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Abstract

Objective:

A right minithoracotomy (RMT) is a minimally invasive surgical approach that has been increasingly performed for the concomitant Cox maze IV procedure (CMP) and mitral valve surgery (MVS). Little is known regarding whether long-term rhythm and survival outcomes are affected by the RMT as compared with the traditional median sternotomy (MS) approach.

Methods:

Between April 2004 and April 2021, 377 patients underwent the concomitant CMP and MVS, of whom 38% had RMT. Propensity score matching yielded 116 pairs. Freedom from atrial tachyarrhythmias (ATA) was assessed with prolonged monitoring annually for 8 years. Survival, rhythm, and perioperative outcomes were compared.

Results:

The unmatched RMT cohort had a greater freedom from ATA recurrence at 1 year (99% vs 90%, P = 0.001) and 3 years (94% vs 86%, P = 0.045). The matched RMT cohort had longer cardiopulmonary bypass (median: 215 [199 to 253] vs 170 [136 to 198] min, P < 0.001) and aortic cross-clamp (110 [98 to 124] vs 86 [71 to 102] min, P < 0.001) times but shorter intensive care time (48 [24 to 95] vs 71 [26 to 144] h, P = 0.001) and length of stay (8 [6 to 11] vs 10 [7 to 14] h, P < 0.001). More pacemakers (18% vs 4%, P < 0.001) and postoperative transfusions (57% vs 41%, P = 0.014) occurred in the MS cohort. The 30-day mortality (P = 0.651) and 8-year survival (P = 0.072) was not significantly different between the cohorts.

Conclusions:

Early 1-year and 3-year freedom from ATA recurrence was better in the RMT cohort compared with the MS cohort. Despite longer operative times, the RMT cohort had shorter lengths of stay, fewer postoperative transfusions, and fewer pacemakers placed.

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Keywords

atrial fibrillation Cox maze procedure mitral valve surgery concomitant ablation surgery right minithoracotomy

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References

Iwasaki

Nishida

Kato

, et al. Atrial fibrillation pathophysiology: implications for management. Circulation 2011; 124: 2264–2274.

Khiabani

MacGregor

Bakir

, et al. The long-term outcomes and durability of the Cox-Maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg 2022; 163: 629–641.

Ruaengsri

Schill

Khiabani

, et al. The Cox-maze IV procedure in its second decade: still the gold standard? Eur J Cardiothorac Surg 2018; 53(suppl_1): i19–i25.

Musharbash

Schill

Sinn

, et al. Performance of the Cox-maze IV procedure is associated with improved long-term survival in patients with atrial fibrillation undergoing cardiac surgery. J Thorac Cardiovasc Surg 2018; 155: 159–170.

Badhwar

Rankin

, et al. Surgical ablation of atrial fibrillation in the United States: trends and propensity matched outcomes. Ann Thorac Surg 2017; 104: 493–500.

McCarthy

Davidson

Kruse

, et al. Prevalence of atrial fibrillation before cardiac surgery and factors associated with concomitant ablation. J Thorac Cardiovasc Surg 2020; 159: 2245–2253.

Lee

Clark

Bailey

, et al. A minimally invasive Cox-maze procedure: operative technique and results. Innovations 2010; 5: 281–286.

Philpott

Zemlin

Cox

, et al. The ABLATE Trial: safety and efficacy of Cox Maze-IV using a bipolar radiofrequency ablation system. Ann Thorac Surg 2015; 100: 1541–1548.

Damiano

Jr Badhwar

Acker

, et al. The CURE-AF trial: a prospective, multicenter trial of irrigated radiofrequency ablation for the treatment of persistent atrial fibrillation during concomitant cardiac surgery. Heart Rhythm 2014; 11: 39–45.

10.

Sündermann

Sromicki

Rodriguez Cetina Biefer

, et al. Mitral valve surgery: right lateral minithoracotomy or sternotomy? A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2014; 148: 1989–1995.

11.

Modi

Hassan

and Chitwood

Jr.

Minimally invasive mitral valve surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2008; 34: 943–952.

12.

and Cox

. The Maze procedure for the treatment of atrial fibrillation: a minimally invasive approach. J Card Surg 2004; 19: 196–200.

13.

Toscano

Barbero

Capuano

, et al. Chronic postsurgical pain and quality of life after right minithoracotomy mitral valve operations. J Card Surg 2022; 37: 1585–1590.

14.

Mariscalco

and Musumeci

. The minithoracotomy approach: a safe and effective alternative for heart valve surgery. Ann Thorac Surg 2014; 97: 356–364.

15.

Al Otaibi

Gupta

Belley-Cote

, et al. Mini-thoracotomy vs. conventional sternotomy mitral valve surgery: a systematic review and meta-analysis. J Cardiovasc Surg 2017; 58: 489–496.

16.

Jiang

Tang

, et al. Right minithoracotomy versus conventional median sternotomy for patients undergoing mitral valve surgery and Cox-maze IV ablation with entirely bipolar radiofrequency clamp. Heart Vessels 2018; 33: 901–907.

17.

Lawrance

Henn

Miller

, et al. A minimally invasive Cox maze IV procedure is as effective as sternotomy while decreasing major morbidity and hospital stay. J Thorac Cardiovasc Surg 2014; 148: 955–962.

18.

Robertson

Saint

Leidenfrost

, et al. Illustrated techniques for performing the Cox-Maze IV procedure through a right mini-thoracotomy. Ann Cardiothorac Surg 2014; 3: 105–116.

19.

Birnie

Verheyden

Pagano

, et al. Predictive models for kidney disease: improving global outcomes (KDIGO) defined acute kidney injury in UK cardiac surgery. Crit Care 2014; 18: 606.

20.

Calkins

Hindricks

Cappato

, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2017; 14: e275–e444.

21.

MacGregor

Khiabani

and Damiano

. The surgical treatment of atrial fibrillation via median sternotomy. Oper Tech Thorac Cardiovasc Surg 2019; 24: 19–37.

22.

Damiano

Jr Schwartz

Bailey

, et al. The Cox maze IV procedure: predictors of late recurrence. J Thorac Cardiovasc Surg 2011; 141: 113–121.

23.

Holmes

Massimiano

, et al. Long-term outcome following concomitant mitral valve surgery and Cox maze procedure for atrial fibrillation. J Thorac Cardiovasc Surg 2018; 155: 983–994.

24.

Henn

Lancaster

Miller

, et al. Late outcomes after the Cox maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg 2015; 150: 1168–1178.

25.

Pet

Robertson

Bailey

, et al. The impact of CHADS2 score on late stroke after the Cox maze procedure. J Thorac Cardiovasc Surg 2013; 146: 85–89.

26.

Saint

Bailey

Prasad

, et al. Cox-Maze IV results for patients with lone atrial fibrillation versus concomitant mitral disease. Ann Thorac Surg 2012; 93: 789–795.

27.

Akpinar

Guden

Sagbas

, et al. Combined radiofrequency modified maze and mitral valve procedure through a port access approach: early and mid-term results. Eur J Cardiothorac Surg 2003; 24: 223–230.

28.

Cho

Heo

Jin

, et al. Sick sinus syndrome after the maze procedure performed concomitantly with mitral valve surgery. J Am Heart Assoc 2018; 7: e009629.

29.

DeRose

Jr Mancini

Chang

, et al. Pacemaker implantation after mitral valve surgery with atrial fibrillation ablation. J Am Coll Cardiol 2019; 73: 2427–2435.

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Minimally Invasive Mitral Valve Surgery With Concomitant Cox Maze Procedure Is as Effective as a Median Sternotomy With Decreased Morbidity

Abstract

Objective:

Methods:

Results:

Conclusions:

Keywords

Get full access to this article

References

Supplementary Material