Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Editorial
. 2022 Dec 5:17:84-93.
doi: 10.1016/j.xjtc.2022.11.009. eCollection 2023 Feb.

The Cox-Maze procedure: What lesions and why

Martha M O McGilvray  1 , Lauren Barron  2 , Tari-Ann E Yates  1 , Christian W Zemlin  1 , Ralph J Damiano Jr  1
Affiliations
Editorial

The Cox-Maze procedure: What lesions and why

Martha M O McGilvray et al. JTCVS Tech. .
No abstract available

Keywords: Cox-Maze procedure; atrial fibrillation; left atrial appendage; pulmonary vein isolation; surgical ablation.

PubMed Disclaimer

Figures

None
The Cox-Maze biatrial lesion set, including the posterior LA box.
Figure 1
Figure 1
Cox-Maze lesions. LAA1: Manage the LAA. LAA2: Connect the LAA exclusion to the Box. L1-4: The Box: Isolate the entirety of the posterior LA. L5: Connect the box to the mitral annulus and the coronary sinus. R1: Make a right atriotomy. R2-3: Create a line of block between the SVC (R2) and the IVC (R3). R4: Connect the atriotomy to the tricuspid annulus at the 2 o'clock position (∗this lesion does not cross the valve itself; it arches over the valve along the anterior wall of the RA with the end of the lesion extending onto the valve annulus at the 2 o'clock position). R5: Connect the tricuspid annulus at the 10 o'clock position to the RAA. R6: Connect the RAA to the RA free wall, making sure to avoid the SAN. RAA, Right atrial appendage; SVC, superior vena cava; IVC, inferior vena cava; LAA, left atrial appendage; PV, pulmonary vein.
Figure 2
Figure 2
LA Cox-Maze lesion set. A, LA lesion set via a sternotomy approach.White lines indicate lesions made by bipolar RF ablation, and the blue oval indicates a lesion made by cryoablation. B, LA lesion set via a right minithoracotomy.Red lines indicate lesions made by bipolar RF ablation, and blue ovals indicate lesions made by cryoablation. Not pictured in B is the LAA exclusion, which we perform using an epicardial approach via the transverse sinus.
Figure 3
Figure 3
The Box: Adequate exclusion of the entire posterior LA. A satisfactory result with long-term efficacy relies on isolation of the entire posterior LA. Specifically, a box-shaped area of tissue, incorporating the ostia of all PVs and the intervening posterior LA wall, must be electrically excluded via a continuous and fully transmural circumferential line of ablation. Note that this box does not need to be made with a single application of a device, but can be constructed from a number of applications.
Figure 4
Figure 4
RA Cox-Maze lesion set. A, RA lesion set via a sternotomy approach.White lines indicate lesions made by bipolar RF ablation, and blue ovals indicate lesions made by cryoablation. B, RA lesion set via a right minithoracotomy.Red lines indicate lesions made by bipolar RF ablation, blue ovals indicate lesions made by cryoablation, and black arrows indicate the 3 purse-string stab-incisions.
See this image and copyright information in PMC

References

    1. Mehaffey J.H., Krebs E., Hawkins R.B., Charles E.J., Tsutsui S., Kron I.L., et al. Variability and utilization of concomitant atrial fibrillation ablation during mitral valve surgery. Ann Thorac Surg. 2021;111:29–34. - PubMed
    1. Weimar T., Schena S., Bailey M.S., Maniar H.S., Schuessler R.B., Cox J.L., et al. The Cox-Maze procedure for lone atrial fibrillation: a single-center experience over 2 decades. Circ Arrhythm Electrophysiol. 2012;5:8–14. - PMC - PubMed
    1. Badhwar V., Rankin J.S., Damiano R.J., Jr., Gillinov A.M., Bakaeen F.G., Edgerton J.R., et al. The Society of Thoracic Surgeons 2017 clinical practice guidelines for the surgical treatment of atrial fibrillation. Ann Thorac Surg. 2017;103:329–341. - PubMed
    1. MacGregor R.M., Khiabani A.J., Damiano R.J. The surgical treatment of atrial fibrillation via median sternotomy. Oper Tech Thorac Cardiovasc Surg. 2019;24:19–37.
    1. Robertson J.O., Saint L.L., Leidenfrost J.E., Damiano R.J., Jr. Illustrated techniques for performing the Cox-Maze IV procedure through a right mini-thoracotomy. Ann Cardiothorac Surg. 2014;3:105–116. - PMC - PubMed

Publication types

LinkOut - more resources