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Ann Thorac Surg 2001;71:816-822
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Modifications of the Cox-Maze III procedure

^a Departments of Thoracic and Cardiovascular Surgery, College of Medicine, Seoul National University, Seoul, South Korea
^b Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, South Korea

Accepted for publication August 25, 2000.

Address reprint requests to Dr Kim, Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, 28 Yeun-Kun Dong, Chong-Ro Ku, Seoul 110-744, Korea
e-mail: kimkb{at}snu.ac.kr

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. The extended operative time needed for surgery with complicated atrial incisions may preclude application of the Cox-Maze III procedure (CM-III) as a concomitant operation. And after the CM-III, left atrial (LA) contraction has been reported to recover in reduced magnitude compared with right atrial (RA) contraction.

Methods. To decrease operative time, we have modified the CM-III (modification I) by: obliterating the LA appendage instead of excising it; cryoablating the bridge between the LA appendage and margin of the pulmonary vein encircling incision; extending the lateral incision of RA onto the RA appendage without excising it, and extending the incision more inferiorly toward the inferior vena cava; and omitting the T-incision of RA. We compared the clinical results of the conventional CM-III (group 1, n = 18) with those of the modified CM-III group (group 2, n = 23) performed in patients with rheumatic mitral valve (MV) disease. To enlarge the contractile area of the LA, we modified the CM-III to encircle the right and left pulmonary veins separately (modification II), and compared the LA contractilities of the conventional CM-III (group A, n = 15) with those of the second modification (group B, n = 9).

Results. Modification I: Mean aortic cross-clamp (ACC) times (135 ± 29 versus 104 ± 18 minutes, p < 0.005) and cardiopulmonary bypass (CPB) times (240 ± 33 versus 185 ± 42 minutes, p < 0.001) were significantly decreased in group 2 compared with those in group 1. In group 1, sinus rhythm was restored in 16 patients (88.9%). RA contractility was demonstrated in 100% of patients with sinus rhythm (16 of 16) and LA contractility in 75% (12 of 16) in the latest follow-up echocardiography. In group 2, sinus rhythm was restored in 21 patients (91.3%). RA contractility was demonstrated in 100% of patients with sinus rhythm (21 of 22) and LA contractility in 76.2% (16 of 21). Modification II: Mean ACC times were increased in group B compared with group A (133 ± 32 versus 172 ± 39 minutes, p = 0.02). The A velocities at LA contraction and the ratio of atrial contraction to peak early diastolic filling velocity (A/E ratio) of the trans-mitral flow were 0.14 ± 0.20 m/sec and 0.23 ± 0.11 in group A, and 0.58 ± 0.33 m/sec and 0.47 ± 0.19 in group B, respectively, both showing a significant increase in group B compared with group A (p < 0.05).

Conclusions. Our first modification of the CM-III showed comparable sinus conversion rates and incidence of atrial contractility restoration with significantly shorter ACC and CPB times than the conventional CM-III. The second modification of the CM-III significantly increased the LA contractility when compared with the conventional CM-III, although the second modification required a longer ACC time.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The Cox-Maze III Procedure (CM-III) has become a safe and efficient surgical treatment for chronic atrial fibrillation (AF). However, the extended operative time needed for complicated multiple atrial incisions may preclude application of the CM-III as a concomitant operation with standard open heart surgery. Furthermore, left atrial (LA) contraction has been reported to recover at a lower rate and in reduced magnitude compared with right atrial (RA) contraction after the CM-III [1–5], and LA contraction is expected to be more reduced especially in patients with large LA. We have performed two different modifications of the CM-III to decrease operative time and to increase LA contractility in patients with large LA. The aims of this study were: (1) to assess the simplicity of our modification (modification I) to decrease operative time while retaining the important principles of the Maze incisions and to demonstrate the efficiency of the modification by comparing with the clinical results of the conventional CM-III; and (2) to demonstrate decreased LA contractility after the CM-III in patients with large LA and to modify the CM-III (modification II) to increase LA contractility in patients with large LA.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Modification I
Forty-one patients who underwent the CM-III for chronic AF combined with procedures to correct rheumatic mitral valve (MV) disease between April 1994 and December 1997 were studied. Patients with nonrheumatic MV disease and patients who also required aortic valve operation or coronary artery bypass grafting in addition to MV operation were excluded from this study. During the study period, we modified the CM-III (modification I) to decrease operative time in November 1996 as follows: (1) we performed the LA procedures first, followed by interatrial septotomy prior to the RA procedures; (2) we mobilized the posterior LA after the initial left atriotomy under cardioplegic arrest to avoid possible thromboembolism complicated by undetected LA thrombi; (3) we obliterated the LA appendage externally or internally instead of excising it; (4) we performed cryoablation on the bridge between the LA appendage and margin of the pulmonary vein encircling incision; (5) we omitted the T-incision of the RA from the lower portion of the posterior longitudinal right atriotomy toward the tricuspid annulus; and (6) we extended the lateral incision of the RA onto the RA appendage without excising it and extended it more inferiorly toward the inferior vena cava (Fig 1). We compared the clinical results of the conventional CM-III (group 1, n = 18) performed prior to November 1996 with those of the modified CM-III (group 2, n = 23) that was performed after November 1996. There were no differences in sex, age, or echocardiographic parameters for left ventricular function and LA size between the 2 groups. The duration of AF was significantly longer in group 2 than in group 1 (Table 1). We analyzed the cardiopulmonary bypass (CPB) times, aortic cross-clamp (ACC) times, conversion rate to sinus rhythm, restoration of atrial contractility, and mortality and morbidity between the 2 groups.

View larger version (17K): [in this window] [in a new window]   Fig 1. Comparative diagram for the conventional Cox-Maze III procedure (A), the modification I to shorten operative time (B), and the modification II performed in patients with large left atrium (C). The crossed lines represent surgical atriotomies, and the thick black line (CR) illustrates cryoablation.

Surgical procedure
The CM-III concomitant with MV operation was performed under cardiopulmonary bypass (CPB) with moderate hypothermia (25°C to 28°C). We performed the conventional CM-III in the manner that Cox and associates had described previously [2], and we modified the CM-III as described above (Fig 1). We usually used antegrade cold blood cardioplegia for induction and maintenance of the cardiac arrest. We also used warm blood cardioplegia just before releasing the ACC in all patients.

Modification I
In group 1, concomitant procedures were mitral valve replacement (MVR) in 10 patients, mitral valve (MV) repair in 3 patients, MVR and tricuspid annuloplasty (TAP) in 3 patients, and redo-MVR in 2 patients. In group 2, concomitant procedures were redo-MVR in 10 patients, MVR in 7 patients, MV repair in 5 patients, and MVR and TAP in 1 patient (Table 3).

In most of the patients who underwent valve replacement, St. Jude mechanical valves (St. Jude Medical, St. Paul, MN) were used, and in elderly patients (> 65 years old) who underwent valve replacement, Carpentier-Edwards pericardial tissue valves (Carpentier-Edwards, Horw, Switzerland) were used.

Postoperative follow-up
All the patients were followed for more than 2 years. Standard 12-lead electrocardiography was checked daily during the postoperative hospital stay, and in the 1st, 3rd, 6th, 12th, 18th, and 24th postoperative months thereafter. To evaluate cardiac function and the recovery of atrial function, transthoracic echocardiography (TTE) was performed before discharge, and in the 1st, 6th, 12th, and 24th postoperative months. The cardiologists who performed TTE were blinded to the procedure that the patients received. The presence of right and left atrial mechanical function was determined by the presence on Doppler echocardiography of the A (peak filling velocity at atrial contraction) wave and E (peak early diastolic filling velocity) wave on the tricuspid and mitral inflow, respectively. When the presence of the A wave in the ventricular inflow was ambiguous, the systemic venous flow or pulmonary venous flow pattern was evaluated for the presence of atrial reversal. The mean values of five consecutive peak E velocities, peak A velocities, and A/E ratios were obtained.

Statistical analysis
Statistical analysis was performed with the Statistical Analysis System software package (version 6.12; SAS Institute, Cary, NC). Continuous variables were compared by the Student’s t test and discrete varables were analyzed with the ² test. All results were expressed as mean ± standard deviation, and a value of p less than 0.05 was considered statistically significant.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Modification I
Operative data
Mean ACC times in group 1 and group 2 were 135 ± 29 and 104 ± 18 minutes, respectively, with significantly shorter ACC times in group 2 compared with group 1 (p < 0.005). Mean CPB times in group 1 and group 2 were 240 ± 33, 185 ± 42 minutes, respectively, with significantly shorter CPB times in group 2 compared with group 1 (p < 0.001).

Mortality and morbidity
There was no in-hospital mortality in both groups. In group 1, postoperative complications were perioperative recurrence of AF in 12 patients (66.7%), low cardiac output syndrome (LCOS) in 1 patient, acute renal failure in 1 patient, and permanent pacemaker implantation in 1 patient with tachycardia-bradycardia syndrome. In group 2, postoperative complications were perioperative recurrence of AF in 13 patients (56.5%), LCOS in 1 patient, and acute renal failure in 1 patient.

Postoperative follow-up
All the patients were followed for more than 2 years with a mean follow-up duration of 47 ± 14 months and 29 ± 4 months in group 1 and group 2, respectively. In group 1, sinus rhythm was restored in 16 patients (88.9%). One patient remained in AF and another patient needed pacemaker implantation due to tachycardia-bradycardia syndrome. Among the 16 patients who regained sinus rhythm, AF was controlled by surgery alone in 93.8% (15 of 16) of patients and by the addition of an antiarrhythmic agent in 1 patient. In group 2, sinus rhythm was restored in 21 patients (91.3%) and 2 patients remained in AF. AF was controlled by surgery alone in 90.5% (19 of 21) of patients and by the addition of an antiarrhythmic agent, such as flecainamide or quinidine, in 2 patients. In group 1, the recovery of RA contractility was demonstrated in 100% of patients (16 of 16) and the recovery of LA contractility in 75% (12 of 16) in the latest follow-up TTE. In group 2, the recovery of RA contractility was demonstrated in 100% of patients (21 of 21) and the recovery of LA contractility in 76.2% (16 of 21). There were no significant differences in sinus rhythm conversion rate, the recovery of the RA, and LA contractilities between both groups (Table 4).

Morbidity
There was no postoperative bleeding in both groups.

Postoperative follow-up
All the patients were followed postoperatively for more than 2 years with a mean follow-up duration of 39 ± 10 months. Perioperative recurrence of AF developed in 66.7% (10 of 15) of patients in group A and 88.9% (8 of 9) of patients in group B, with no statistical differences between groups. AF was controlled by the addition of an antiarrhythmic agent, such as flecainide or quinidine in 13.3% (2 of 15) of patients in group A and 11.1% (1 of 9) of patients in group B. RA contractility was demonstrable in 100% of patients in both groups in the latest follow-up TTE. LA contractility was demonstrable in 40.0% (6 of 19) of patients in group A and 66.7% (6 of 9) of those in group B (p = NS, group A versus group B) in the latest follow-up TTE. The A velocities at RA contraction and the A/E ratios of the trans-tricuspid flow were 0.36 ± 0.15 m/sec and 0.71 ± 0.29 in group A, and 0.50 ± 0.31 m/sec and 0.56 ± 0.28 in group B, with no significant difference between the 2 groups. The A velocities at LA contraction and the A/E ratios of the trans-mitral flow were 0.14 ± 0.20 m/sec and 0.23 ± 0.11 in group A, and 0.58 ± 0.33 m/sec and 0.47 ± 0.19 in group B, both showing a significant increase in group B compared with group A (p < 0.05) (Table 5; Fig 2).

View larger version (27K): [in this window] [in a new window]   Fig 2. Representative Doppler echocardiographic findings after the conventional Cox-Maze III procedure (A) and modified Cox-Maze III procedure (B) in the modification II performed in patients with large left atrium. (A) The Doppler echocardiographic finding for transmitral flow after the conventional CM-IV and the A/E ratio calculated was 0.27. (B) The Doppler echocardiographic finding for transmitral flow after the modified CM-IV (modification II) and the A/E ratio calculated was 0.45. (A/E ratio = ratio of atrial contraction to peak early diastolic filling velocity.)

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
This study reveals two main findings. First, our modified CM-III (modification I) demonstrates a comparable sinus conversion rate and recovery of atrial contractility, with significantly shorter ACC and CPB times than the conventional CM-III. Second, modification of the CM-III by separate isolation of the right and left pulmonary veins (modification II) creates increased LA contractility in patients with large LA, compared with the conventional CM-III.

Since the initial development of the Maze procedure for medically refractory AF by Cox and associates in 1987, there have been several modifications to improve surgical results and to decrease the operative time needed for complicated multiple atrial incisions. The CM-III, the latest modification of the Maze procedure [6], has become a safe and efficient surgical technique for medically refractory AF. Cox and associates [7, 8] demonstrated that CM-III patients had a higher incidence of postoperative sinus rhythm, less arrhythmia recurrence, and improved atrial transport function than patients who underwent either the Maze I or Maze II procedure. However, the extended operative time that was still needed for complicated multiple atrial incisions may preclude application of the CM-III as a concomitant operation with standard open heart surgery. To decrease the number of atrial incisions and reduce the operative time, some groups used cryoablation as a substitute for the multiple atrial incisions or modified the atrial incisions [9–11]. Extensive use of cryoablation might produce a wide band of frozen atrium that would become noncontractile myocardium [10], and simply omitting some atrial incisions might allow macroreentrant circuits to develop. As Cox and associates [12] have pointed out, postoperative persistent AF is considered to be related to the relationship between the duration of the local refractory period and enough atrial area for a reentrant circuit to form, which is dependent on the distance of incisions. Other groups [13, 14] even reported a right-sided or left-sided Maze procedure. Although they demonstrated that unilateral-sided Maze procedure was effective in eliminating AF in a select group of patients, there was a persistent possibility of recurrence of AF, which would seem to be too great a price to pay simply to decrease a slightly longer operative time. We modified the CM-III (modification I) to treat chronic AF along with MV operation, while retaining the important principles of the Maze incisions. We performed the LA procedures first, followed by interatrial septotomy prior to the RA procedures, and mobilized the posterior LA after the initial left atriotomy under cardioplegic arrest. By performing the LA procedures first, we avoided possible thromboembolism complicated by preoperatively undetected thrombi during posterior LA mobilization, and reduced the CPB times by performing the RA procedures during rewarming of the patients. Sueda and colleagues [11] suggested the maintenance of AF associated with MV disease may be related to an area at the base of the LA appendage, rather than appendage itself, and the posterior wall lateral to the left pulmonary veins. We obliterated the LA appendage externally or internally, instead of excising it, and performed cryoablation on the bridge between the LA appendage and margin of the pulmonary vein encircling incision to decrease the number of atrial incisions and reduce operative time. On the right side, we omitted the excision of the RA appendage and T-incision of the RA from the lower portion of posterior longitudinal right atriotomy toward the tricuspid annulus. Instead, we extended the lateral incision of the RA onto the RA appendage and more inferiorly toward the inferior vena cava (Fig 1). The T-incision toward the tricuspid annulus was omitted because the anterior RA counterincision, beginning at the anteromedial border of the RA auricle, extends to the anteromedial tricuspid valve annulus. We expect that the decreased number of suture lines and avoidance of excision of the RA appendage, a main source of atrial natriuretic peptide (ANP) production, appear to decrease both operative time and the tendency for postoperative fluid retention caused by a decrease in ANP [15].

We previously demonstrated that perioperative recurrence of AF after the CM-III developed in 63% of patients with rheumatic MV disease, sinus conversion occurred about 2 months after the operation, and the RA and LA contractilities were restored a mean of 69 ± 93 and 126 ± 136 days after the operation, respectively [1]. In this regard, the results of any modified procedures for the CM-III should be evaluated after long-term follow-up of more than 1 year. In the present study, all the patients were followed more than 2 years. Comparison of the results between the conventional CM-III and our first modification showed that our modified CM-III (modification I) demonstrated comparable sinus rhythm conversion rate and recovery of the RA and LA contractilities, with significantly shorter ACC times (p < 0.005) and CPB times (p < 0.001) than the conventional CM-III.

Among the three therapeutic goals of the CM-III, the permanent ablation of AF, restoration of atrioventricular synchrony, and restoration of atrial transport function, the last goal has been one of the major concerns in long term follow-up of CM-III patients because vulnerability to thromboembolic complication may be reduced in patients with recovered atrial contraction. The CM-III has demonstrated a high sinus conversion rate in patients with chronic AF; however, LA contraction has been reported to recover at a lower rate and in reduced magnitude compared with RA contraction after the CM-III [2–5]. We previously demonstrated that LA contractility was restored at a lower rate and in reduced magnitude compared with RA contractility in patients operated on for rheumatic MV disease [1, 5]. Possible mechanisms for the lower recovery rate of LA contractility are disuse atrophy or hypotrophy of atrial muscle in chronic AF [16], and secondary changes to the LA wall, which may be thickened, calcified, enlarged or degenerated, especially in patients with rheumatic MV disease [3, 4, 8]. The possible mechanisms for the reduced LA contractility are: delayed interatrial conduction resulting in less than optimal left atrioventricular synchronization; isolation of too wide an area of the posterior wall of the LA by the pulmonary vein encircling incision, which might cause a tethering effect on the posterior wall of the LA [2]; and secondary changes to the LA wall influenced by MV disease and the rheumatic inflammatory process [3, 4, 8]. In patients with large LA, there is a possibility of developing AF postoperatively because the area between the suture lines of the CM-III would be greater than the critical area required for the development of AF. Cox and associates [12] suggested making a wider incision around the pulmonary veins to encompass and isolate more of the LA and the pulmonary veins, thereby leaving less of the LA available for fibrillation. However, this large isolated posterior LA around the pulmonary veins would fibrillate or contract independently from the rest of the LA and thereby might result in a detrimental effect to atrial transport function and provide a nidus for the development of thrombi. Tsui and associates [17] demonstrated that the endocardial surface area of the isolated LA block, including pulmonary veins, represented 35% of the endocardial surface area of the entire LA. This LA block would be of sufficient size to allow macroreentrant circuits to develop and have the potential to fibrillate if isolated from the rest of the LA. We measured the IPVD intraoperatively and modified the CM-III in patients with a large LA to isolate the right and left pulmonary veins separately (modification II), thereby allowing an area of the posterior LA of at least 3 cm in width to be electrically activated. Our results showed that the A/E ratios of the trans-mitral flow increased significantly in the second modification group (group B) compared with group A. This suggested that the recruited area between the right and left pulmonary veins significantly contributed to LA contraction. Nitta and associates [18, 19] recently developed the radial incision approach for AF to attain a more physiological activation sequence and greater atrial transport function, and demonstrated a greater LA contraction after the radial incision approach compared with the CM-III. We cannot determine at this time whether the magnitude of restoration of LA contraction is enough to provide sufficient atrial transport function and to eliminate the risk of thromboembolism. Cox and associates [20] demonstrated that the risk of stroke associated with AF decreased dramatically after the Maze procedure. The reasons for the CM-III’s protective effect against thromboembolism would be the restoration of sinus rhythm and atrial contractility in combination with surgical removal or obliteration of the LA appendage, the major site of the thrombi formation. We hope that the risk of thromboembolism might be reduced even further by this modification of the CM-III (modification II) in patients with a large LA. The limitations of this second modification are prolonged operative time and the possibility of surgical bleeding from the additional suture lines.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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