequency ablation of both atria for atrial fibrillation. results of a multicenter trial. J Thorac Cardiovasc Surg 2003;126:1357-1366.[Abstract/Free Full Text]
  28. Raman JS, Ishikawa S, Power JM. Epicardial radiofrequency ablation of both atria in the treatment of atrial fibrillation. experience in patients. Ann Thorac Surg 2002;74:1506-1509.[Abstract/Free Full Text]
  29. Schuetz A, Schulze CJ, Sarvanakis KK, et al. Surgical treatment of permanent atrial fibrillation using microwave energy ablation. a prospective randomized clinical trial. Eur J Cardiothorac Surg 2003;24:475-480.[Abstract/Free Full Text]
  30. Starck C, Botha CA, Roser D, et al. Results of a modified left atrial maze procedure as a combined procedure. Thorac Cardiovasc Surg 2003;51:147-153.[Medline]
  31. Ad N, Cox JL. Combined mitral valve surgery and the Maze III procedure. Semin Thorac Cardiovasc Surg 2002;14:206-209.[Medline]
  32. Deneke T, Khargi K, Grewe PH, et al. Left atrial versus bi-atrial maze operation using intraoperatively cooled-tip radiofrequency ablation in patients undergoing open-heart surgery. safety and efficacy. J Am Coll Cardiol 2002;39:1644-1650.[Abstract/Free Full Text]
  33. Guden M, Akpinar B, Sanisoglu I, et al. Intraoperative saline-irrigated radiofrequency modified Maze procedure for atrial fibrillation. Ann Thorac Surg 2002;74(suppl):S1301-S1306.[Abstract/Free Full Text]
  34. Guang Y, Zhen-jie C, Yong LW, et al. Evaluation of clinical treatment of atrial fibrillation associated with rheumatic mitral valve disease by radiofrequency ablation. Eur J Cardiothorac Surg 2002;21:249-254.[Abstract/Free Full Text]
  35. Knaut M, Tugtekin SM, Spitzer S, Gulielmos V. Combined atrial fibrillation and mitral valve surgery using microwave technology. Semin Thorac Cardiovasc Surg 2002;14:226-231.[Medline]
  36. Kobayashi J, Sasako Y, Bando K, et al. Eight-year experience of combined valve repair for mitral regurgitation and maze procedure. J Heart Valve Dis 2002;11:165-171.[Medline]
  37. Kress DC, Sra J, Krum D, et al. Radiofrequency ablation of atrial fibrillation during mitral valve surgery. Semin Thorac Cardiovasc Surg 2002;14:210-218.[Medline]
  38. Maessen JG, Nijs JF, Smeets JL, Vainer J, Mochtar B. Beating-heart surgical treatment of atrial fibrillation with microwave ablation. Ann Thorac Surg 2002;74(suppl):S1307-S1311.[Abstract/Free Full Text]
  39. Mohr FW, Fabricius AM, Falk V, et al. Curative treatment of atrial fibrillation with intraoperative radiofrequency ablation. short-term and midterm results. J Thorac Cardiovasc Surg 2002;123:919-927.[Abstract/Free Full Text]
  40. Nakajima H, Kobayashi J, Bando K, et al. The effect of cryo-maze procedure on early and intermediate term outcome in mitral valve disease. case matched study. Circulation 2002;106(suppl 1):I46-I50.
  41. Ngodngamthaweesuk M, Boonkasem S, Subhannachart W, et al. Modified Cox maze procedure for atrial fibrillation with mitral valve diseases. J Med Assoc Thai 2002;85:1182-1188.[Medline]
  42. Ruchat P, Schlaepfer J, Delabays A, et al. Left atrial radiofrequency compartmentalization for chronic atrial fibrillation during heart surgery. Thorac Cardiovasc Surg 2002;50:155-159.[Medline]
  43. Tanaka H, Narisawa T, Mori T, et al. Pulmonary vein isolation for chronic atrial fibrillation associated with mitral valve disease. the midterm results. Ann Thorac Cardiovasc Surg 2002;8:88-91.[Medline]
  44. Wellens F, Casselman F, Geelen P, et al. Combined atrial fibrillation and mitral valve surgery using radiofrequency technology. Semin Thorac Cardiovasc Surg 2002;14:219-225.[Medline]
  45. Khargi K, Deneke T, Haardt H, et al. Saline-irrigated, cooled-tip radiofrequency ablation is an effective technique to perform the maze procedure. Ann Thorac Surg 2001;72(suppl):S1090-S1095.[Abstract/Free Full Text]
  46. Kim KB, Huh JH, Kang CH, et al. Modifications of the Cox-Maze III procedure. Ann Thorac Surg 2001;71:816-822.[Abstract/Free Full Text]
  47. Isobe F, Kumano H, Ishikawa T, et al. A new procedure for chronic atrial fibrillation. bilateral appendage-preserving maze procedure. Ann Thorac Surg 2001;72:1473-1478.[Abstract/Free Full Text]
  48. Pasic M, Bergs P, Muller P, et al. Intraoperative radiofrequency maze ablation for atrial fibrillation. the Berlin modification. Ann Thorac Surg 2001;72:1484-1490.[Abstract/Free Full Text]
  49. Raanani E, Albage A, David TE, et al. The efficacy of the Cox/maze procedure combined with mitral valve surgery. a matched control study. Eur J Cardiothorac Surg 2001;19:438-442.[Abstract/Free Full Text]
  50. Raman JS, Seevanayagam S, Storer M, et al. Combined endocardial and epicardial radiofrequency ablation of right and left atria in the treatment of atrial fibrillation. Ann Thorac Surg 2001;72(suppl):S1096-S1099.[Abstract/Free Full Text]
  51. Sie HT, Beukema WP, Misier AR, et al. Radiofrequency modified maze in patients with atrial fibrillation undergoing concomitant cardiac surgery. J Thorac Cardiovasc Surg 2001;122:249-256.[Abstract/Free Full Text]
  52. Williams MR, Stewart JR, Bolling SF, et al. Surgical treatment of atrial fibrillation using radiofrequency energy. Ann Thorac Surg 2001;71:1939-1943.[Abstract/Free Full Text]
  53. Arcidi Jr JM, Doty DB, Millar RC. The Maze procedure. the LDS Hospital experience. Semin Thorac Cardiovasc Surg 2000;12:38-43.[Medline]
  54. Gaita F, Gallotti R, Calo L, et al. Limited posterior left atrial cryoablation in patients with chronic atrial fibrillation undergoing valvular heart surgery. J Am Coll Cardiol 2000;36:159-166.[Abstract/Free Full Text]
  55. Izumoto H, Kawazoe K, Eishi K, et al. Medium-term results after the modified Cox/Maze procedure combined with other cardiac surgery. Eur J Cardiothorac Surg 2000;17:25-29.[Abstract/Free Full Text]
  56. Jatene MB, Cial MB, Tarasoutchi F, et al. Influence of the maze procedure on the treatment of rheumatic atrial fibrillation—evaluation of rhythm control and clinical outcome in a comparative study. Eur J Cardiothorac Surg 2000;17:117-124.[Abstract/Free Full Text]
  57. Jessurun ER, van Hemel NM, Defauw JA, et al. Results of maze surgery for lone paroxysmal atrial fibrillation. Circulation 2000;101:1559-1567.[Abstract/Free Full Text]
  58. McCarthy PM, Gillinov AM, Castle L, Chung M, Cosgrove Dl. The Cox-Maze procedure. the Cleveland Clinic experience. Semin Thorac Cardiovasc Surg 2000;12:25-29.[Medline]
  59. Schaff HV, Dearani JA, Daly RC, Orszulak TA, Danielson GK. Cox-Maze procedure for atrial fibrillation. Mayo clinic experience. Semin Thorac Cardiovasc Surg 2000;12:30-37.[Medline]
  60. Tuinenburg AE, Van Gelder IC, Tieleman RG, et al. Mini-maze suffices as adjunct to mitral valve surgery in patients with preoperative atrial fibrillation. J Cardiovasc Electrophysiol 2000;11:960-967.[Medline]
  61. Handa N, Schaff HV, Morris JJ, et al. Outcome of valve repair and the Cox maze procedure for mitral regurgitation and associated atrial fibrillation. J Thorac Cardiovasc Surg 1999;118:628-635.[Abstract/Free Full Text]
  62. Kalil RA, Albrecht A, Lima GG, et al. Results of the surgical treatment of chronic atrial fibrillation. Arq Bras Cardiol 1999;73:139-148.[Medline]
  63. Kim KB, Cho KR, Sohn DW, et al. The Cox-Maze III procedure for atrial fibrillation associated with rheumatic mitral valve disease. Ann Thorac Surg 1999;68:799-803.[Abstract/Free Full Text]
  64. Nitta T, Ishii Y, Ogasawara H, et al. Initial experience with the radial incision approach for atrial fibrillation. Ann Thorac Surg 1999;68:805-810.[Abstract/Free Full Text]
  65. Szalay ZA, Skwara W, Pitschner HF, et al. Midterm results after the Mini-Maze procedure. Eur J Cardiothorac Surg 1999;16:306-311.[Abstract/Free Full Text]
  66. Izumoto H, Kawazoe K, Kitahara H, Kamata J. Operative results after the Cox/maze procedure combined with a mitral valve operation. Ann Thorac Surg 1998;66:800-804.[Abstract/Free Full Text]
  67. Cox JL, Schuessler RB, Lappas DG, Boineau JP. An 8 1/2-year clinical experience with surgery for atrial fibrillation. Ann Surg 1996;224:267-273.[Medline]
  68. Vigano M, Graffigna A, Ressia L, et al. Surgery for atrial fibrillation. Eur J Cardiothorac Surg 1996;10:490-497.[Abstract]
  69. Gregori Jr F, Cordeiro CO, Couto WJ, et al. Cox maze operation without cryoablation for the treatment of chronic atrial fibrillation. Ann Thorac Surg 1995;60:361-363.[Abstract/Free Full Text]
  70. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Erlbaum; 1988.
  71. Hunter JE, Schmidt FL. Methods of meta-analysis. correcting error and bias in research findings. Newbury Park (CA): Sage; 1990.
  72. Haissaguerre M, Jais P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998;339:659-666.[Abstract/Free Full Text]
  73. Nademanee K, McKenzie J, Kosar E, et al. A new approach for catheter ablation of atrial fibrillation. mapping of the electrophysiologic substrate. J Am Coll Cardiol 2004;43:2044-2053.[Abstract/Free Full Text]
  74. Pasic M, Musci M, Siniawski H, Edelmann B, Tedoriya T, Hetzer R. Transient sinus node dysfunction after the Cox-maze III procedure in patients with organic heart disease and chronic fixed atrial fibrillation. J Am Coll Cardiol 1998;32:1040-1047.[Abstract/Free Full Text]

Related Article

Surgery for atrial fibrillation: Are we heading in the right direction?
Joao Q. Melo
J. Thorac. Cardiovasc. Surg. 2006 131: 949-951. [Extract] [Full Text] [PDF]



This article has been cited by other articles:


Home page
 MMCTSHome page
A. C. Kiser and W. Cockfield
Paracardioscopic ex-maze procedure for atrial fibrillation
MMCTS, February 1, 2010; 2010(0201): 3863.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll Cardiol IntvHome page
H. Sievert and Y. L. Bayard
Percutaneous Closure of the Left Atrial Appendage: A Major Step Forward
J. Am. Coll. Cardiol. Intv., July 1, 2009; 2(7): 601 - 602.
[Full Text] [PDF]

Home page
 HeartHome page
J Pontoppidan, J C Nielsen, S H Poulsen, H K Jensen, H Walfridsson, A K Pedersen, and P S Hansen
Prophylactic cavotricuspid isthmus block during atrial fibrillation ablation in patients without atrial flutter: a randomised controlled trial
Heart, June 15, 2009; 95(12): 994 - 999.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
S. Benussi, A. Galanti, S. Nascimbene, A. Fumero, E. Dorigo, V. Zerbi, and O. Alfieri
Complete right atrial ablation with bipolar radiofrequency.
Ann. Thorac. Surg., May 1, 2009; 87(5): 1573 - 1576.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
U. O. von Oppell, N. Masani, P. O'Callaghan, R. Wheeler, G. Dimitrakakis, and S. Schiffelers
Mitral valve surgery plus concomitant atrial fibrillation ablation is superior to mitral valve surgery alone with an intensive rhythm control strategy
Eur. J. Cardiothorac. Surg., April 1, 2009; 35(4): 641 - 650.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
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]

Home page
 HeartHome page
Y. L Bayard, S. H Ostermayer, and H. Sievert
Alternatives to warfarin in atrial fibrillation: drugs and devices
Heart, September 1, 2008; 94(9): 1113 - 1116.
[Full Text] [PDF]

Home page
 Asian Cardiovasc. Thorac. Ann.Home page
S. Chaiyaroj, T. Ngarmukos, and P. Lertsithichai
Predictors of Sinus Rhythm after Radiofrequency Maze and Mitral Valve Surgery
Asian Cardiovasc Thorac Ann, August 1, 2008; 16(4): 292 - 297.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
H. Grubitzsch, C. Grabow, H. Orawa, and W. Konertz
Factors predicting the time until atrial fibrillation recurrence after concomitant left atrial ablation.
Eur. J. Cardiothorac. Surg., July 1, 2008; 34(1): 67 - 72.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
M. P. Marques, J. Q. Melo, M. Knaut, O. Alfieri, S. Benussi, M. R. Williams, and F. Hornero
Restoring sinus rhythm in patients with previous pacemaker implantation submitted to cardiac surgery and concomitant surgical ablation of atrial fibrillation
Eur. J. Cardiothorac. Surg., April 1, 2008; 33(4): 596 - 599.
[Abstract] [Full Text] [PDF]

Home page
 ICVTSHome page
Y.-Q. Lai, J.-H. Li, J.-W. Li, S.-D. Xu, Y. Luo, and Z.-G. Zhang
Concomitant irrigated monopolar radiofrequency ablation of atrial fibrillation in adults with congenital heart disease
Interactive CardioVascular and Thoracic Surgery, February 1, 2008; 7(1): 80 - 83.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
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]

Home page
 Ann. Thorac. Surg.Home page
W. Wisser, G. Seebacher, T. Fleck, C. Aigner, C. Khazen, G. Stix, D. Hutschala, and E. Wolner
Permanent Chronic Atrial Fibrillation: Is Pulmonary Vein Isolation Alone Enough?
Ann. Thorac. Surg., October 1, 2007; 84(4): 1151 - 1157.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
F. Hornero, I. Rodriguez, V. Estevez, A. Vazquez, O. Gil, S. Canovas, R. G. Fuster, and J. Martinez-Leon
Intraoperative Cryoablation of Atrial Fibrillation With the Old-Fashioned Cryode Tips: A Simple, Effective, and Inexpensive Method
Ann. Thorac. Surg., October 1, 2007; 84(4): 1408 - 1411.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
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]

Home page
 Ann. Thorac. Surg.Home page
A. M. Gillinov and L. G. Svensson
Ablation of Atrial Fibrillation With Minimally Invasive Mitral Surgery
Ann. Thorac. Surg., September 1, 2007; 84(3): 1041 - 1042.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
F. Hornero, I. Rodriguez, V. Estevez, O. Gil, S. Canovas, R. Garcia, and J. M. Leon
Analysis of the postoperative epicardial auriculogram after surgical ablation of atrial fibrillation: Risk stratification of late recurrences
J. Thorac. Cardiovasc. Surg., June 1, 2007; 133(6): 1493 - 1498.
[Abstract] [Full Text] [PDF]

Home page
 EuropaceHome page
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]

Home page
 Eur. J. Cardiothorac. Surg.Home page
C. Alexiou, G. Doukas, M. Oc, B. Oc, J. Swanevelder, N. J. Samani, and T. J. Spyt
The effect of preoperative atrial fibrillation on survival following mitral valve repair for degenerative mitral regurgitation
Eur. J. Cardiothorac. Surg., April 1, 2007; 31(4): 586 - 591.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
N. Ad
How do we spell maze? A dialogue concerning definitions and goals
J. Thorac. Cardiovasc. Surg., December 1, 2006; 132(6): 1253 - 1255.
[Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
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]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Niv Ad
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Barnett, S. D.
Right arrow Articles by Ad, N.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Barnett, S. D.
Right arrow Articles by Ad, N.
Related Collections
Right arrow Electrophysiology - arrhythmias
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS