HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Tirone E. David Terrence M. Yau Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Raanani, E. Articles by Armstrong, S. Search for Related Content PubMed PubMed Citation Articles by Raanani, E. Articles by Armstrong, S. Related Collections Electrophysiology - arrhythmias Valve disease

Eur J Cardiothorac Surg 2001;19:438-442
© 2001 Elsevier Science NL

The efficacy of the Cox/maze procedure combined with mitral valve surgery: a matched control study

Division of Cardiovascular Surgery of Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada

Received 31 August 2000; received in revised form 15 December 2000; accepted 29 December 2000.

Corresponding author. 200 Elizabeth Street, 13EN219, Toronto, Ontario, M5G 2C4 Canada. Tel.: +1-416-340-5062; fax: +1-416-340-4020
e-mail: tirone.david{at}uhn.on.ca

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Objective: To evaluate the results of the maze procedure combined with mitral valve (MV) surgery in patients with chronic atrial fibrillation (AF). Methods: From 1994–1999, 47 patients with chronic AF underwent the maze procedure combined with MV surgery (maze group). They were compared to 47 patients matched for age, sex, left ventricular function and type of MV surgery (non-maze group). The maze group had less severe symptoms but larger left atrium, and AF of longer duration than the non-maze group. One surgeon performed all operations in both groups of patients. Results: There were two early deaths in the maze group (4.5%) and one (2.2%) in the non-maze group. The duration of cardiopulmonary bypass (P=0.0001) and aortic crossclamping (P=0.0001) were greater in the maze group. Mean follow-up was 26±3 months in the maze group and 32±4 months in the non-maze group, and was 100% complete. Three-year survival was 96±3% for the maze group compared to 85±7% for the non-maze group (P=0.16). At the latest follow-up, 75% of the maze patients were in sinus rhythm compared to 36% of the non-maze patients (P=0.0004); 38% of the maze group were on coumadin postoperatively, compared to 69% in the non-maze group (P=0.003); and patients in the maze group were on fewer antiarrhythmic medications (P=0.0002). Three-year freedom from thromboembolic complications was 100% for the maze group compared to 83±7% for the non-maze group (P=0.03). Conclusions: In this retrospective study the maze procedure did not seem to increase operative mortality of MV surgery, was effective in eliminating atrial fibrillation, and reduced the risk of thromboembolic complications and the need for long-term anticoagulation after mitral valve repair or replacement with a bioprosthesis.

Key Words: Cox/maze procedure • Mitral valve surgery

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Atrial fibrillation (AF) is present in 40–60% of patients undergoing mitral valve (MV) surgery [1–3]. Furthermore, it has been reported that 60% to 80% of patients with preoperative AF remained in AF after their mitral valve surgery, especially if the AF is long-standing [4,5]. Due to the increased risk of stroke, the majority of these patients are on chronic anti-coagulation therapy. Unfortunately, this treatment does not eliminate the risk of future thromboembolic complications. The Cox/maze procedure has been concomitantly performed with MV surgery in an attempt to eliminate AF, and reduce the morbidity and mortality associated with chronic AF and long-term anticoagulation treatment [6–10]. Although randomized studies are lacking, those reports supported the concept of a combined procedure as being safe and efficient in abolishing AF. In fact, Cox and associates have advocated the maze procedure as a preventive intervention for stroke [11]. To further evaluate the risks and benefits of the combined operation, we analyzed the effect of the Cox/maze procedure in a case matched study of patients with chronic AF and MV disease.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
The Cox/maze procedure has been performed in combination to MV repair or replacement with a bioprosthetic heart valve since 1994. From February 1994 to October 1999, 413 patients had MV repair and the maze procedure was performed in 40 of 81 who had longstanding AF. During the same time interval 40 patients had MV replacement with a bioprosthesis and the maze procedure was performed in seven of 32 with AF. These 47 patients (maze group) were individually matched for age (±5 years), sex, left ventricular function (grades 1 through 4), New York Heart Association functional class (1 and 2 vs. 3 and 4), and type of MV operation to 47 patients who had MV surgery, had longstanding AF but did not have the maze procedure (non-maze group). In order to increase the pool of patients who did not have the maze procedure we had include patients operated on before 1994. Thus, in the non-maze group 34 patients had MV surgery prior to 1994 and 13 had MV surgery during the same period as the maze procedure was being performed. One surgeon (T.E.D) operated on all patients. Patients characteristics are shown in Table 1. The non-maze group had more advanced symptoms according to the New York Heart Association (NYHA) functional class (P=0.04) and higher incidence of paroxysmal AF (P=0.05). However, preoperative echocardiography revealed that 77% of the patients in the maze group had left atrial (LA) size larger then 50 mm compared to 51% in the non-maze group (P=0.001).

2.2. Follow-up and data analysis
The patients’ clinical profile and perioperative outcomes were recorded prospectively. Follow-up was conducted by mailed questionnaire or telephone interview with the patient and by review of the cardiologist's office chart and current electrocardiogram reports. Information regarding each patient who died during the follow-up was obtained from family physician and relatives by telephone interview and from death certificates. The closing data for this study was March 2000. Late survival and valve-related outcomes were recorded and analyzed according to the guidelines of the Joint STS-AATS Ad Hoc Liaison Committee for Standardizing definitions of Prosthetic Heart Valve Morbidity [12].

Data were collected and managed in dBase IV datasets and analyzed using JMP and SAS System Software (SAS Institute, Cary, NC). The clinical profile of the two groups of patients was compared by chi-square test or Fisher's exact test when appropriate. Late survival and time-dependent morbidity were evaluated univariately by Kaplan–Meier analysis and multivariably by Cox regression.

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
3.1. Early outcomes
As shown in Table 2 the mean duration of cardiopulmonary bypass (P=0.0001) and aortic cross-clamp (P=0.0001) were significantly higher in the maze group. Table 3 shows the operative mortality and morbidity in each group. There were two early deaths in the maze group compared to one death in the non-maze group (P=0.9). In the maze group one patient's post-operative course was complicated by large bowel volvulus that required bowel resection, and this patient died 17 days after operation from sepsis and multi-organ failure. The second patient had normal postoperative course, but died on postoperative day 9 from sudden cardiac arrest after being in normal sinus rhythm for few days. Autopsy showed a recent myocardial infarction. In the non-maze group one patient who had redo MV replacement and coronary artery bypass surgery died on postoperative day 3 from low cardiac output syndrome and multi-organ failure.

Mean intensive care unit (ICU) stay time was significantly prolonged in the maze group, 3.0±1.8 days compared to 1.8±0.7 days in the non-maze group (P=0.006). Hospital stay was 11.4±4.8 days for the maze group and 10.3±4.0 days in the non-maze group (P=0.4).

3.2. Late outcomes
The mean duration of follow-up was 26±3 months for the maze group and 32±4 months for the non-maze group (P=0.19). Follow-up for both groups was 100% complete.

3.2.1. Patients’ survival
There was no late death in the maze group. There were six late deaths in the non-maze group. One patient died from congestive heart failure, one from stroke, one from anticoagulation-related bleeding, one from complication of reoperation on his aortic valve, and one from cancer. The 3-year survival was 96±3% for the maze group compared to 85±7% for the non-maze group (P=0.16) as shown in Fig. 1 .

View larger version (19K): [in this window] [in a new window]   Fig. 1. Survival in maze and non-maze patients.

View larger version (20K): [in this window] [in a new window]   Fig. 2. Freedom from thromboembolism in maze and non-maze patients.

3.2.4. NYHA functional class
Preoperatively 17% of the maze patients were in class I or II, compared to 79% at follow-up; 13% of the non-maze patients were in class I or II preoperatively compared to 72% at follow-up.

3.3. Electrocardiogram (ECG)
In the most recent ECG, 75% of the maze patients were in sinus rhythm compared to 36% of the non-maze patients (P=0.0004). Table 4 shows the results of the univariable analysis of predictors for remaining in AF. Non-maze operation, preoperative chronic AF (opposed to paroxysmal AF), preoperative decreased left ventricular function and higher NYHA class were all associated with sustained AF at follow-up. Larger LA size preoperatively did not emerge as predictor for remaining in AF. In multivariable analysis (Table 5) non-maze procedure, preoperative chronic AF, older age and decreased left ventricular function were associated with sustained AF.

Before the operation, mean number of antiarrhythmic drugs per patient was similar in both groups (1.29±0.66 per patient in the maze group compared to 1.25±0.61 per patient in the non-maze group, P=0.8). At follow-up, mean number of antiarrhythmic drugs in the maze group was 0.47±0.63 per patient compared to 1.0±0.60 per patient in the non-maze group (P=0.0001). In the maze group 60% of the patients were free of any antiarrhythmic drug compared to 18% in the non-maze group (P=0.0001).

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Several previous studies [6–8] reported the efficacy of the maze procedure in eliminating AF in patients with preoperative AF undergoing MV surgery. Since adding the maze procedure to MV surgery complicates the operation, there is a concern that the combination will result in increased early morbidity and mortality. In order to evaluate the risks and benefits of adding the maze procedure other studies tried to compare outcomes of the combined procedure with isolated MV surgery [9,10]. Unfortunately, none of these was a prospective randomized trial. We performed a matched control study, which is obviously inferior to a prospective randomized trial but superior to any other clinical comparative study. We were able to match the patients for 5 important parameters, but there were still several other parameters such as NYHA functional class, preoperative LA size and preoperative duration of AF, in which there was a significant difference between the groups (Table 1).

Previous studies reported 70–90 % conversion to sinus rhythm after the combined procedure [6–10]. In this study, at follow-up 75% of the maze group patients were in sinus rhythm compared to 36% in the non-maze group (P=0.0004). These results are encouraging taking into consideration that in the maze group more patients were in chronic AF and the duration of AF was longer (Table 1). Kobayashi et al [13] have demonstrated that factors like large LA size, small voltage of the fibrillatory wave, and large cardiothoracic ratio were associated with reduced success rate in conversion to sinus rhythm. In our series these exclusion criteria were not used and patients with giant LA, severe left ventricular dysfunction and longstanding AF were included (Table 1). In our study, increased LA size did not emerge as predictor of failure to restore sinus rhythm but left ventricular dysfunction did emerge as independent predictor of failure (Table 5). It is possible that by implementing some inclusion/exclusion criteria and having a more selective group, it would have been possible to improve the success rate in converting to sinus rhythm. Moreover, early in the series patients in AF in the first 3–6 months after the maze procedure were not treated aggressively enough and failure to convert to sinus rhythm was considered ‘acceptable’. We now believe that by early electric cardioversion or anti-arrhythmic therapy most of them will revert to sinus rhythm.

Cardiopulmonary bypass time, cross-clamping time and ICU stay were all significantly longer in the maze group. However, these prolonged times did not translate into higher morbidity or hospital stay (Tables 1–3). In the maze group there were two early deaths compared to one in the non-maze group. Since we were dealing with relative small number of patients this difference did not reach statistical significance.

Restoring sinus rhythm in this group of patients has several potential benefits as described below.

4.1.1. Reduced late thromboembolic events and ACH
Recent studies in patients with non-valvular AF have reported an overall risk for stroke as 5% per year [14,15]. Treatment with coumadin or in some cases with aspirin decreases the incidence of stroke to approximately 2% per year [16] but chronic treatment with coumadin is associated with risk of bleeding from 0.5 to 3% per year [16,17]. In this study, none of the patients in the maze group experienced a thromboembolic event. In the non-maze group 5 patients suffered a thromboembolic events with one death (P=0.03). Moreover, at follow-up only 38% of the maze group were on coumadin compared with 69% in the non-maze group (P=0.005).

4.1.2. Reduction in the use of antiarrhythmic medications
Besides the reduction in medical expenditure, several clinical trials [18,19] suggested that drugs like amiodarone and quinidine have pro-arrhythmic effects. In the maze group there was a reduction from 1.29±0.66 drugs per patient preoperatively to 0.47±0.63 at follow-up. In the non-maze group the reduction was from 1.25±0.61 per patient to only 1.0±0.60. There are other potential benefits to restoring sinus rhythm such as improved quality of life (by symptomatic relief of palpitation) that was not examined in this study.

The two principal limitations of our study are that it was retrospective and we the two groups of patients were different in various aspects in spite of our attempt to match them for as many clinical variables as possible. However, the mid-term results of the maze group are superior to those of the non-maze group justify its continued use in patients with chronic AF and MV disease who have MV repair or replacement with a bioprosthesis.

	Footnotes

 
Presented at the 14th Annual Meeting of the European Association for Cardio-thoracic Surgery, Frankfurt, Germany, October 7–11, 2000.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 

1. Cohn L.H., Couper G.S., Aranki S.F., Rizzo R.J., Kinchla N.M., Collins J.J., Jr Long-term results of mitral valve reconstruction for regurgitation of the myxomatous mitral valve. J Thorac Cardiovasc Surg 1994;107:143-150.[Abstract/Free Full Text]
2. David T.E., Armstrong S., Sun Z., Daniel L. Late results of mitral valve repair for mitral regurgitation due to degenerative disease. Ann Thorac Surg 1993;56:7-12.[Abstract]
3. Alvarez J.M., Deal C.W., Loveridge K., Brennan P., Eisenberg R., Ward M., Bhattacharya K., Atkinson S.J., Choong C. Repairing the degenerative mitral valve: ten to fifteen-year follow-up. J Thorac Cardiovasc Surg 1996;112:238-247.[Abstract/Free Full Text]
4. Chua Y.L., Schaff H.V., Orszulak T.A., Morris J.J. Outcome of mitral valve repair in patients with preoperative atrial fibrillation. J Thorac Cardiovasc Surg 1994;107:408-415.[Abstract/Free Full Text]
5. Brodell G.K., Cosgrove D., Schiavone W., Underwood D.A., Loop F.D. Cardiac rhythm and conduction disturbances in patients undergoing mitral valve surgery. Clev Clin J Med 1991;58:397-399.[Medline]
6. Kosakai Y., Kawaguchi A.T., Isobe F., Sasko Y., Nakano K., Eishi K., Tanaka N., Kito Y., Kawashima Y. Cox maze procedure for chronic atrial fibrillation associated with mitral valve disease. J Thorac Cardiovasc Surg 1994;108:1049-1055.[Abstract/Free Full Text]
7. McCarthy P.M., Castle L.W., Maloney J.D., Trophaman R.G., Simmons T.W., White R.D., Klein A.L. Initial experience with the maze procedure for atrial fibrillation. J Thorac Cardiovasc Surg 1993;105:1077-1087.[Abstract]
8. Izumoto H., Kawazoe K., Kitahara H., Nasu M., Sasaki T., Kamata J., Tsuji I., Yagi Y. Can the maze procedure be combined safely with mitral valve repair?. J Heart Valve Dis 1997;6:166-170.[Medline]
9. Handa N., Schaff H.V., Morris J.J., Anderson B.J., Kopecky S.L., Enriquez-Sarano M. Outcome of valve repair and the cox maze procedure for mitral regurgitation and associated atrial fibrillation. J Thorac Cardiovasc Surg 1999;118:628-635.[Abstract/Free Full Text]
10. Jatene M.B., Marcial M.B., Tarasoutchi F., Cardoso R.A., Pomerantzeff P., Jatene A.D. Influence of the maze procedure on the treatment of rheumatic atrial fibrillation – evaluation of rhythm control and clinical outcome in a comparative study. Eur J Cardio-thorac Surg 2000;17:117-124.[Abstract/Free Full Text]
11. Cox J.L., Ad N., Palazzo T. Impact of the maze procedure on the stroke rate in patients with atrial fibrillation. J Thorac Cardiovasc Surg 1999;118:833-840.[Abstract/Free Full Text]
12. Edmunds L.H., Clark R.E., Cohn L.H., Grunkemeier G.L., Miller D.C., Weisel R.D. Guidelines for reporting morbidity and mortality after cardiac valvular operations. Eur J Cardio-thorac Surg 1996;10:812-816.[Abstract]
13. Kobayashi J., Kosakai Y., Nakano K., Sasako Y., Eishi K., Yamamoto F. Improved success rate of the maze procedure in mitral valve disease by new criteria for patient's selection. Eur J Cardio-thorac Surg 1998;13:247-252.[Abstract/Free Full Text]
14. Wolf P.A., Abott R.D., Kannel W.B. Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 1991;22:983-988.[Abstract/Free Full Text]
15. Hart R.G., Sherman D.G., Easton J.D., Crains J.A. Prevention of stroke in patients with nonvalvular atrial fibrillation. Neurology 1998;51:674-681.[Abstract/Free Full Text]
16. Atrial Fibrillation Investigators: Atrial Fibrillation, Aspirin, Anticoagulation Study; Boston Area Anticoagulation Trial for Atrial Fibrillation; Canadian Atrial Fibrillation Anticoagulation Study; Stroke Prevention in Atrial Fibrillation Study; Veterans Affairs Stroke Prevention in Non-rheumatic Atrial Fibrillation Study.. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med 1994;154:1449-1457.[Abstract/Free Full Text]
17. Fihn S.D. Aiming for safe anticoagulation (editorial). N Engl J Med 1995;333:54-55.[Free Full Text]
18. Josephson M.E. Antiarrhythmic agents and the danger of proarrhythmic events. Ann Inter Med 1989;111:101-103.
19. Coplen S.E., Antman E.M., Berlin J.A., Hewitt P., Chalmers T.C. Efficacy and safety of quinidine therapy for maintenance of sinus rhythm after cardioversion: a meta-analysis of randomized control trials. Circulation 1990;82:1106-1116.[Abstract/Free Full Text]

This article has been cited by other articles:

				G. Reyes, A. Benedicto, J. Bustamante, A. Sarraj, J. Manuel Nuche, P. Alvarez, and J. Duarte Restoration of atrial contractility after surgical cryoablation: clinical, electrical and mechanical results Interactive CardioVascular and Thoracic Surgery, October 1, 2009; 9(4): 609 - 612. [Abstract] [Full Text] [PDF]

				F. T. Han, V. Kasirajan, M. Kowalski, R. Kiser, L. Wolfe, G. Kalahasty, R. K. Shepard, M. A. Wood, and K. A. Ellenbogen Results of a Minimally Invasive Surgical Pulmonary Vein Isolation and Ganglionic Plexi Ablation for Atrial Fibrillation: Single-Center Experience With 12-Month Follow-Up Circ Arrhythm Electrophysiol, August 1, 2009; 2(4): 370 - 377. [Abstract] [Full Text] [PDF]

				U. O. von Oppell, N. Masani, P. O'Callaghan, R. Wheeler, G. Dimitrakakis, and S. Schiffelers Mitral valve surgery plus concomitant atrial fibrillation ablation is superior to mitral valve surgery alone with an intensive rhythm control strategy Eur. J. Cardiothorac. Surg., April 1, 2009; 35(4): 641 - 650. [Abstract] [Full Text] [PDF]

				Y. Louagie, M. Buche, P. Eucher, J.-C. Schoevaerdts, M. Gerard, J. Jamart, and D. Blommaert Improved patient survival with concomitant Cox Maze III procedure compared with heart surgery alone. Ann. Thorac. Surg., February 1, 2009; 87(2): 440 - 446. [Abstract] [Full Text] [PDF]

				A. Vahanian, B. Iung, L. Piérard, R. Dion, and J. Pepper CHAPTER 21 Valvular Heart Disease ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter. [Abstract] [Full Text] [PDF]

				W. P. Beukema, H. T. Sie, A. R. Ramdat Misier, P. P. H.M. Delnoy, H. J.J. Wellens, and A. Elvan Intermediate to Long-Term Results of Radiofrequency Modified Maze Procedure as an Adjunct to Open-Heart Surgery Ann. Thorac. Surg., November 1, 2008; 86(5): 1409 - 1414. [Abstract] [Full Text] [PDF]

				2006 WRITING COMMITTEE MEMBERS, R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, et al. 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Circulation, October 7, 2008; 118(15): e523 - e661. [Full Text] [PDF]

				W. P. Beukema, H. T. Sie, A. R. 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 Eur. J. Cardiothorac. Surg., October 1, 2008; 34(4): 771 - 775. [Abstract] [Full Text] [PDF]

				R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons J. Am. Coll. Cardiol., September 23, 2008; 52(13): e1 - e142. [Full Text] [PDF]

				R. J. Damiano Jr What Is the Best Way to Surgically Eliminate the Left Atrial Appendage? J. Am. Coll. Cardiol., September 9, 2008; 52(11): 930 - 931. [Full Text] [PDF]

				A. A. Ghavidel, H. Javadpour, M. Shafiee, M.-B. Tabatabaie, K. Raiesi, and S. Hosseini Cryoablation for surgical treatment of chronic atrial fibrillation combined with mitral valve surgery: a clinical observation Eur. J. Cardiothorac. Surg., June 1, 2008; 33(6): 1043 - 1048. [Abstract] [Full Text] [PDF]

				J. S. Gammie, M. Haddad, S. Milford-Beland, K. F. Welke, T. B. Ferguson Jr, S. M. O'Brien, B. P. Griffith, and E. D. Peterson Atrial Fibrillation Correction Surgery: Lessons From The Society of Thoracic Surgeons National Cardiac Database Ann. Thorac. Surg., March 1, 2008; 85(3): 909 - 914. [Abstract] [Full Text] [PDF]

				S. Lonnerholm, P. Blomstrom, L. Nilsson, and C. Blomstrom-Lundqvist Long-Term Effects of the Maze Procedure on Atrial Size and Mechanical Function Ann. Thorac. Surg., March 1, 2008; 85(3): 916 - 920. [Abstract] [Full Text] [PDF]

				R. K. Voeller, R. B. Schuessler, and R. J. Damiano Jr. Surgical Treatment of Atrial Fibrillation Card. Surg. Adult, January 1, 2008; 3(2008): 1375 - 1394. [Full Text]

				M. Lamotte, L. Annemans, B. Bridgewater, S. Kendall, and M. Siebert A health economic evaluation of concomitant surgical ablation for atrial fibrillation Eur. J. Cardiothorac. Surg., November 1, 2007; 32(5): 702 - 710. [Abstract] [Full Text] [PDF]

				D. L. Ngaage, H. V. Schaff, C. J. Mullany, S. Barnes, J. A. Dearani, R. C. Daly, T. A. Orszulak, and T. M. Sundt III Influence of Preoperative Atrial Fibrillation on Late Results of Mitral Repair: Is Concomitant Ablation Justified? Ann. Thorac. Surg., August 1, 2007; 84(2): 434 - 443. [Abstract] [Full Text] [PDF]

				H. Calkins, J. Brugada, D. L. Packer, R. Cappato, S.-A. Chen, H. J.G. Crijns, R. J. Damiano Jr, D. W. Davies, D. E. Haines, M. Haissaguerre, 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, June 1, 2007; 9(6): 335 - 379. [Full Text] [PDF]

				Authors/Task Force Members, A. Vahanian, H. Baumgartner, J. Bax, E. Butchart, R. Dion, G. Filippatos, F. Flachskampf, R. Hall, B. Iung, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology Eur. Heart J., January 26, 2007; (2007) ehl428v1. [Full Text] [PDF]

				I. Bakir, F. P. Casselman, P. Brugada, P. Geelen, F. Wellens, I. Degrieck, F. Van Praet, Y. Vermeulen, R. De Geest, and H. Vanermen Current Strategies in the Surgical Treatment of Atrial Fibrillation: Review of the Literature and Onze Lieve Vrouw Clinic's Strategy Ann. Thorac. Surg., January 1, 2007; 83(1): 331 - 340. [Abstract] [Full Text] [PDF]

				M.-J. Baek, C.-Y. Na, S.-S. Oh, C.-H. Lee, J. H. Kim, H. J. Seo, S.-W. Park, and W. S. Kim Surgical treatment of chronic atrial fibrillation combined with rheumatic mitral valve disease: effects of the cryo-maze procedure and predictors for late recurrence Eur. J. Cardiothorac. Surg., November 1, 2006; 30(5): 728 - 736. [Abstract] [Full Text] [PDF]

				J. W.W. Wong and K.-H. Mak Impact of Maze and Concomitant Mitral Valve Surgery on Clinical Outcomes Ann. Thorac. Surg., November 1, 2006; 82(5): 1938 - 1947. [Abstract] [Full Text] [PDF]

				S. Carasso, R. Kuperstein, E. Konen, M. Glikson, and M. S. Feinberg Plowing the atrium and growing thrombi: Two cases of large atrial thrombi following ablative and surgical procedure for atrial fibrillation Eur J Echocardiogr, October 1, 2006; 7(5): 383 - 386. [Abstract] [Full Text] [PDF]

				R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons J. Am. Coll. Cardiol., August 1, 2006; 48(3): e1 - e148. [Full Text] [PDF]

				R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons J. Am. Coll. Cardiol., August 1, 2006; 48(3): 598 - 675. [Full Text] [PDF]

				S. D. Barnett and N. Ad Surgical ablation as treatment for the elimination of atrial fibrillation: A meta-analysis J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 1029 - 1035. [Abstract] [Full Text] [PDF]

				S. Forlani, R. De Paulis, L. G. Wolf, R. Greco, P. Polisca, M. Moscarelli, and L. Chiariello Conversion to Sinus Rhythm by Ablation Improves Quality of Life in Patients Submitted to Mitral Valve Surgery Ann. Thorac. Surg., March 1, 2006; 81(3): 863 - 867. [Abstract] [Full Text] [PDF]

				A. M. Gillinov, J. Sirak, E. H. Blackstone, P. M. McCarthy, J. Rajeswaran, G. Pettersson, F. J. Sabik III, L. G. Svensson, J. L. Navia, D. M. Cosgrove, et al. The Cox maze procedure in mitral valve disease: Predictors of recurrent atrial fibrillation J. Thorac. Cardiovasc. Surg., December 1, 2005; 130(6): 1653 - 1660. [Abstract] [Full Text] [PDF]

				J. T. Reston and J. H. Shuhaiber Meta-analysis of clinical outcomes of maze-related surgical procedures for medically refractory atrial fibrillation Eur. J. Cardiothorac. Surg., November 1, 2005; 28(5): 724 - 730. [Abstract] [Full Text] [PDF]

				M. Mabuchi, M. Imamura, N. Kubo, K. Morita, K. Noriyasu, T. Tsukamoto, K. Yasuda, and N. Tamaki Sympathetic Denervation and Reinnervation After the Maze Procedure J. Nucl. Med., July 1, 2005; 46(7): 1089 - 1094. [Abstract] [Full Text] [PDF]

				M.-J. Baek, S.-S. Oh, C.-H. Lee, and C.-Y. Na Outcome of the modified maze procedure for atrial fibrillation combined with rheumatic mitral valve disease using cryoablation Interactive CardioVascular and Thoracic Surgery, April 1, 2005; 4(2): 130 - 134. [Abstract] [Full Text] [PDF]

				G. Golovchiner, A. Mazur, A. Kogan, B. Strasberg, Y. Shapira, M. Fridman, J. Kuzniec, B. A. Vidne, and E. Raanani Atrial Flutter After Surgical Radiofrequency Ablation of the Left Atrium for Atrial Fibrillation Ann. Thorac. Surg., January 1, 2005; 79(1): 108 - 112. [Abstract] [Full Text] [PDF]

				Z. A. Szalay, A. Civelek, T. Dill, W. P. Klovekorn, I. Kilb, and E. P. Bauer Long-term follow-up after the mini-maze procedure Ann. Thorac. Surg., April 1, 2004; 77(4): 1277 - 1281. [Abstract] [Full Text] [PDF]

				S. M. Prasad, H. S. Maniar, C. J. Camillo, R. B. Schuessler, J. P. Boineau, T. M. Sundt III, J. L. Cox, and R. J. Damiano Jr The Cox maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 1822 - 1827. [Abstract] [Full Text] [PDF]

				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 J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1357 - 1365. [Abstract] [Full Text] [PDF]

				T. E. David, J. Ivanov, S. Armstrong, and H. Rakowski Late outcomes of mitral valve repair for floppy valves: Implications for asymptomatic patients J. Thorac. Cardiovasc. Surg., May 1, 2003; 125(5): 1143 - 1152. [Abstract] [Full Text] [PDF]

				G. Bonanomi, M. A. Zenati, and D. Schwartzman Left atrial appendectomy and maze J. Am. Coll. Cardiol., January 1, 2003; 41(1): 170 - 170. [Full Text] [PDF]

				A. M. Gillinov, E. H. Blackstone, and P. M. McCarthy Atrial fibrillation: current surgical options and their assessment Ann. Thorac. Surg., December 1, 2002; 74(6): 2210 - 2217. [Abstract] [Full Text] [PDF]

				H. Nakajima, J. Kobayashi, K. Bando, K. Niwaya, O. Tagusari, Y. Sasako, T. Nakatani, and S. Kitamura The Effect of Cryo-Maze Procedure on Early and Intermediate Term Outcome in Mitral Valve Disease: Case Matched Study Circulation, September 24, 2002; 106(12_suppl_1): I-46 - I-50. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Tirone E. David Terrence M. Yau Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Raanani, E. Articles by Armstrong, S. Search for Related Content PubMed PubMed Citation Articles by Raanani, E. Articles by Armstrong, S. Related Collections Electrophysiology - arrhythmias Valve disease