Surgery for atrial fibrillation

Abstract

Atrial fibrillation is the most common cardiac arrhythmia, and its treatment options include drug therapy or catheter-based or surgical interventions. The surgical treatment of atrial fibrillation has undergone multiple evolutions over the last several decades. The Cox-Maze procedure went on to become the gold standard for the surgical treatment of atrial fibrillation and is currently in its fourth iteration (Cox-Maze IV). This article reviews the indications and preoperative planning for performing a Cox-Maze IV procedure. This article also reviews the literature describing the surgical results for both approaches including comparisons of the Cox-Maze IV to the previous cut-and-sew method.

Keywords: Atrial fibrillation; Cox-Maze; Minimally invasive; Surgical ablation.

Figure 1

Positioning for right mini-thoracotomy approach

Figure 2

Cox-Maze IV Lesion Set as performed through a Sternotomy. A) Right atrial lesion set – RF ablations consist of SVC/IVC ablation and RA free wall ablation. Cryoablations include linear cryoablations through a pursestring to the 10’o clock position of the tricuspid valve annulus and through the superior aspect of the atriotomy to the 2’o clock position of tricuspid valve annulus. B) Left atrial lesion set – Bipolar RF ablation lines consist of bilateral pulmonary vein isolations, ablations between the left superior pulmonary vein and amputated atrial appendage, pulmonary vein roof and floor connecting ablations, and ablation between inferior aspect of the atriotomy to mitral valve annulus. Cryoablations include linear epicardial cryoablation over the coronary sinus and at the mitral valve annulus.

Figure 3

Cox-Maze IV Lesion Set as performed through a right-ministernotomy. A) Right atrial lesion set – Three separate pursestrings and replacement of right atriotomy with a line of bipolar RF ablation. All other lesions are identical to the sternotomy approach. B) Left atrial lesion set – Left pulmonary vein isolation is achieved through sequential endocardial cryoablation and LAA is oversewn in two layers endocardially. All other lesion are identical to the sternotomy approach.