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Ann Thorac Surg 2001;72:1793-1794
© 2001 The Society of Thoracic Surgeons

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Correspondence

Modifications of the Cox-maze procedure: letter 2

^a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, F24, 9500 Euclid Ave, Cleveland, OH 44195, USA

e-mail: gillinom{at}ccf.org

To the Editor

In the March issue of The Annals, Kim and colleagues [1] described two interesting modifications of the Cox-maze III procedure. The first modification includes a series of minor changes that reduce the aortic cross-clamp time, and the second is designed to increase left atrial contractility. Both procedures result in excellent freedom from atrial fibrillation, with an incidence similar to that reported with the classic Cox-maze III procedure [2, 3].

We urge caution in adopting the second set of modifications described by Kim and associates. In this procedure, separate encircling incisions are made around the right and left pulmonary veins. In patients with a large left atrium, this has the potential theoretical advantage of resulting in improved left atrial contractility; in fact, the authors provide evidence to support this hypothesis. However, Kim and coauthors note, there are two disadvantages to this modified procedure. The first is an increased time of ischemia; when this procedure was combined with a mitral valve procedure, the cross-clamp time was nearly 3 hours. With careful attention to myocardial protection, this is probably not a major problem in most patients. Of greater concern, however, is the potential for bleeding in inaccessible areas. If the medial portion of either pulmonary vein–encircling incision were to bleed, this would create an extremely difficult problem. Although the authors did not encounter bleeding, it is likely that widespread application of this technique would occasionally result in troublesome bleeding from this area.

The authors’ hope is that the improved left atrial contractility associated with their modification will reduce the risk of thromboembolism after the Cox-maze procedure. In fact, application of the classic Cox-maze III procedure results in an exceedingly low risk of late thromboembolic events [2, 3]. Therefore, we do not believe that a potential reduction in the risk of an extremely unusual late event justifies a modification that could increase the risk of the procedure.

References

1. Kim K.-B., Huh J.-H., Kang C.H., Ahn H., Sohn D.-W. Modifications of the Cox-Maze III procedure. Ann Thorac Surg 2001;71:816-822.[Abstract/Free Full Text]
2. Cox J.L., Ad N., Palazzo T. Impact of the maze procedure on the stroke rate in patients with atrial fibrillation. J Thorac Cardiovasc Surg 1999;118:833-840.[Abstract/Free Full Text]
3. McCarthy P.M., Gillinov A.M., Castle L., Chung M., Cosgrove D., III The Cox-Maze procedure: the Cleveland Clinic experience. SemThorac Cardiovasc Surg 2000;12:25-29.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Patrick M. McCarthy Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Gillinov, A. M. Articles by McCarthy, P. M. Search for Related Content PubMed Articles by Gillinov, A. M. Articles by McCarthy, P. M. Related Collections Related Article