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Meta-Analysis
. 2022 Nov;37(11):3801-3810.
doi: 10.1111/jocs.16888. Epub 2022 Aug 30.

Comparing mid-term outcomes of Cox-Maze procedure and pulmonary vein isolation for atrial fibrillation after concomitant mitral valve surgery: A systematic review

Davorin Sef  1 , Vladimir Trkulja  2 , Shahzad G Raja  1 , Joanne Hooper  3 , Marko I Turina  4
Affiliations
Meta-Analysis

Comparing mid-term outcomes of Cox-Maze procedure and pulmonary vein isolation for atrial fibrillation after concomitant mitral valve surgery: A systematic review

Davorin Sef et al. J Card Surg. 2022 Nov.

Abstract

Background: Although concomitant pulmonary vein isolation (PVI) is used more frequently than the Cox-Maze procedure, which is currently the gold standard treatment for atrial fibrillation (AF), data on the comparative effectiveness of the two procedures after concomitant mitral valve (MV) surgery are still limited.

Objective: We conducted a systematic review to identify randomized controlled trials (RCTs) and observational studies comparing the mid-term mortality and recurrence of AF after concomitant Cox-Maze and PVI in patients with AF undergoing MV surgery based on 12-month follow-up.

Methods: Medline, EMBASE databases, and the Cochrane Library were searched from 1987 up to March 2022 for studies comparing concomitant Cox-Maze and PVI. Additionally, a meta-analysis of RCTs was performed to compare the mid-term clinical outcomes between these two surgical ablation techniques.

Results: Three RCTs and three observational studies meeting the inclusion criteria were included in this systematic review with 790 patients in total (532 concomitant Cox-Maze and 258 PVI during MV surgery). Most studies reported that the concomitant Cox-Maze procedure was associated with higher freedom from AF at 12-month follow-up than PVI. Regarding AF recurrence, estimates pooled across the three RCTs indicated large heterogeneity and high uncertainty. In the largest and highest quality RCT, 12-month AF recurrence was higher in the PVI arm (risk ratio = 1.58, 95% CI: 0.91-2.73). In two out of three higher-quality observational studies, 12-month AF recurrence was higher in PVI than in the Cox-Maze arm (estimated adjusted probabilities 11% vs. 8% and 35% vs. 17%, respectively). RCTs demonstrated comparable 12-month mortality between concomitant Cox-Maze and PVI, while observational studies demonstrated the survival benefit of Cox-Maze.

Conclusions: Concomitant Cox-Maze in AF patients undergoing MV surgery is associated with better mid-term freedom from AF when compared to PVI with comparable mid-term survival. Large observational studies suggest that there might be a mid-term survival benefit among patients after concomitant Cox-Maze. Further large RCTs with longer standardized follow-up are required to clarify the benefits of concomitant Cox-Maze in AF patients during MV surgery.

Keywords: Cox-Maze; ablation surgery; atrial fibrillation; mitral valve surgery; pulmonary vein isolation.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐analyses) flow diagram. RCT, randomized controlled trial.
Figure 2
Figure 2
Forest plot showing the effect of PVI and Cox‐Maze procedure for AF during the mitral valve surgery on 12‐month mortality and recurrence of AF in randomized controlled trials. AF, atrial fibrillation; CI, confidence interval; M‐H, Mantel–Haenszel statistic; PVI, pulmonary vein isolation.
See this image and copyright information in PMC

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