Minimally Invasive Stand-Alone Cox Maze Procedure for Persistent and Long-Standing Persistent Atrial Fibrillation: Perioperative Safety and 5-Year Outcomes

BACKGROUND: Rhythm control is challenging in patients with extended atrial fibrillation (AF) duration and persistent/long-standing persistent AF. Among surgical approaches to treat AF, the Cox maze procedure performed using alternative energy sources remains superior to other beating heart techniques. We examined permanence of safety and success for the on-pump, minimally invasive, stand-alone Cox maze procedure 5 years after surgery.

METHODS AND RESULTS: Stand-alone, right 5 cm minithoracotomy, Cox maze III/IV procedure for nonparoxysmal AF was conducted in 133 patients (mean follow-up=65±34 months). Data collected prospectively at 3, 6, 9, 12, 18, 24 months and yearly thereafter and reported per Heart Rhythm Society Guidelines. Paired-samples t tests evaluated quality of life changes. Mean age was 57.3±9.2 years, mean LA size was 4.9±1.1 cm, median AF duration was 51 months, and 78% had long-standing persistent AF. All procedures performed with no conversion to midsternotomy, no renal failure, strokes, or operative mortality (<30 days), transient ischemic attack in 1 patient, reoperation for bleeding in 2 patients, and median length of stay was 4 days [3-5.5 days]. At 5 years, 73% were in sinus rhythm off antiarrhythmic medications after single intervention, 1 stroke (718 patient-years) with 81% off anticoagulation, catheter ablation reinterventions in 13 patients for atrial arrhythmia, and cardioversions in 15 patients. Quality of life scores improved significantly by 12 months after surgery.

CONCLUSIONS: Successful ablation for nonparoxysmal AF is challenging. Therefore, periprocedural safety and long-term efficacy of minimally invasive Cox maze procedures should be noted. Continued refinement of decision-making techniques is warranted to improve patient selection for the appropriate intervention to treat AF.