Related Experiment Video
Updated: Mar 1, 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 Minimally Invasive Stand-alone Cox-Maze Procedure Is as Effective as Median Sternotomy Approach
Matthew R Schill1, Laurie A Sinn, Jason W Greenberg
1From the *Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO USA; and †Saint Louis University School of Medicine, St. Louis, MO USA.
Insights
The Cox-Maze IV procedure for atrial fibrillation is equally effective via minithoracotomy and sternotomy. Minithoracotomy offers a shorter hospital stay, making it a preferred minimally invasive option.
Area of Science:
- Cardiovascular Surgery
- Electrophysiology
- Minimally Invasive Procedures
Background:
- The Cox-Maze IV procedure is an established treatment for atrial fibrillation.
- Both median sternotomy and right minithoracotomy approaches have demonstrated efficacy.
- Comparative outcomes for stand-alone Cox-Maze IV using these approaches are less understood, particularly in lone atrial fibrillation.
Purpose of the Study:
- To compare the outcomes of stand-alone Cox-Maze IV procedures performed via sternotomy versus minithoracotomy.
- To identify differences in patient characteristics, procedural details, and clinical outcomes between the two surgical approaches.
- To evaluate the effectiveness and safety of a minimally invasive approach for lone atrial fibrillation treatment.
Main Methods:
- A retrospective review of 195 patients undergoing stand-alone biatrial Cox-Maze IV between 2002 and 2015.
- Patients were divided into two groups: minithoracotomy (n=75) and sternotomy (n=120).
- Freedom from atrial tachyarrhythmias was assessed up to 60 months post-procedure; predictors of recurrence were analyzed using logistic regression.
Main Results:
- Minithoracotomy patients had shorter hospital stays (7 vs. 8 days) and a similar rate of major complications (4% vs. 6%) compared to sternotomy patients.
- Both groups showed comparable freedom from atrial tachyarrhythmias and mortality rates.
- Minithoracotomy was associated with a smaller left atrial diameter and a higher utilization of the box lesion technique.
Conclusions:
- Stand-alone Cox-Maze IV via minithoracotomy is as effective as the sternotomy approach for treating atrial fibrillation.
- The minithoracotomy approach results in a shorter hospital stay.
- A minimally invasive strategy is favored for stand-alone Cox-Maze IV procedures.
Objective:
The Cox-Maze IV procedure has been shown to be an effective treatment for atrial fibrillation when performed concomitantly with other operations either via median sternotomy or right minithoracotomy. Few studies have compared these approaches in patients with lone atrial fibrillation. This study examined outcomes with sternotomy versus minithoracotomy in stand-alone Cox-Maze IV procedures at our institution.
Methods:
Between 2002 and 2015, 195 patients underwent stand-alone biatrial Cox-Maze IV. Minithoracotomy was used in 75 patients, sternotomy in 120. Freedom from atrial tachyarrhythmias was ascertained using electrocardiography, Holter, or pacemaker interrogation at 3 to 60 months. Predictors of recurrence were determined using logistic regression.
Results:
Of 23 preoperative variables, the only differences between groups were that minithoracotomy patients had a higher rate of New York Heart Association 3/4 symptoms and a lower rate of previous stroke. Minithoracotomy and sternotomy patients had similar atrial fibrillation duration and type. Minithoracotomy patients had a smaller left atrial diameter (4.5 vs 4.8 cm, P = 0.03). More minithoracotomy patients received a box lesion (73/75 vs 100/120, P = 0.002). Minithoracotomy patients had a shorter hospital stay (7 vs 8 days, P = 0.009) and a similar rate of major complications (3/75 (4%) vs 7/120 (6%), P = 0.74). There were no differences in mortality or freedom from atrial tachyarrhythmias. Predictors of atrial fibrillation recurrence included a preoperative pacemaker, omission of the left atrial roof line, and New York Heart Association 3/4 symptoms.
Conclusions:
Stand-alone Cox-Maze IV via minithoracotomy was as effective as via sternotomy with a shorter hospital stay. A minimally invasive approach is our procedure of choice.
