Cox maze procedure for chronic atrial fibrillation associated with mitral valve disease

Between April 1992 and October 1993, we combined a modified maze procedure with mitral valve repair (n = 26) or replacement (n = 36) in 62 patients with atrial fibrillation, including 16 patients undergoing reoperation. Associated procedures included aortic valve operation (n = 22), tricuspid annuloplasty (n = 28), atrial plication (n = 10), and others (n = 3). Duration of atrial fibrillation varied from 0.1 to 23 years (average 8.3 +/- 6.4 years), the f-wave voltage ranged from 0 to 0.45 mV (0.16 +/- 0.09 mV), and cardiothoracic ratio varied from 46% to 85% (64% +/- 9%). We modified the maze atriotomies to preserve the sinus node artery and used cryoablation to simplify procedures. Aortic crossclamp time was 142 +/- 25 minutes and cardiopulmonary bypass time 226 +/- 34 minutes. No early or late deaths occurred in a total of 783 patient-months of follow-up. In 52 patients (84%) who regained atrial rhythm, an atrial A-wave was detected in 84% for transtricuspid flow and in 71% for transmitral flow. One patient with sinus rhythm had an episode of transient neurologic ischemia 4 months after mechanical valve implantation. The 10 patients who remained in atrial fibrillation had preoperative fibrillation for a significantly longer time than the rest of the patients with atrial rhythm (14.8 versus 7.2 years p < 0.001) and a larger left atrial dimension (70 versus 58 mm, p < 0.01). Nonetheless, no variable alone could have predicted postoperative rhythm for individual patients. The results suggest that the maze procedure is safe and effective and therefore should be considered for patients with chronic atrial fibrillation undergoing mitral valve operations.