Atrial arrhythmia recurrence after the Maze procedure: Insights from catheter-based mapping
Dylan Goings1, Ikram U Haq2, Michael Brandt1
1Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota.
Heart Rhythm
|November 16, 2025
Summary
Recurrent atrial arrhythmias after Maze procedures are often caused by pulmonary vein reconnection and incomplete lesions. The durable cut-and-sew Maze technique shows better outcomes than thermal ablation methods for treating atrial fibrillation and flutter.
Area of Science:
- Cardiology
- Cardiac Surgery
- Electrophysiology
Background:
- The Cox-Maze procedure is a surgical treatment for atrial fibrillation (AF) utilizing lesion sets to isolate pulmonary veins (PVs) and disrupt atrial reentrant circuits.
- Understanding the mechanisms of arrhythmia recurrence post-Maze is crucial for improving patient outcomes.
Purpose of the Study:
- To characterize the mechanisms underlying recurrent atrial arrhythmias following Maze procedures.
- To evaluate the effectiveness of electroanatomic mapping in assessing Maze procedure outcomes.
Main Methods:
- Retrospective analysis of 86 patients undergoing Maze procedures (2008-2023) requiring subsequent catheter ablation for recurrent AF or atrial flutter (AFl).
- Electroanatomic mapping was employed to assess lesion integrity, identify arrhythmia patterns, and evaluate ablation success.
- Comparison of recurrence rates based on different Maze techniques (cut-and-sew, cryothermal, radiofrequency) and associated surgical factors.
Main Results:
- Post-Maze, 31.8% experienced both AF and AFl recurrence, while 33.7% had AF only, and 33.7% had AFl only.
- Pulmonary vein (PV) reconnection was observed in 78.3% of patients after PV isolation, with significantly lower rates for cut-and-sew Maze (5%) compared to cryothermal (67%) and radiofrequency (56%) techniques.
- Macroreentrant flutter was inducible in 77.9% of patients, often linked to incomplete linear lesions. Surgical factors like left atrial appendage-to-mitral annulus lesions and mitral valve repair correlated with increased flutter recurrence.
Conclusions:
- Recurrent atrial arrhythmias post-Maze are primarily attributed to PV reconnection and incomplete linear lesions.
- The cut-and-sew Maze technique demonstrates superior durability compared to thermal ablation methods.
- Emphasizing meticulous lesion creation and intraoperative verification is vital for reducing recurrence and enhancing Maze procedure efficacy.
Keywords:
Atrial fibrillationAtrial flutterCox-Maze procedureCryoablationCut-and-sew MazeElectrophysiology mappingMacroreentrant tachycardiaPulmonary vein isolationRadiofrequency ablationSurgical ablationMore Related Videos
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