Anson M. Lee, Marci S. Bailey, Abdulhameed Aziz, Richard B. Schuessler, Ralph J. Damiano, Jr.
Washington University, Saint Louis, MO, USA.
OBJECTIVE - The Cox-Maze procedure (CMP) for the surgical treatment of atrial fibrillation (AF) historically has required a median sternotomy and cardiopulmonary bypass (CPB). This study describes a safe, efficacious method using ablation technologies to create the full Cox-Maze lesion set through a 5-6 cm right mini-thoracotomy.
METHODS - Sixteen consecutive patients underwent a CMP via right mini-thoracotomy and CPB. All patients were followed prospectively with ECG and 24 hour Holter monitoring at 3, 6, and 12 months.
The mean age was 55 ± 10 years, and 38% were male. 88% of patients had paroxysmal AF. The mean duration of preoperative AF was 68 ± 48 months. LA size was 4.5 ± 1.0 cm. Ten patients had a lone CMP, and six had concomitant mitral ± tricuspid valve procedures.
The CMP lesion set was created via a right mini-thoracotomy through the fourth intercostal space, using bipolar radiofrequency (RF) and cryothermy (Figure). The femoral vessels were cannulated for CPB. All right sided lesions were created before cross clamping. Through a left atriotomy, bipolar RF and a T-shaped cryoprobe were used to complete the isolation of the posterior left atrium and to connect this encircling lesion to the base of left atrial appendage. The appendage was oversewn from the endocardial side.
RESULTS - There was no operative mortality or major complications. One patient required a permanent pacemaker. Four patients (25%) had early atrial tachyarrhythmias. At last followup (mean 9 ± 7 months), 100% of patients (n=16) were free from atrial dysrhythmias. At 3 months (n=15), 73% of patients were also off antiarrhythmics. By 6 months (n=11) 91% of patients were off antiarrhythmics. At 12 months (n=6), no patients were on antiarrhythmics, and only one patient remained on Coumadin for a mechanical mitral valve.
CONCLUSION - This study has shown that a full CMP can be performed through a right mini-thoracotomy with outstanding short term results. This less invasive procedure can be offered to patients without compromising efficacy.
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