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Eur J Cardiothorac Surg 2005;28:183
© 2005 Elsevier Science NL

Letter to the Editor

Maze III—still the holy grail?

Ganesh Shanmugam *

Department of Cardio-Thoracic Surgery, Glasgow Royal Infirmary, Glasgow, UK

Received 20 February 2005; accepted 18 March 2005.

* Tel: +44 141 339 1433. (Email: sgunpat{at}hotmail.com).

Key Words: Atrial fibrillation

Khargi et al. [1] are to be congratulated on an excellent review comparing the efficacies of alternative energy sources to the classic Cox-Maze III, which has been considered as the gold standard for the surgical treatment of AF.

The maze III was developed as a procedure that interrupted any and all atrial macro re-entrants circuits, thereby precluding AF. The maze III had unparalleled success because the lesion set was comprehensive, continuous and transmural. Any procedure that can effectively reproduce these principles, would potentially achieve the same results.

The use of a procedure is determined by three interacting factors: complexity, adoptability, and efficacy. Left atrial [LA] procedures cure AF in only 70% of the patients. Despite this, they are simpler to perform, and therefore are more widely adopted [2].

It is interesting that although the postoperative SR rates for the two groups were different, the higher rates of SR in the Cox-Maze group are attributable to the larger proportion of young patients, and patients with ‘lone’ and ‘paroxysmal’ AF in this cohort. When controlled for these factors, the SR rates in the two groups are comparable.

The authors state that a clear relation between the atrial lesion pattern and postoperative SR could not be established. It would be interesting to compare SR rates between left and biatrial lesion patterns in the non-Cox-Maze group.

There was a statistically significant difference in postoperative SR rates between the Cox-Maze group and those who had biatrial lesion patterns in the non-Cox-Maze group. This has been explained by the uncertainty of the continuity and transmurality of the lesions in the non-Cox-Maze group. The authors suggest that even non-transmural lesions have resulted in SR, in other studies, but it is difficult to accept this as the basis for an explanation that non-transmural lesions are not critical to overall outcome. The number of patients in the two series was very small.

Besides, there might have been other confounding variables, such as the duration and pattern of AF that influenced eventual outcome in these patients.

The heterogeneity of left-sided lesion patterns in the non-Cox-Maze group confounds the analysis of the results in the non-Cox-Maze group.

The choice of procedure for a given patient is a trade-off between the higher SR rates following the Cox-Maze III and the simplicity of performing LA procedures:

(1) The precise foci and patterns of atrial activation determine the choice between a left or biatrial procedure. While most patients, especially those with paroxysmal AF, would be cured with an LA procedure there will still be those (continuous AF, non-pulmonary vein foci, right atrial foci) who will require a biatrial procedure.
(2) The choice of energy source is irrelevant, as long as (a) the lesion set is appropriately matched to the activation pattern in a given patient, (b) the lesions are continuous and transmural.

References

  1. Khargi K, Hutten BA, Lemke B, Deneke T. Surgical treatment of atrial fibrillation; a systematic review. Eur J Cardiothorac Surg 2005;27(2):258-265.[Abstract/Free Full Text]
  2. Cox JL. Atrial fibrillation II: rationale for surgical treatment. J Thorac Cardiovasc Surg 2003;126:1693-1699.[Free Full Text]




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