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Minimally Invasive Cox-Maze Procedure: A Single Center’s Experience With 100 Consecutive Cases
Niv Ad, Linda Henry, Sharon Hunt.
Inova Heart and Vascular Institute, Falls Church, VA, USA.
OBJECTIVE:
Surgical ablation for atrial fibrillation (AF) is well established with the first cut and sew Cox-Maze procedure (CM) performed 25 years ago. Over the past few years different off pump minimally invasive (MI) approaches were developed all of which showed to be safe, however, somewhat limited when treating patients with non-paroxysmal AF. In this study we aim to assess our results with the first 100 consecutive MI CM procedures performed on pump.
METHODS:
Since 2005, stand alone CM procedures were performed on 158 patients of which 100 were performed through right mini thoracotomy (6 cm) and femoral cannulation. All patients were followed prospectively through our unique AF registry at 3,6,12,18,24 months and then yearly. Rhythm was verified by EKG and 24 hour holter. Health related quality of life (HRQL, SF-12) and symptom frequency and severity was assessed preoperatively and at 6 and 12 months post procedure.
RESULTS:
The average age of the patients was 56.7±13.2 years, 74% were male. No patients had paroxysmal AF- 78% had longterm persistent AF with average duration of 80.2 months. There were no operative (30 days) mortalities, TIA in 1 (1%) patient, re-operation for bleeding in 1 (1%), no renal failure was documented, 6 patients required a new pacemaker for sinus node dysfunction. The return to sinus rhythm at 6, 12, 24 months on and off antiarrhythmic drugs was 92%,86%;91%/85%;89%,79%, respectively. Interestingly, when comparing the first 20 patients in this series to the rest of the group the success rate at 12 and 24 months improved significantly from 80% to 96% and 76% to 100% respectively. Kaplan Meier showed 96.6% survival at 48 months. HRQL and symptoms related to AF improved significantly over the course of the first year.
CONCLUSIONS:
Minimally invasive Cox-Maze procedure with the use of the heart lung machine can be performed with very low morbidity. The long term success rate in a very challenging group of patients with non-paroxysmal AF is promising. Even with the new technologies and innovations, educational strategies need to be developed to help the surgeon overcome the initial learning curve for the betterment of patient outcomes.
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