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. 2018 Mar;155(3):983-994.
doi: 10.1016/j.jtcvs.2017.09.147. Epub 2017 Nov 14.

Long-term outcome following concomitant mitral valve surgery and Cox maze procedure for atrial fibrillation

Niv Ad  1 , Sari D Holmes  2 , Paul S Massimiano  3 , Anthony J Rongione  3 , Lisa M Fornaresio  2
Affiliations

Long-term outcome following concomitant mitral valve surgery and Cox maze procedure for atrial fibrillation

Niv Ad et al. J Thorac Cardiovasc Surg. 2018 Mar.

Abstract

Objective: Atrial fibrillation (AF) is associated with increased early and long-term morbidity/mortality following valve surgery. This study examined long-term influence of concomitant full Cox maze (CM) and mitral valve procedures on freedom from atrial arrhythmia and stroke.

Methods: This sample comprised patients who underwent CM with a mitral valve procedure (N = 473). Data on rhythm, medication status, and clinical events captured according to Heart Rhythm Society guidelines at 6, 9, 12, 18, and 24 months and yearly thereafter up to 7 years.

Results: Mean age was 65 years, mean left atrium size was 5.3 cm, and 15% had paroxysmal AF. Perioperative stroke occurred in 2 patients (0.4%) and operative mortality was 2.7% (n = 13). Return to sinus rhythm regardless of antiarrhythmic drugs at 1, 5, and 7 years was 90%, 80%, and 66%. Sinus rhythm off antiarrhythmic drugs at 1, 5, and 7 years was 83%, 69%, and 55%. Freedom from embolic stroke at 7 years was 96.6% (0.4 strokes per 100 patient-years) with a majority of patients off anticoagulation medication. Greater odds of atrial arrhythmia recurrence during 7 years was associated with longer AF duration (odds ratio [OR], 1.07; P = .001), whereas lower odds were associated with cryothermal energy only (OR, 0.64; P = .045) and greater surgeon experience (OR, 0.98; P = .025).

Conclusions: This study suggests that the addition of CM to mitral valve procedures, even with a high degree of complexity, did not increase operative risk. In long-term follow-up, the CM procedure demonstrated acceptable rhythm success, reduced AF burden, and remarkably low stroke rate. Individual surgeon experience and training may notably influence long-term surgical ablation for AF success.

Keywords: atrial fibrillation; cardiac surgery; mitral valve.

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Conflict of interest statement

Conflict of Interest Statement

N.A. is a consultant for Medtronic, a member of the speaker’s bureau for AtriCure, proctor and member of the speaker’s bureau for LivaNova, on the advisory board for Nido Surgical, and co-owner of Left Atrial Appendage Occlusion, LLC. All other authors have nothing to disclose with regard to commercial support.

Figures

FIGURE 1
FIGURE 1
Percent of patients in sinus rhythm (SR) and SR off antiarrhythmic drugs (AAD) during 7 years of follow-up.
FIGURE 2
FIGURE 2
Burden of atrial arrhythmias during 7 years of follow-up.
FIGURE 3
FIGURE 3
Distribution lines from histograms of preoperative atrial fibrillation (AF) duration and left atrium size for patients in sinus rhythm off antiarrhythmic drugs (blue line) and not in sinus rhythm off antiarrhythmic drugs (gold line) at 7 years. Vertical lines represent median values for AF duration and mean values for left atrium size by group.
FIGURE 4
FIGURE 4
Cumulative freedom from embolic stroke during 7 years of follow-up. 95% CI, 95% Confidence interval.
See this image and copyright information in PMC

Comment in

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