Related Experiment Video
Updated: Mar 6, 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 single center's experience with pacemaker implantation after the Cox maze procedure for atrial fibrillation
Niv Ad1, Sari D Holmes2, Rabia Ali3
1Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa.
Insights
Pacemaker implantation (PMI) after the Cox maze procedure (CM) for atrial fibrillation is less common than previously reported. When needed, PMI did not worsen patient outcomes or freedom from arrhythmia.
Area of Science:
- Cardiology
- Cardiac Surgery
- Electrophysiology
Background:
- The Cox maze procedure (CM) is a recognized treatment for atrial fibrillation (AF).
- Recent studies indicated a high rate of pacemaker implantation (PMI) after CM.
- The actual incidence and impact of PMI post-CM require further investigation.
Purpose of the Study:
- To determine the incidence of in-hospital pacemaker implantation (PMI) following the Cox maze procedure (CM).
- To identify risk factors associated with PMI after CM.
- To evaluate the impact of PMI on short- and long-term outcomes after CM.
Main Methods:
- A prospective analysis of 739 patients undergoing CM between 2005 and 2015.
- Multivariable logistic regression to identify risk factors for PMI.
- Propensity score matching to compare outcomes between CM patients and those without surgical ablation.
Main Results:
- The in-hospital PMI rate was 7.0% (52 patients).
- Sick sinus syndrome was the most common indication for PMI (67%).
- Patients undergoing multiple valve procedures had a higher risk of PMI. Perioperative outcomes and freedom from arrhythmia were similar between patients with and without PMI.
Conclusions:
- The incidence of PMI after CM is lower than previously suggested.
- Indicated PMI following CM is not associated with increased morbidity or reduced freedom from atrial arrhythmia.
- Enhanced surgeon training and postoperative management awareness may further minimize adverse events and reduce PMI rates.
Objective:
The Cox maze procedure (CM) is safe and effective for all atrial fibrillation (AF) types. A recent randomized trial found alarming rates of pacemaker implantation (PMI) during hospitalization after CM. The purpose of this study was to assess the rate of PMI and its impact on outcomes after CM.
Methods:
Incidence of PMI was captured for all CM patients (2005-2015; N = 739). Data were collected prospectively. Multivariable logistic regression was conducted to determine risk factors for PMI. Propensity score matching was conducted between concomitant CM patients and patients without surgical ablation since 2011.
Results:
Fifty-two patients (7.0%) had in-hospital PMI after CM. Most common primary indication for PMI was sick sinus syndrome (67%), followed by complete heart block (23%) and sinus bradycardia (10%). The only risk factor for in-hospital PMI was type of procedure (P = .020). Patients with multiple valve procedures were at greatest risk (P = .004-.035). STS-defined perioperative outcomes were similar for patients with and without in-hospital PMI. Sinus rhythm off antiarrhythmic drugs were similar by PMI. After propensity score matching (n = 180 per group), in-hospital PMI was similar in CM patients and those without surgical ablation (5% vs 4%, P = .609).
Conclusions:
This study demonstrated lower incidence of PMI after CM procedures than recently reported. When indicated, PMI was not associated with increased short- or long-term morbidity or inferior freedom from atrial arrhythmia. Efforts to increase surgeon training with the CM procedure and postoperative management awareness are warranted to improve rhythm outcome and minimize adverse events and PMI.
Related Concept Videos
01:25Dysrhythmias VI: Management of Dysrhythmias
01:26Mitral Stenosis III: Medical Management
01:25ECG Interpretation of Arrhythmias II: Atrial, Junctional and Ventricular Arrhythmias