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Updated: May 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
Interim results of the 5-box thoracoscopic maze procedure
John H Sirak1, David Schwartzman
1Division of Cardiac Surgery, Ohio State University, Columbus, Ohio 43210, USA. johnsirak@gmail.com
Insights
This study demonstrates that a thoracoscopic Maze procedure effectively treats atrial fibrillation (AF) by isolating arrhythmogenic substrate. Patient outcomes show high rates of freedom from AF, achieving results comparable to traditional Maze surgery.
Area of Science:
- Cardiovascular Surgery
- Cardiac Electrophysiology
- Minimally Invasive Procedures
Background:
- Atrial fibrillation (AF) treatment requires comprehensive atrial lesion sets to prevent reentry and eliminate foci.
- The Cox-Maze paradigm outlines critical surgical endpoints for AF ablation.
- Previous closed-chest procedures have not fully incorporated all Cox-Maze endpoints.
Purpose of the Study:
- To report patient outcomes of a totally thoracoscopic Maze procedure.
- To evaluate the efficacy of a 5-box thoracoscopic Maze approach in treating drug-resistant AF.
- To assess the feasibility of achieving Cox-Maze benchmark outcomes via a minimally invasive approach.
Main Methods:
- 179 consecutive patients with drug-resistant AF underwent a 5-box thoracoscopic Maze procedure.
- The procedure involved creating 5 discrete, contiguous left atrial compartments for isolation.
- Postoperative surveillance included continuous ambulatory monitoring at set intervals.
Main Results:
- High rates of freedom from AF were observed: 137/142 at 3 months, 115/119 at 6 months, 75/78 at 13 months, and 24/25 at 24 months.
- Only one serious procedural complication occurred (pulmonary artery injury).
- Two patients remained in sinus rhythm on low-dose antiarrhythmia therapy.
Conclusions:
- A totally thoracoscopic Maze procedure effectively replicates the Cox-Maze lesion set, isolating arrhythmogenic substrate.
- Meticulous verification of compartment integrity leads to outcomes equivalent to the Cox-Maze benchmark.
- This minimally invasive approach offers a viable alternative for AF treatment.
Background:
In accordance with the Cox-Maze paradigm, successful treatment of atrial fibrillation (AF) requires (1) complete posterior left atrial isolation, (2) elimination of corridors for perimitral reentry, (3) elimination of cardiac venous (superior vena cava and coronary sinus) arrhythmogenic foci, (4) complete autonomic denervation, and (5) occlusion or removal of the left atrial appendage. Using a totally thoracoscopic approach, isolation of all left atrial arrhythmogenic substrate is achieved through the creation of 5 discrete but contiguous compartments, thereby enabling unambiguous verification with bidirectional block. Since no previous closed-chest procedure incorporates all these end points, an update on patient outcomes is reported.
Methods:
One hundred seventy-nine consecutive patients with antiarrhythmic drug-resistant AF (3 paroxysmal, 5 persistent, 171 longstanding persistent cases), known preoperatively for 5.7 (range 0.5 to 25) years, underwent the 5-box thoracoscopic Maze procedure. Only 1 patient suffered a serious procedural complication (sternotomy for pulmonary artery injury). Postoperative rhythm surveillance consisted of 1 week of continuous ambulatory monitoring at 3, 6, 13, and 24 months. Failure was defined as any tachyarrhythmia exceeding 30 seconds beyond the 3-month anniversary.
Results:
Freedom from AF was observed in 137 of 142 patients at 3 months, 115 of 119 patients at 6 months, 75 of 78 patients at 13 months, and 24 of 25 patients at 24 months. Two patients remain in sinus rhythm on low-dose antiarrhythmia therapy. Warfarin is discontinued only after the first monitoring session confirms rhythm stability.
Conclusions:
Replication of the left atrial Cox-Maze lesion set through a totally thoracoscopic approach isolates virtually all arrhythmogenic substrate. Meticulous verification of compartment integrity allows for outcomes equivalent to the Cox-Maze benchmark.
