Atrial fibrillation (AF) is associated with substantial morbidity, mortality, and economic burden and confers a lifetime risk of up to 25%. Current medical management involves thromboembolism prevention, rate, and rhythm control. An increased understanding of AF pathophysiology has led to enhanced pharmacological and medical therapies; however this is often limited by toxicity, variable symptom control, and inability to modulate the atrial substrate. Surgical AF ablation has been available since the original description of the Cox Maze procedure, either as a standalone or concomitant intervention. Advances in novel energy delivery systems have allowed the development of less technically demanding procedures potentially eliminating the need for median sternotomy and cardiopulmonary bypass. Variations in the definition, duration, and reporting of AF have produced methodological limitations impacting on the validity of interstudy comparisons. Standardization of these parameters may, in future, allow us to further evaluate clinical endpoints and establish the efficacy of these techniques. 1. Introduction Atrial fibrillation (AF) is associated with significant morbidity and mortality in both medical and surgical patients. Results from the Framingham Heart study found AF to be associated with an overall lifetime risk of 1 in 4 adults aged 40–95 years or 1 in 6 of those without previous myocardial infarction or congestive cardiac failure [1]. Coronary artery bypass grafting alone has been associated with an incidence of AF reaching 30% in multicentre observational studies [2, 3] and may be significantly higher following valvular surgery [4]. More importantly, postoperative AF has been found to triple the risk of death from cardiac causes and quadruple the risk of stroke and other disabling embolic events [2]. The original “corridor” procedure for the treatment of AF was described by Guiraudon in 1985, but for a number of reasons was soon superseded by the “Maze” procedure as described by Cox et al. in 1991 [5, 6]. His work outlined a series of “cut and sew” lesions which aimed to direct electrical impulses in one direction through the atrium, disrupting the macro reentrant circuits which allow the development and propagation of AF. This procedure, whilst effective, was not without its complications, and the resultant inability to mount a tachycardic response to exercise and left atrial dysfunction led to two further adaptations of this procedure culminating in the Cox Maze III lesion set [5]. These modifications resulted in an improvement in the rates of
References
[1]
D. M. Lloyd-Jones, T. J. Wang, E. P. Leip et al., “Lifetime risk for development of atrial fibrillation: the framingham heart study,” Circulation, vol. 110, no. 9, pp. 1042–1046, 2004.
[2]
G. Mariscalco, C. Klersy, M. Zanobini et al., “Atrial fibrillation after isolated coronary surgery affects late survival,” Circulation, vol. 118, no. 16, pp. 1612–1618, 2008.
[3]
J. P. Mathew, M. L. Fontes, I. C. Tudor et al., “A multicenter risk Index for atrial fibrillation after cardiac surgery,” Journal of the American Medical Association, vol. 291, no. 14, pp. 1720–1729, 2004.
[4]
L. L. Creswell, R. B. Schuessler, M. Rosenbloom, and J. L. Cox, “Hazards of postoperative atrial arrhythmias,” Annals of Thoracic Surgery, vol. 56, no. 3, pp. 539–549, 1993.
[5]
J. L. Cox, J. P. Boineau, R. B. Schuessler, R. D. B. Jaquiss, and D. G. Lappas, “Modification of the maze procedure for atrial flutter and atrial fibrillation. I. Rationale and surgical results,” Journal of Thoracic and Cardiovascular Surgery, vol. 110, no. 2, pp. 473–484, 1995.
[6]
J. L. Cox, R. B. Schuessler, H. J. D'Agostino Jr. et al., “The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure,” Journal of Thoracic and Cardiovascular Surgery, vol. 101, no. 4, pp. 569–583, 1991.
[7]
J. M. Stulak, J. A. Dearani, T. M. Sundt III et al., “Superiority of cut-and-sew technique for the Cox maze procedure: comparison with radiofrequency ablation,” Journal of Thoracic and Cardiovascular Surgery, vol. 133, no. 4, pp. 1022–1027, 2007.
[8]
G. M. Guiraudon, C. S. Campbell, D. L. Jones, D. G. Mclellan, and J. L. Macdonald, “Combined sinoatrial node atrioventricular isolation: a surgical alternative to His-bundle ablation in patients with atrial-fibrillation,” Circulation, vol. 72, p. 220, 1985.
[9]
J. L. Cox, J. P. Boineau, R. B. Schuessler et al., “Electrophysiologic basis, surgical development, and clinical results of the maze procedure for atrial flutter and atrial fibrillation,” Advances in Cardiac Surgery, vol. 6, pp. 1–67, 1995.
[10]
J. L. Cox, R. B. Schuessler, D. G. Lappas, and J. P. Boineau, “An 8 1/2-year clinical experience with surgery for atrial fibrillation,” Annals of Surgery, vol. 224, no. 3, pp. 267–273, 1996.
[11]
S. L？nnerholm, P. Blomstr？m, L. Nilsson, and C. Blomstr？m-Lundqvist, “Long-term effects of the Maze procedure on atrial size and mechanical function,” Annals of Thoracic Surgery, vol. 85, no. 3, pp. 916–920, 2008.
[12]
R. J. Damiano and S. L. Gaynor, “Atrial fibrillation ablation during mitral valve surgery using the device,” Operative Techniques in Thoracic and Cardiovascular Surgery, vol. 9, pp. 24–33, 2004.
[13]
S. L. Gaynor, R. B. Schuessler, M. S. Bailey et al., “Surgical treatment of atrial fibrillation: predictors of late recurrence,” Journal of Thoracic and Cardiovascular Surgery, vol. 129, no. 1, pp. 104–111, 2005.
[14]
G. M. Comas, Y. Imren, and M. R. Williams, “An overview of energy sources in clinical use for the ablation of Aatrial fibrillation,” Seminars in Thoracic and Cardiovascular Surgery, vol. 19, no. 1, pp. 16–24, 2007.
[15]
J. Raman, S. Ishikawa, M. M. Storer, and J. M. Power, “Surgical radiofrequency ablation of both atria for atrial fibrillation: results of a multicenter trial,” Journal of Thoracic and Cardiovascular Surgery, vol. 126, no. 5, pp. 1357–1366, 2003.
[16]
V. Srivastava, S. Kumar, S. Javali et al., “Efficacy of three different ablative procedures to treat atrial fibrillation in patients with valvular heart disease: a randomised trial,” Heart Lung and Circulation, vol. 17, no. 3, pp. 232–240, 2008.
[17]
J. Wang, X. Meng, H. Li, Y. Cui, J. Han, and C. Xu, “Prospective randomized comparison of left atrial and biatrial radiofrequency ablation in the treatment of atrial fibrillation,” European Journal of Cardio-Thoracic Surgery, vol. 35, no. 1, pp. 116–122, 2009.
[18]
B. Chiappini, S. Martìn-Suàrez, A. LoForte, G. Arpesella, R. Di Bartolomeo, and G. Marinelli, “Cox/Maze III operation versus radiofrequency ablation for the surgical treatment of atrial fibrillation: a comparative study,” Annals of Thoracic Surgery, vol. 77, no. 1, pp. 87–92, 2004.
[19]
W. P. Beukema, H. T. Sie, A. R. Misier, P. P. Delnoy, H. J. J. Wellens, and A. Elvan, “Predictive factors of sustained sinus rhythm and recurrent atrial fibrillation after a radiofrequency modified Maze procedure,” European Journal of Cardio-Thoracic Surgery, vol. 34, no. 4, pp. 771–775, 2008.
[20]
V. K. Topkara, M. R. Williams, F. H. Cheema et al., “Surgical ablation of atrial fibrillation: the Columbia Presbyterian experience,” Journal of Cardiac Surgery, vol. 21, no. 5, pp. 441–448, 2006.
[21]
C. Vicol, D. Kellerer, P. Petrakopoulou, I. Kaczmarek, P. Lamm, and B. Reichart, “Long-term results after ablation for long-standing atrial fibrillation concomitant to surgery for organic heart disease: is microwave energy reliable?” Journal of Thoracic and Cardiovascular Surgery, vol. 136, no. 5, pp. 1156–1159, 2008.
[22]
J. C. Pruitt, R. R. Lazzara, and G. Ebra, “Minimally invasive surgical ablation of atrial fibrillation: the thoracoscopic box lesion approach,” Journal of Interventional Cardiac Electrophysiology, vol. 20, no. 3, pp. 83–87, 2007.
[23]
M. Knaut, S. M. Tugtekin, S. G. Spitzer, F. Jung, and K. Matschke, “Intraoperative endocardial microwave ablation for treatment of permanent atrial fibrillation during coronary artery bypass surgery: 1-year follow-up,” Europace, vol. 8, no. 1, pp. 16–20, 2006.
[24]
T. A. Molloy, “Midterm clinical experience with microwave surgical ablation of atrial fibrillation,” Annals of Thoracic Surgery, vol. 79, no. 6, pp. 2115–2118, 2005.
[25]
A. Hurlé, A. Ibá？ez, J. M. Parra, and J. G. Martínez, “Preliminary results with the microwave-modified Maze III procedure for the treatment of chronic atrial fibrillation,” Pacing and Clinical Electrophysiology, vol. 27, no. 12, pp. 1644–1646, 2004.
[26]
W. Wisser, C. Khazen, E. Deviatko et al., “Microwave and radiofrequency ablation yield similar success rates for treatment of chronic atrial fibrillation,” European Journal of Cardio-Thoracic Surgery, vol. 25, no. 6, pp. 1011–1017, 2004.
[27]
S. Mitnovetski, A. A. Almeida, J. Goldstein, A. W. Pick, and J. A. Smith, “Epicardial high-intensity focused ultrasound cardiac ablation for surgical treatment of atrial fibrillation,” Heart Lung and Circulation, vol. 18, no. 1, pp. 28–31, 2009.
[28]
M. J. Baek, C. Y. Na, S. S. Oh et al., “Surgical treatment of chronic atrial fibrillation combined with rheumatic mitral valve disease: effects of the cryo-maze procedure and predictors for late recurrence,” European Journal of Cardio-Thoracic Surgery, vol. 30, no. 5, pp. 728–736, 2006.
[29]
A. M. Gillinov, F. Bakaeen, P. M. McCarthy, et al., “Surgery for paroxysmal atrial fibrillation in the setting of mitral valve disease: a role for pulmonary vein isolation?” Annals of Thoracic Surgery, vol. 81, pp. 19–26, 2006.
[30]
M. C. Chen, J. P. Chang, G. B. F. Guo, and H. W. Chang, “Atrial size reduction as a predictor of the success of radiofrequency maze procedure for chronic atrial fibrillation in patients undergoing concomitant valvular surgery,” Journal of Cardiovascular Electrophysiology, vol. 12, no. 8, pp. 867–874, 2001.
[31]
G. Speziale, R. Bonifazi, G. Nasso et al., “Minimally invasive radiofrequency ablation of lone atrial fibrillation by monolateral right minithoracotomy: operative and early follow-up results,” Annals of Thoracic Surgery, vol. 90, no. 1, pp. 161–167, 2010.
[32]
J. Sirak, D. Jones, B. Sun, C. Sai-Sudhakar, J. Crestanello, and M. Firstenberg, “Toward a definitive, totally thoracoscopic procedure for atrial fibrillation,” Annals of Thoracic Surgery, vol. 86, no. 6, pp. 1960–1964, 2008.
[33]
H. Li, Y. Li, L. Sun et al., “Minimally invasive surgical pulmonary vein isolation alone for persistent atrial fibrillation: preliminary results of epicardial atrial electrogram analysis,” Annals of Thoracic Surgery, vol. 86, no. 4, pp. 1219–1225, 2008.
[34]
T. Nitta, “Invited commentary,” Annals of Thoracic Surgery, vol. 86, pp. 1225–1226, 2008.
[35]
S. Maltais, J. Forcillo, D. Bouchard et al., “Long-term results following concomitant radiofrequency modified maze ablation for atrial fibrillation,” Journal of Cardiac Surgery, vol. 25, no. 5, pp. 608–613, 2010.
[36]
F. T. Han, V. Kasirajan, M. Kowalski et al., “Results of a minimally invasive surgical pulmonary vein isolation and ganglionic plexi ablation for atrial fibrillation: single-center experience with 12-month follow-up,” Circulation: Arrhythmia and Electrophysiology, vol. 2, no. 4, pp. 370–377, 2009.
[37]
J. Sirak, D. Jones, and D. Schwartzman, “The five-box thoracoscopic maze procedure,” Annals of Thoracic Surgery, vol. 90, no. 3, pp. 986–989, 2010.
[38]
S. Benussi, R. Cini, S. L. Gaynor, O. Alfieri, and A. M. Calafiore, “Bipolar radiofrequency maze procedure through a transseptal approach,” Annals of Thoracic Surgery, vol. 90, no. 3, pp. 1025–1027, 2010.
[39]
S. Kangavari, Y. S. Oh, S. Zhou et al., “Radiofrequency catheter ablation and nerve growth factor concentration in humans,” Heart Rhythm, vol. 3, no. 10, pp. 1150–1155, 2006.
[40]
J. S. Gammie, P. Didolkar, L. S. Krowsoski et al., “Intermediate-term outcomes of surgical atrial fibrillation correction with the CryoMaze procedure,” Annals of Thoracic Surgery, vol. 87, no. 5, pp. 1452–1458, 2009.
[41]
J. B. Kim, W. C. Cho, S. H. Jung, C. H. Chung, S. J. Choo, and J. W. Lee, “Alternative energy sources for surgical treatment of atrial fibrillation in patients undergoing mitral valve surgery: microwave ablation vs cryoablation,” Journal of Korean Medical Science, vol. 25, no. 10, pp. 1467–1472, 2010.
[42]
T. Funatsu, J. Kobayashi, H. Nakajima, Y. Iba, Y. Shimahara, and T. Yagihara, “Long-term results and reliability of cryothermic ablation based maze procedure for atrial fibrillation concomitant with mitral valve surgery,” European Journal of Cardio-Thoracic Surgery, vol. 36, no. 2, pp. 267–271, 2009.
[43]
A. Luik, M. Merkel, D. Hoeren, T. Riexinger, M. Kieser, and C. Schmitt, “Rationale and design of the FreezeAF trial: a randomized controlled noninferiority trial comparing isolation of the pulmonary veins with the cryoballoon catheter versus open irrigated radiofrequency ablation in patients with paroxysmal atrial fibrillation,” American Heart Journal, vol. 159, no. 4, pp. 555–560, 2010.
[44]
J. Koistinen, M. Valtonen, J. Savola, and J. Airaksinen, “Thoracoscopic microwave ablation of atrial fibrillation,” Interactive Cardiovascular and Thoracic Surgery, vol. 6, no. 6, pp. 695–698, 2007.
[45]
NICE, High-Intensity Focused Ultrasound for Atrial Fibrillation in Association with Other Cardiac Surgery, National Institute for Health and Clinical Excellence, London, UK, 2006.
[46]
M. A. Groh, O. A. Binns, H. G. Burton III, G. L. Champsaur, S. W. Ely, and A. M. Johnson, “Epicardial ultrasonic ablation of atrial fibrillation during concomitant cardiac surgery is a valid option in patients with ischemic heart disease,” Circulation, vol. 118, no. 14, pp. S78–S82, 2008.
[47]
J. Ninet, X. Roques, R. Seitelberger et al., “Surgical ablation of atrial fibrillation with off-pump, epicardial, high-intensity focused ultrasound: results of a multicenter trial,” Journal of Thoracic and Cardiovascular Surgery, vol. 130, no. 3, pp. 803–809, 2005.
[48]
M. A. Groh, O. A. Binns, H. G. Burton III, S. W. Ely, and A. M. Johnson, “Ultrasonic cardiac ablation for atrial fibrillation during concomitant cardiac surgery: long-term clinical outcomes,” Annals of Thoracic Surgery, vol. 84, no. 6, pp. 1978–1983, 2007.
[49]
K. Neven, B. Schmidt, A. Metzner, et al., “Fatal end of a safety algorithm for pulmonary vein isolation with use of high-intensity focused ultrasound,” Circulation: Arrhythmia and Electrophysiology, vol. 3, pp. 260–265, 2010.
[50]
M. Argenziano and M. R. Williams, “Robotic atrial septal defect repair and endoscopic treatment of atrial fibrillation,” Seminars in Thoracic and Cardiovascular Surgery, vol. 15, no. 2, pp. 130–140, 2003.
[51]
G. Bolotin, A. P. Kypson, L. W. Nifong, and W. R. Chitwood Jr., “Robotically-assisted left atrial fibrillation ablation and mitral valve repair through a right mini-thoracotomy,” Annals of Thoracic Surgery, vol. 78, no. 4, pp. e63–e64, 2004.
[52]
R. K. Wolf, E. W. Schneeberger, R. Osterday et al., “Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation,” Journal of Thoracic and Cardiovascular Surgery, vol. 130, no. 3, pp. 797–802, 2005.
[53]
J. H. Wudel, P. Chaudhuri, and J. J. Hiller, “Video-assisted epicardial ablation and left atrial appendage exclusion for atrial fibrillation: extended follow-up,” Annals of Thoracic Surgery, vol. 85, no. 1, pp. 34–38, 2008.
[54]
J. R. Edgerton, W. T. Brinkman, T. Weaver et al., “Pulmonary vein isolation and autonomic denervation for the management of paroxysmal atrial fibrillation by a minimally invasive surgical approach,” Journal of Thoracic and Cardiovascular Surgery, vol. 140, pp. 823–828, 2010.
[55]
N. Charokopos, E. Rouska, I. Styliadis, P. Antonitsis, C. Papakonstantinou, and P. Spanos, “Totally endoscopic microwave ablation for lone atrial fibrillation: an alternative method of treatment,” Hellenic Journal of Cardiology, vol. 47, no. 6, pp. 377–380, 2006.
[56]
J. L. Cox, “The longstanding, persistent confusion surrounding surgery for atrial fibrillation,” Journal of Thoracic and Cardiovascular Surgery, vol. 139, no. 6, pp. 1374–1386, 2010.
[57]
M. Ha？ssaguerre, P. Ja？s, D. C. Shah et al., “Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins,” New England Journal of Medicine, vol. 339, no. 10, pp. 659–666, 1998.
[58]
M. C. Chen, J. P. Chang, and H. W. Chang, “Preoperative atrial size predicts the success of radiofrequency maze procedure for permanent atrial fibrillation in patients undergoing concomitant valvular surgery,” Chest, vol. 125, no. 6, pp. 2129–2134, 2004.
[59]
N. Ad, L. Henry, S. Hunt, S. Barnett, and L. Stone, “The Cox-Maze III procedure success rate: comparison by electrocardiogram, 24-hour holter monitoring and long-term monitoring,” Annals of Thoracic Surgery, vol. 88, no. 1, pp. 101–105, 2009.
[60]
H. G. Je, J. W. Lee, S. H. Jung et al., “Risk factors analysis on failure of maze procedure: mid-term results,” European Journal of Cardio-Thoracic Surgery, vol. 36, no. 2, pp. 272–278, 2009.
[61]
P. Pagé, “Canadian cardiovascular society atrial fibrillation guidelines 2010: surgical therapy,” The Canadian Journal of Cardiology, vol. 27, pp. 67–73, 2011.
[62]
Y. Q. Cui, Y. Li, F. Gao et al., “Video-assisted minimally invasive surgery for lone atrial fibrillation: a clinical report of 81 cases,” Journal of Thoracic and Cardiovascular Surgery, vol. 139, no. 2, pp. 326–332, 2010.
[63]
M. Ha？ssaguerre, M. Wright, M. Hocini, and P. Ja？s, “The substrate maintaining persistent atrial fibrillation,” Circulation: Arrhythmia and Electrophysiology, vol. 1, no. 1, pp. 2–5, 2008.
[64]
W. E. Garrey, “The nature of fibrillatory contraction of the heart: its relation to tissue mass and form,” American Journal of Physiology, vol. 33, pp. 397–414, 1914.
[65]
G. D. Byrd, S. M. Prasad, C. M. Ripplinger et al., “Importance of geometry and refractory period in sustaining atrial fibrillation: testing the critical mass hypothesis,” Circulation, vol. 112, no. 9, pp. I7–I13, 2005.
[66]
A. Marui, T. Nishina, K. Tambara et al., “A novel atrial volume reduction technique to enhance the Cox maze procedure: initial results,” Journal of Thoracic and Cardiovascular Surgery, vol. 132, no. 5, pp. 1047–1053, 2006.
[67]
M. Scherer, P. Therapidis, T. Wittlinger, A. Miskovic, and A. Moritz, “Impact of left atrial size reduction and endocardial radiofrequency ablation on continuous atrial fibrillation in patients undergoing concomitant cardiac surgery: three-year results,” The Journal of Heart Valve Disease, vol. 16, no. 2, pp. 126–131, 2007.
[68]
W. Wang, L. R. Guo, A. M. Martland, X. D. Feng, J. Ma, and X. Q. Feng, “Biatrial reduction plasty with reef imbricate technique as an adjunct to maze procedure for permanent atrial fibrillation associated with giant left atria,” Interactive Cardiovascular and Thoracic Surgery, vol. 10, no. 4, pp. 577–581, 2010.
[69]
V. Badhwar, J. D. Rovin, G. Davenport et al., “Left atrial reduction enhances outcomes of modified maze procedure for permanent atrial fibrillation during concomitant mitral surgery,” Annals of Thoracic Surgery, vol. 82, no. 5, pp. 1758–1763, 2006.
[70]
M. Scherer, O. Dzemali, T. Aybek, G. Wimmer-Greinecker, and A. Moritz, “Impact of left atrial size reduction on chronic atrial fibrillation in mitral valve surgery,” Journal of Heart Valve Disease, vol. 12, no. 4, pp. 469–474, 2003.
[71]
O. A. García-Villarreal, A. B. Gouveia, R. González, and R. Argüero, “Left atrial reduction. A new concept in surgery for chronic atrial fibrillation,” Revista Espanola de Cardiologia, vol. 55, no. 5, pp. 499–504, 2002.
[72]
N. M. Sankar and A. E. Farnsworth, “Left atrial reduction for chronic atrial fibrillation associated with mitral valve disease,” Annals of Thoracic Surgery, vol. 66, no. 1, pp. 254–256, 1998.
[73]
H. Calkins, J. Brugada, D. L. Packer et al., “HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society,” Europace, vol. 11, no. 1, p. 132, 2009.
[74]
S. L？nnerholm, P. Blomstr？m, L. Nilsson, and C. Blomstr？m-Lundqvist, “A high quality of life is maintained late after Maze III surgery for atrial fibrillation,” European Journal of Cardio-Thoracic Surgery, vol. 36, no. 3, pp. 558–562, 2009.
[75]
S. M. Prasad, H. S. Maniar, C. J. Camillo et al., “The Cox maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures,” Journal of Thoracic and Cardiovascular Surgery, vol. 126, no. 6, pp. 1822–1828, 2003.
[76]
J. L. Cox, N. Ad, and T. Palazzo, “Impact of the maze procedure on the stroke rate in patients with atrial fibrillation,” Journal of Thoracic and Cardiovascular Surgery, vol. 118, no. 5, pp. 833–840, 1999.
[77]
K. Khargi, B. A. Hutten, B. Lemke, and T. Deneke, “Surgical treatment of atrial fibrillation; a systematic review,” European Journal of Cardio-Thoracic Surgery, vol. 27, no. 2, pp. 258–265, 2005.
