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Ann Thorac Surg 2004;77:1282-1287
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Atrial reduction plasty Cox maze procedure: extended indications for atrial fibrillation surgery

Matthew A. Romano, MDa, David S. Bach, MDb, Francis D. Pagani, MD, PhDa, Richard L. Prager, MDa, G. Michael Deeb, MDa, Steven F. Bolling, MDa*

a Section of Cardiac Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
b Section of Cardiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA

* Address reprint requests to Dr Bolling, Section of Cardiac Surgery, University of Michigan, 2120 Taubman Center, Box 0348, 1500 East Medical Center Dr, Ann Arbor, MI 48105-0348, USA.
e-mail: sbolling{at}umich.edu

Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Discussion
 References
 
BACKGROUND: The Cox maze procedure yields good results for atrial fibrillation (AF). However, patients with predictors of failure—chronic long-standing AF, low amplitude fibrillatory waves, and large left atriums—are generally thought not to benefit from a maze procedure. We report an aggressive approach for these patients, utilizing biatrial reduction plasty concomitantly with the Cox maze procedure for AF.

METHODS: A complete Cox maze procedure utilizing supplemental RF ablation was performed in 36 patients. All underwent resection of both atrial appendages and biatrial reduction plasty encompassing resection of the left atrial posterior wall from left to right pulmonary veins and from inferior pulmonary veins to the mitral annulus, as well as removal of the right atrial lateral wall. Mitral or tricuspid valve repair, or both, was performed on 32 patients.

RESULTS: These patients had a mean AF duration of 45 ± 89 months. Their preoperative left atria measured 66 ± 16 mm, with mean AF waves of 0.74 ± 0.3 mm. Mean preoperative New York Heart Association class was 2.7 ± 0.7 and left ventricular ejection fraction was 48 ± 9. Cross clamp and bypass times were 91 ± 35 minutes and 124 ± 33 minutes, respectively. The average posterior left atrial tissue resected was 5.4 x 2.1 cm, and mean resected atrial weight was 10.3 ± 2 g. There were no deaths and length of stay was 5.5 ± 2 days. At a follow-up time of 19 ± 16 months, 32 of the 36 patients were in normal sinus rhythm and New York Heart Association class I.

CONCLUSIONS: Aggressive biatrial reduction plasty Cox maze procedure was effective in 89% of these "low success" AF patients. This simple procedure can extend utilization of the Cox maze procedure to more patients with chronic AF.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Discussion
 References
 
Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is responsible for significant patient morbidity and mortality. Atrial fibrillation is present in approximately 2% of the general population and in more than 6% of those more than 65 years of age, and adversely effects survival [1–3]. It is well known that AF is an independent risk factor for stroke; it is associated with a fourfold to fivefold higher stroke risk than in the unaffected population [3–5]. Furthermore, AF is known to increase the relative mortality risk as much as 20% above the general population and results in an eightfold to 22-fold increase in Medicare spending in the first year after onset [6]. Pharmacologic therapy has been the mainstay of AF treatment. Instead of addressing the underlying pathology of AF, however, this approach attempts to minimize its sequelae. The maze procedure, introduced by Cox and others, has been the most successful nonpharmacologic procedure for AF [7–9]. The Cox maze procedure was initially conceived as an isolated surgical procedure for atrial fibrillation, but recently, wider indications have broadened its application and have resulted in the simultaneous performance of the maze procedure with other cardiac operations for organic heart disease. With various modifications to the initial procedure, there has been a steady increase in the success rate of conversion to a sinus rhythm. In fact, with new understanding of the impact of AF and reported conversion to sinus rhythm rates as high as 99%, interest in utilizing the maze procedure is increasing [7, 10, 11].

Certain patient characteristics, however, such as chronic AF for longer than 6 months, low amplitude fibrillatory waves of less than 1 mm, large left atrial size greater than 60 mm, and mitral valve disease are associated with failure to restore sinus rhythm after a maze procedure. These proposed predictors of failure would seemingly limit the wide application of the maze procedure to the overall AF population. It may also deter some from performing the maze procedure operation in this high-risk subgroup [12, 13].

In this study, we report on an aggressive approach to treating these complicated patients, who otherwise might be left in atrial fibrillation or even not operated on owing to their predisposing predictors of failure. We propose that, by utilizing an aggressive biatrial reduction plasty concomitantly with a full Cox maze procedure for AF, patients who were considered unlikely to benefit from this procedure may in fact have a successful outcome and be restored to a regular rhythm.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Discussion
 References
 
Patient population
Data were collected from all patients undergoing the maze operation for isolated AF or concomitantly with other organic cardiac disease. Thirty-six consecutive patients with predictors of maze operation "failure" as entrance criteria, long-standing AF for longer than 6 months, low amplitude fibrillatory waves less than 1 mm, large left atrial size greater than 60 mm, and mitral valve disease were prospectively observed for this study. Patients had at least two of these criteria; most had all three. All procedures were performed at one institution between August 1997 and December 2002. The majority of operations were performed after 1999. All patients underwent a full Cox maze III procedure using supplemental radiofrequency ablation, bilateral atrial appendage resections, and aggressive biatrial reduction plasty.

Preoperative analysis
The preoperative standard 12-lead electrocardiogram was reviewed on all patients. Utilizing the methods described by Peter [14], fibrillatory waves were measured in lead V1. Calipers were used to measure the fibrillatory wave with the greatest amplitude. This measurement was made from the upper edge of the trough to the upper edge of the peak and expressed in millimeters. Fibrillatory waves in V1 with an amplitude of 1.0 mm or greater were designated coarse waves, and those less than 1.0 mm were defined as fine fibrillatory waves. All measurements were performed by an independent observer. Echocardiographic studies were performed on all subjects preoperatively and postoperatively and at follow-up by an independent echochardiographer. Left atrial diameter and left ventricular volume and function were measured in the standard fashion.

Operative procedure
The operative procedure was based primarily on the description by Cox and subsequent modifications [8, 9, 15]. After median sternotomy, patients were placed on standard cardiopulmonary bypass with bicaval cannulation and cooled to 32°C. Standard blood cardioplegic arrest was initiated with antegrade flow in all de novo patients. Two redo patients underwent the procedure through a right thoracotomy.

A standard right-sided left atriotomy was made parallel to the interatrial groove and extended and wrapped around the pulmonary veins. The left atrial appendage was inverted, excluded by excision, and the stump was oversewn (Fig 1). The aggressive left atrial reduction plasty was performed in part by the excision of the left atrial posterior wall from the os of the inferior right pulmonary vein to the os of the left inferior pulmonary vein. To complete the excision of the posterior left atrial wall, an incision parallel to the inferior pulmonary veins was made from the right to the left side, closely following the mitral annulus. Care was taken to avoid the coronary sinus. These two incisions were brought together at the far side of the atrium near the os of the left inferior pulmonary vein to complete the reduction atrioplasty (Fig 2). By this method, the posterior left atrial wall was nearly completely removed. Next, endocardial radiofrequency ablation was used to complete the pulmonary vein isolation around the far side of the left pulmonary veins. A separate radiofrequency ablation lesion isolated the excised left atrial appendage orifice down to the left atriotomy incision (Fig 3). To begin the left atrial closure, the pulmonary vein island was sewn to the mitral annular cuff. The mean size of excised posterior left atrial wall was 5.4 x 2.1 cm, and the mean weight was 3.1 ± 1.8 g.



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  		Fig 1. Inversion and excision of the left atrial appendage. The remaining left atrial appendage orifice is oversewn with 3-0 Prolene.

 


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  		Fig 2. Left atrial reduction plasty. The left atrial posterior wall is excised by making an incision that courses along the os of the inferior pulmonary veins and a parallel incision from right to left that closely follows the mitral annulus.

 


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  		Fig 3. Endocardial ablation lesions are placed to complete the pulmonary vein isolation. A lesion is placed from the sewn orifice of the left atrial appendage to the left atriotomy incision.

 
After closure of the left atrium, the right atrial appendage was excised. Then, an incision was carried from the right atrial stump parallel to the right atrioventricular groove extending toward the inferior vena cava. A second parallel posterior longitudinal incision was then made from below the inferior vena cava orifice to above the superior vena cava orifice. It is important to ensure that this incision is placed significantly posterior to avoid errant injury to the sinoatrial node. The lateral right atrial free wall was then excised to complete the removal of right atrial tissue (Fig 4). All trabecular right atrial tissue was removed. Standard radiofrequency ablation lesions were then placed to isolate the tricuspid annulus and across the atrial septum. These incisions, when closed, resulted in a small "tubular" right atrium. All atrial incisions were closed with running 3-0 Prolene. The mean size of the right atrial tissue excised was 6.4 x 1.8 cm, and the mean weight was 2.4 ± 0.67 g. The mean total excised biatrial tissue, including the appendages, was 10.3 ± 2 g.



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  		Fig 4. Right atrial reduction plasty. The right atrial appendage is excised. An incision is then made from the right atrial stump parallel to the right atrioventricular groove toward the inferior vena cava. A second parallel posterior longitudinal incision is made from below the inferior vena cava orifice to above the superior vena cava orifice.

 
Postoperative protocol
All patients received prophylactic low dose (150 mg) amiodarone, loaded in the operating room with the patient on cardiopulmonary bypass. Supplemental antiarrhythmic medications were administered when necessary to treat AF in the perioperative period. A continuous infusion of the calcium-channel blocker diltiazem was added to the treatment of these patients. No patient needed electrical cardioversion. Amiodarone was usually discontinued at 1 month, but ultimately this decision was by the primary cardiologist. Anticoagulation therapy was started on all patients after discontinuation of chest tubes for a recommended duration of 3 months, unless other indications, such as mechanical valve replacement, for permanent anticoagulation therapy were present.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Discussion
 References
 
Thirty-six consecutive patients underwent this maze procedure with aggressive biatrial reduction plasty. The mean age of this patient population was 66 years. There were no perioperative deaths and only two reoperations for bleeding. Only 2 patients required postoperative ventilation for more than 24 hours. No patient left the operating room in AF or atrial flutter. Postoperative atrial fibrillation occurred in 6 patients (17%), and was successfully controlled with additional antiarrhythmics as above. The complete patient demographic data are displayed in Table 1. The mean duration of AF was 45 ± 89 months, with a range of 3 to 480 months. The left atrial diameter and atrial fibrillatory wave amplitude were 66 ± 16 mm and 0.74 ± 0.3, respectively. All of these demographic variables are beyond the published and accepted values for maze operation "success" and fall within the predicted range of failure. The maze procedure was combined with an additional cardiac repair in 33 cases. Concomitant procedures are shown in Table 2. The mean cross-clamp times and bypass times were 91 ± 35 minutes and 124 ± 33 minutes, respectively. The postoperative hospital stay was 5.5 ± 2.0 days. There were no transient ischemic attacks, strokes, or perioperative myocardial infarctions. There was no need for permanent pacemaker in any postoperative patient.


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  		Table 1. Patient Demographics

 

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  		Table 2. Concomitant Operative Procedures

 
Follow-up was obtained through a combination of surgical clinic appointment and phone interview with the primary cardiologist. Late-term follow-up was 93% complete. At a mean follow-up time of 19 ± 16 months (range, 1 to 58), 32 of the 36 patients (89%) who underwent this procedure were in sinus rhythm and New York Heart Association class I. Postoperative echocardiography showed a left atrial mean reduction of 26%. Forty-three percent of patients were off all anticoagulation and antiarrhythmic drugs. Two patients are receiving coumadin for a valve replacement. The other patients, while in a regular rhythm, remained on anticoagulation therapy, mostly because of practitioner bias rather than actual need for anticoagulation. To date, there has not been any report of an embolic event in these patients.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Discussion
 References
 
This report demonstrates that utilizing aggressive biatrial reduction plasty in addition to the Cox maze procedure, even for patients with the known "predictors for failure" for restoration of sinus rhythm such as low amplitude fibrillatory waves, markedly enlarged atria, and prolonged history of atrial fibrillation and mitral valve disease can in fact have a successful outcome. While each of the above criteria may independently predict failure of a maze procedure, our sinus rhythm restoration rate is quite acceptable given that the patients presented here may represent the "worst chance" of conversion.

Predictors of failure or success for the maze procedure are not entirely formalized. Nonetheless, it has been suggested, first, that the presence of fine atrial fibrillatory waves measured as less than 1.0 mm on a standard 12-lead electrocardiogram has been associated with poor conversion rate. In a series by Kamata and associates [12], sinus rhythm was restored overall in 68 of the 86 patients (79%) presenting for surgical correction of atrial fibrillation. However, this study also demonstrated an odds ratio of only 0.14 for restoration of sinus rhythm in the presence of these fine fibrillatory waves. Our cohort demonstrated significantly better results, with an 89% success rate despite the presence of fine fibrillatory waves.

Second, enlarged left atria, greater than 60 mm, are known to be a determining factor in the development and maintenance of AF [16, 17]. Atrial fibrillation is rare when left atrial diameters are less than 4 cm [18]. The ability of the left atrium to fibrillate is determined by the relation between the effective refractory period of the atrial myocardium and the atrial area available for the macroreentrant circuit [19]. This fact—that a critical area of atrial tissue is needed to support or sustain atrial fibrillation—would therefore suggest the importance of reducing the size of the atrium to eliminate AF. In a recent report by Chen [20], atrial size reduction had a predictive value in determining long term success of sinus conversion. Furthermore, by Laplace's law, decreasing the size of the atrium will ultimately decrease the wall stress of the chamber and may reduce a primary stimulus for fibrillation [20, 21]. Recently, it has been reported that atrial size remained unchanged after an isolated maze procedure [22]. Therefore, surgical reduction in atrial size may play a significant role in the restoration of normal geometric size and wall stress to these large atria.

Third, prolonged duration of atrial fibrillation—for longer than 6 months, particularly when associated with mitral valve disease—has also been associated with poor conversion rate to sinus rhythm after the maze procedure [23]. Conversely, our experience found a high success rate of conversion to sinus rhythm in this difficult setting, despite a long duration of AF. Our series is supported by others, who have also reported similar maze success in patients with long-standing preoperative atrial fibrillation [24]. One patient in our series had atrial fibrillation for 3 months; however, this patient also had two of the other predictors of failure.

The concern for potential failure for reversion to a regular rhythm and increased perioperative mortality and morbidity with operations for concomitant organic heart disease, especially mitral valve disease, has been documented [12, 25]. However, recent reports have demonstrated very good results when the maze procedure is combined with a valvular procedure [24, 26]. Data from this present series concur; the repair of mitral valvular disease did not result in a lower incidence of sinus conversion.

Because late follow-up echocardiography was not routinely performed, we were unable to definitively determine atrial transport function in all of our patients. Nevertheless, it has been demonstrated that atrial transport return will occur in greater than 90% of patients who revert to regular rhythm [27, 28]. Furthermore, anticoagulated patients with normal sinus rhythm and small atrial size have a much lower embolic risk than those in AF and anticoagulated [29–32].

In this aggressive biatrial reduction maze operation, right atrial tissue was routinely excised in addition to the right atrial appendage. Recently, several authors have reported success with a partial maze operation that does not involve the right atrium; resulting restoration of sinus rhythm has occurred in as many as 80% of patients [33, 34]. These patients did not have giant left atriums or other predictors of maze operation failure, however. Furthermore, although left-sided lesions alone may eliminate AF, there is an increased risk of atrial flutter, which may be of right atrial origin [35–37]. None of the patients in the present series experienced atrial flutter beyond the perioperative period. This finding may reflect the inclusion of a right-sided atrial reduction and a maze procedure, which could be important to long-term outcome. Finally, preservation of the right atrial appendage has been reported to maintain plasma levels of atrial natriuretic peptide and to improve the ability of the kidneys to excrete a fluid load after the operation [38]. That was not noted in our patients, as fluid retention was not a problem.

Garcia [39] has advocated the left atrium and mitral valve as a functional unit and has emphasized the importance of mitral valvular repair and atrial reduction in restoration and maintenance of sinus rhythm. We have previously stressed the importance of mitral valve repair to restore and maintain cardiac geometry as a means of treating heart failure [40]. Effective atrial size reduction, not only by eliminating mitral regurgitation, but also by aggressive atrial reduction plasty, in addition to interruption of macroreentrant circuits with a Cox maze procedure, appears to have an additive or even synergistic effect upon the ablation of atrial fibrillation. We believe that the concept of restoring the "normal" atrial geometry is additive to restoring sinus rhythm.

In conclusion, perhaps a more aggressive approach should be considered for patients in atrial fibrillation, even those who have predictors that would otherwise suggest failure to restore sinus rhythm after a Cox maze procedure. Given these findings, the application of the maze procedure could theoretically be expanded to a much larger patient population in the treatment of atrial fibrillation.


   Discussion
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Discussion
References
 
DR JAMES COX (Naples, FL): I first would like to congratulate Dr Romano and Dr Bolling and associates at Michigan on an excellent paper. I think this paper is important for three reasons.

The first is that it documents that the length of time that a patient has had atrial fibrillation before interventional therapy of either surgery or catheter is absolutely irrelevant to the success of the procedure if it is done correctly, and I would emphasize that I think this is true not only for the maze procedure but for other types of intervention.

The second thing is that the paper documents that the coarse atrial fibrillation and fine atrial fibrillation that people talk about are really visual concepts probably related to catecholamine levels and that they really don't mean anything regarding the effectiveness of interventional therapy. I think the literature is replete with this type of misconception, along with a few others. They are used to explaining away the failures of interventional therapy when the real cause of the failure is overlooked. Fortunately, this paper should dispel some of those problems and clarify the issues for the future.

Third, this study documents extremely well that atrial fibrillation associated with extremely large atria can be treated successfully with the maze procedure, but only if the atrium is reduced in size as a part of the procedure. The maze itself depends on placing the incisions close enough to preclude the development of macro re-entrant circuits in the atrium. A maze can be performed absolutely perfectly in a huge atrium, but if the resultant lesions are far enough away from one another that macro re-entrant circuits can form between them, then the operation will fail and the atrial fibrillation will persist. This study by the Michigan group shows how to avoid these failures.

My only tangential comment about what was presented here this morning is that I think it would be good if the authors clarified that the lesion that is placed between the pulmonary veins and the mitral valve is not quite as close to the pulmonary veins as it might appear on some of those slides. You have to obviously stay above the level of the coronary sinus. But I know they know that.

I have three questions for Dr Romano, and before I ask them I would like to comment that I think I have rarely seen a paper that was more professionally presented. You did a wonderful job. The first question is, it has been said many times that resection of both atrial appendages eliminates the atrial natriuretic factor and causes postoperative fluid retention, and my question is, did you measure any of the perioperative atrial natriuretic peptide in these patients?

My second question being a corollary, did you experience any problems with postoperative fluid retention?

And my third question is, your incidence of transient perioperative atrial fibrillation was ony 17% in your series as opposed to most other series which report twice that level of atrial fibrillation immediately postoperatively. It was certainly our experience. Do you think that the extensive resection and downsizing of the atrium in your series explains the lower incidence or do you have another explanation?

Again, I wish to congratulate you on an excellent and important paper, and I thank the Society of Thoracic Surgeons for allowing me to discuss this work.

DR ANTON MORITZ (Frankfurt, Germany): I want to support your findings that reducing the left atrial size will increase the rate of sinus rhythm recurrence. We did sole atrial size reduction in patients having mitral valve disease and chronic A-fib. The conversion rate, by only reducing the size of the left atrium, was about 66%. So everything added to size reduction of course will improve further the conversion rate.

My question is, I didn't see in your slides, how much did you do about the right atrium in addition to your excision?

Just one technical point. We try to avoid resection of left atrial tissue. We do a lot of the procedures through a small thoracotomy, and it is very difficult to access the left side if there is any bleeder. So we kind of only fold, exclude or telescope the wall of the atrium, and it is not necessary to resect all the tissue, in our experience.

DR CARLOS DEL CAMPO (Fullerton, CA): In these patients did you do echocardiograms at 3 and 6 months, and was the atrium contracting effectively in all those patients who remained in sinus rhythm?

DR ROMANO: I would like to thank Dr Cox for his review and his comments. In response to his questions, we did not measure postoperative atrial natriuretic peptide. However, we did not experience a problem with fluid retention, and we believe that this is related to our aggressive use of diuretics postoperatively. Our postoperative rate of atrial fibrillation is a little lower than that reported from 32–38%. However, the left atria described in this series are much larger than those often reported elsewhere. I do think that decreasing the atrial size plays a key factor in decreasing the incidence of immediate postoperative atrial fibrillation.

To answer the second question, we place standard right-sided Maze lesions in addition to the excision of the right atrial tissue. In response to the extent of our excision of the left atrium, we do all our cases through a median sternotomy, and this facilitates exposure to the giant left atria. Furthermore, doing so allows us to maximize the amount of tissue that we can resect. So again, it is very important to decrease the atrial size, and I think if you were to do it through a smaller incision, you would limit the ability to excise an adequate amount of tissue.

And finally, follow-up was based on contacting the primary physicians of these patients who were not immediately followed at our institution. We demonstrated atrial transport, or I should say sinus rhythm, based on electrocardiogram. Not all patients would come in to have a transesophageal echocardiogram to actually measure atrial transport or activity. Thank you.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Discussion
 References
 

  1. Kannel W., Abbott R., Savage D., McNamara P. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 1982;306:1018-1022.[Abstract]
  2. Benjamin E.J., Wolf P.A., D'Agostino R.B., et al. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 1998;98:946-952.[Abstract/Free Full Text]
  3. Chugh S.S., Blackshear J.L., Shen W.-K., et al. Epidemiology and natural history of atrial fibrillation: clinical implications. J Am Coll Cardiol 2001;37:371-378.[Abstract/Free Full Text]
  4. Cairns J.A., Connolly S.J. Nonrheumatic atrial fibrillation. Risk of stroke and role of antithrombotic therapy. Circulation 1991;84:469-481.[Free Full Text]
  5. Wolf P.A., Abbott R.D., Kannel W.B. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991;22:983-988.[Abstract/Free Full Text]
  6. Wolf P.A., Mitchell J.B., Baker C.S., et al. Impact of atrial fibrillation on mortality, stroke, and medical costs. Arch Intern Med 1998;158:229-234.[Abstract/Free Full Text]
  7. Cox J.L., Ad N., Palazzo T., et al. Current status of the maze procedure for the treatment of atrial fibrillation. Semin Thorac Cardiovasc Surg 2000;12:15-19.[Medline]
  8. Cox J.L., Boineau J.P., Schuessler R.B., et al. Modification of the maze procedure for atrial flutter and atrial fibrillation. I. Rationale and surgical results. J Thorac Cardiovasc Surg 1995;110:473-484.[Abstract/Free Full Text]
  9. Cox J.L., Jaquiss R.D., Schuessler R.B., Boineau J.P. Modification of the maze procedure for atrial flutter and atrial fibrillation. II. Surgical technique of the maze III procedure. J Thorac Cardiovasc Surg 1995;110:485-495.[Abstract/Free Full Text]
  10. McCarthy P.M., Gillinov A.M., Castle L., et al. The Cox-Maze procedure: the Cleveland Clinic experience. Semin Thorac Cardiovasc Surg 2000;12:25-29.[Medline]
  11. Schaff H.V., Dearani J.A., Daly R.C., et al. Cox-Maze procedure for atrial fibrillation. Mayo Clinic experience. Semin Thorac Cardiovasc Surg 2000;12:30-37.[Medline]
  12. Kamata J., Kawazoe K., Izumoto H., et al. Predictors of sinus rhythm restoration after Cox maze procedure concomitant with other cardiac operations. Ann Thorac Surg 1997;64:394-398.[Abstract/Free Full Text]
  13. Kosakai Y., Kawaguchi A.T., Isobe F., et al. Modified maze procedure for patients with atrial fibrillation undergoing simultaneous open heart surgery. Circulation 1995;92(Suppl 2):359-364.[Abstract/Free Full Text]
  14. Peter R.H., Morris J.J., Jr, McIntosh H.D. Relationship of fibrillatory waves and P waves in the electrocardiogram. Circulation 1966;33:599-606.[Abstract/Free Full Text]
  15. Cox J.L. Evolving applications of the maze procedure for atrial fibrillation. Ann Thorac Surg 1993;55:578-580.[Medline]
  16. Henry W., Morganroth J., Pearlman A., et al. Relation between echocardiographically determined left atrial size and atrial fibrillation. Circulation 1976;53:273-279.[Abstract/Free Full Text]
  17. Maria Oliver J., Gallego P., Gonzalez A., et al. Predisposing conditions for atrial fibrillation in atrial septal defect with and without operative closure. Am J Cardiol 2002;89:39-43.[Medline]
  18. Winlaw D.S., Farnsworth A.E., Macdonald P.S., et al. Left atrial reduction: the forgotten Batista. Lancet 1998;351:879-880.[Medline]
  19. Cox J.L., Boineau J.P., Schuessler R.B., et al. Five-year experience with the maze procedure for atrial fibrillation. Ann Thorac Surg 1993;56:814-824.[Abstract]
  20. Chen M.C., Chang J.P., Guo G.B., Chang H.W. Atrial size reduction as a predictor of the success of radiofrequency maze procedure for chronic atrial fibrillation in patients undergoing concomitant valvular surgery. J Cardiovasc Electrophysiol 2001;12:867-874.[Medline]
  21. Bolca O., Akdemir O., Eren M., et al. Left atrial maximum volume is a recurrence predictor in lone atrial fibrillation: an acoustic quantification study. Jpn Heart J 2002;43:241-248.[Medline]
  22. Jessurun E.R., van Hemel N.M., Kelder J.C., et al. The effect of maze operations on atrial volume. Ann Thorac Surg 2003;75:51-56.[Abstract/Free Full Text]
  23. Chua Y.L., Schaff H.V., Orszulak T.A., Morris J.J. Outcome of mitral valve repair in patients with preoperative atrial fibrillation. Should the maze procedure be combined with mitral valvuloplasty?. J Thorac Cardiovasc Surg 1994;107:408-415.[Abstract/Free Full Text]
  24. Williams M.R., Stewart J.R., Bolling S.F., et al. Surgical treatment of atrial fibrillation using radiofrequency energy. Ann Thorac Surg 2001;71:1939-1944.[Abstract/Free Full Text]
  25. Izumoto H., Kawazoe K., Kitahara H., Kamata J. Operative results after the Cox/maze procedure combined with a mitral valve operation. Ann Thorac Surg 1998;66:800-804.[Abstract/Free Full Text]
  26. Kawaguchi A.T., Kosakai Y., Isobe F., et al. Factors affecting rhythm after the maze procedure for atrial fibrillation. Circulation 1996;94(Suppl 2):139-142.
  27. Benussi S., Pappone C., Nascimbene S., et al. A simple way to treat chronic atrial fibrillation during mitral valve surgery: the epicardial radiofrequency approach. Eur J Cardiothorac Surg 2000;17:524-529.[Abstract/Free Full Text]
  28. Melo J., Adragao P., Neves J., et al. Endocardial and epicardial radiofrequency ablation in the treatment of atrial fibrillation with a new intra-operative device. Eur J Cardiothorac Surg 2000;18:182-186.[Abstract/Free Full Text]
  29. American Geriatrics Society. The use of oral anticoagulants (warfarin) in older people. American Geriatrics Society guideline. J Am Geriatr Soc 2002;50:1439-1447.[Medline]
  30. Albers G.W., Dalen J.E., Laupacis A., et al. Antithrombotic therapy in atrial fibrillation. Chest 2001;119(Suppl):194-206.
  31. Albirini A., Scalia G.M., Murray R.D., et al. Left and right atrial transport function after the maze procedure for atrial fibrillation: an echocardiographic Doppler follow-up study. J Am Soc Echocardiogr 1997;10:937-945.[Medline]
  32. Yuda S., Nakatani S., Isobe F., et al. Comparative efficacy of the maze procedure for restoration of atrial contraction in patients with and without giant left atrium associated with mitral valve disease. J Am Coll Cardiol 1998;31:1097-1102.[Abstract/Free Full Text]
  33. Tuinenburg A.E., Van Gelder I.C., Tieleman R.G., et al. Mini-maze suffices as adjunct to mitral valve surgery in patients with preoperative atrial fibrillation. J Cardiovasc Electrophysiol 2000;11:960-967.[Medline]
  34. Szalay Z.A., Skwara W., Pitschner H.F., et al. Midterm results after the mini-maze procedure. Eur J Cardiothorac Surg 1999;16:306-311.[Abstract/Free Full Text]
  35. Mohr F.W., Fabricius A.M., Falk V., et al. Curative treatment of atrial fibrillation with intraoperative radiofrequency ablation: short-term and midterm results. J Thorac Cardiovasc Surg 2002;123:919-927.[Abstract/Free Full Text]
  36. Usui A., Inden Y., Mizutani S., et al. Repetitive atrial flutter as a complication of the left-sided simple maze procedure. Ann Thorac Surg 2002;73:1457-1459.[Abstract/Free Full Text]
  37. Deneke T., Khargi K., Grewe P.H., et al. Left atrial versus bi-atrial maze operation using intraoperatively cooled-tip radiofrequency ablation in patients undergoing open-heart surgery: safety and efficacy. J Am Coll Cardiol 2002;39:1644-1650.[Abstract/Free Full Text]
  38. Yoshihara F., Nishikimi T., Sasako Y., et al. Preservation of the right atrial appendage improves reduced plasma atrial natriuretic peptide levels after the maze procedure. J Thorac Cardiovasc Surg 2000;119:790-794.[Abstract/Free Full Text]
  39. Garcia-Villarreal O.A., Rodriguez H., Trevino A., et al. Left atrial reduction and mitral valve surgery: the "functional-anatomic unit" concept. Ann Thorac Surg 2001;71:1044-1045.[Abstract/Free Full Text]
  40. Bolling S.F., Smolens I.A., Pagani F.D. Surgical alternatives for heart failure. J Heart Lung Transplant 2001;20:729-733.[Medline]



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