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Updated: Jul 19, 2026
Cox-Maze IV Procedure Concomitant with Valvular Surgery In Situs Inversus Dextrocardia: A Single-Center Experience in China
Published on: February 11, 2022
A novel atrial volume reduction technique to enhance the Cox maze procedure: initial results
Akira Marui1, Takeshi Nishina, Keiichi Tambara
1Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
Insights
A novel left atrial volume reduction technique enhances the Cox maze procedure, improving sinus rhythm recovery in patients with atrial fibrillation and enlarged left atria. This safe method increases success rates without added complications.
Area of Science:
- Cardiology
- Cardiac Surgery
Background:
- Large left atrial diameter is a predictor of recurrent atrial fibrillation post-Cox maze procedure.
- Left atrial diameter impacts sinus rhythm recovery and maintenance.
- Current methods to reduce left atrial diameter can increase operative time and bleeding risk.
Purpose of the Study:
- To develop and evaluate a novel, less invasive left atrial volume reduction technique.
- To enhance the Cox maze procedure by reducing left atrial size without increasing complications.
- To improve sinus rhythm recovery rates in patients with atrial fibrillation and enlarged left atria.
Main Methods:
- A modified Cox maze III procedure with cryoablation was performed in 80 patients with atrial fibrillation and enlarged left atria (>=60 mm).
- 44 patients underwent concomitant left atrial volume reduction (VR group) using plication sutures and cryoablation along the pulmonary vein isolation line.
- 36 patients served as the control group without the volume reduction technique.
Main Results:
- The VR group achieved significantly smaller postoperative left atrial diameters (47.6 +/- 6.3 mm) compared to the control group (62.1 +/- 7.9 mm).
- Both groups showed no significant difference in crossclamp/bypass time or chest tube drainage.
- Twelve months post-surgery, the VR group demonstrated a superior sinus rhythm recovery rate (90%) versus the control group (69%).
Conclusions:
- The novel left atrial volume reduction technique, combined with the maze procedure, effectively improves sinus rhythm recovery in patients with long-standing atrial fibrillation and enlarged left atria.
- This technique is safe, does not increase complications, and offers a potential advantage over catheter-based ablation for complex cases.
- Further research with larger cohorts and longer follow-up is warranted to fully establish its long-term efficacy and expand indications.
Objective:
Large left atrial diameter is reported to be a predictor for recurrent atrial fibrillation after the Cox maze procedure, and left atrial diameter by itself influences the chance of sinus rhythm recovery, as well as maintenance of sinus rhythm. However, additional cut-and-sew procedures to decrease left atrial diameter extend operative time and can cause bleeding. Thus we developed a no-bleeding, faster, and therefore less invasive left atrial volume reduction technique to enhance the Cox maze procedure.
Methods:
The modified Cox maze III procedure with cryoablation or the left atrial maze procedure in association with mitral valve surgery was performed in 80 patients with atrial fibrillation and enlarged left atria (> or =60 mm). Among them, 44 patients had the concomitant volume reduction technique (VR group); continuous horizontal mattress sutures for left atrial plication were placed on the left atrial wall along the pulmonary vein isolation line. Cryoablation was applied to the suture line so that the plicated left atrium is anatomically and electrically isolated. Another 36 patients did not have the volume reduction technique (control group).
Results:
The VR group had preoperative left atrial diameters similar to those of the control group (67.1 +/- 7.8 vs 64.5 +/- 6.7 mm) and a longer preoperative duration of atrial fibrillation (14.1 +/- 5.4 vs 9.5 +/- 5.1 years, P < .05) but had smaller postoperative left atrial diameters (47.6 +/- 6.3 vs 62.1 +/- 7.9 mm, P < .01). There were no differences in mean crossclamp/bypass time and chest tube drainage for 12 hours between the groups. Twelve months after surgical intervention, the sinus rhythm recovery rate of the VR group was better than that of the control group (90% vs 69%, P < .05).
Conclusions:
Even in patients with long-standing atrial fibrillation and an enlarged left atrium, maze procedures concomitant with the novel left atrial volume reduction technique improved the sinus rhythm recovery rate without increasing complications. Although further study with a larger number of patients and a longer follow-up period is needed, this safe and thus far potent technique that catheter-based ablation cannot copy might extend indication of the Cox maze procedure for patients with tough atrial fibrillation.
