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Original Articles: Adult Cardiac

Improved Patient Survival With Concomitant Cox Maze III Procedure Compared With Heart Surgery Alone

^a Cardiovascular Department, Université Catholique de Louvain, Cliniques Universitaires de Mont-Godinne,Yvoir, Belgium
^b Biostatistical Unit, Université Catholique de Louvain, Cliniques Universitaires de Mont-Godinne, Yvoir, Belgium

Accepted for publication October 1, 2008.

^_* Address correspondence to Dr Louagie, Department of Cardiology, Cliniques Universitaires de Mont Godinne, 1 Ave Therasse, Mont Yvoir, 5530, Belgium (Email: louagie{at}chir.ucl.ac.be).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background: The benefit of the Cox Maze procedure combined with heart surgery was evaluated at long-term follow-up.

Methods: The outcome for 37 patients who underwent a Cox Maze III procedure combined with heart surgery (Maze group) was compared with that of 66 patients who had heart surgery alone (control group). All patients were in persistent atrial fibrillation preoperatively. The two groups had similar preoperative characteristics and were operated upon during the same era (1996 to 2004).

Results: Five-year survival, including hospital deaths, was 89% ± 5% in the Maze group and 60% ± 7% in the control group (log rank p = 0.008). Causes of death were predominantly related to heart failure (1 of 37 in the Maze group and 12 of 66 in the control group; p = 0.02) and to sudden death (0 of 37 in the Maze group and 9 of 66 in the control group; p = 0.02). After correction for preoperative variables, Cox regression analysis showed that the Maze procedure improved survival independently (p = 0.019). In a subgroup of patients with left atrial diameter of more than 60 mm preoperatively, the 5-year survival estimate was 92% ± 6% in the Maze group versus 59% ± 9% in the control group (log rank p = 0.012). The 5-year estimate of conversion to sinus rhythm was 91% ± 7% in the Maze group and 33% ± 7% in the control group (log rank p < 0.001).

Conclusions: The restoration of sinus rhythm by a Maze procedure combined with heart surgery markedly improved long-term survival in this series.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The aim of arrhythmia surgery associated with cardiac surgery in patients with chronic atrial fibrillation (AF) is to improve postoperative morbidity and mortality. Several studies indicate that, in comparison with AF, postoperative sinus rhythm is associated with improved long-term survival after mitral valve repair [1], coronary artery bypass grafting [2], or aortic valve replacement [3]. Prospective randomized [4–8] and comparative [9–15] studies analyzing outcomes of the Maze procedure in association with mitral valve surgery showed a very significant influence on the conversion to sinus rhythm, reduction of thromboembolism [9–11, 14, 15], and anticoagulant-related hemorrhage [9]. However, a clear benefit on survival could not be demonstrated. A meta-analysis of the available literature [16] reached the same conclusions.

This retrospective study was undertaken to evaluate the efficacy at long-term follow-up of the Cox Maze procedure associated with concomitant surgical treatment in consecutive patients, and to compare the results with a group of patients who underwent surgical treatment only during the same period.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The database was reviewed to find all patients undergoing valvular heart surgery or coronary artery bypass graft surgery and with a persistent supraventricular arrhythmia preoperatively, recently defined as continuous AF sustained beyond 7 days before the operation and not self-terminating [17]. Among the patients who underwent concomitant arrhythmia surgery, only patients undergoing the full Cox Maze III pattern were selected. Thus, patients having a procedure limited to the left or right atrium were excluded. Our institutional Ethics Committee approved this study and waived the need for patient consent.

One hundred and three patients fulfilled the criteria and were included in the study. They had either persistent AF (n = 99) or flutter (n = 4) associated with valvular or coronary pathology. The duration of AF was defined as the number of months between the earliest date when AF was reliably documented in the medical records and the operation date. The average duration of arrhythmia was 87.4 ± 81.1 months (minimum 3; maximum 360). The Cox Maze III procedure was performed in 37 patients in addition to primary cardiac surgery (Maze group) and 66 patients underwent cardiac surgery alone (control group). Baseline characteristics are depicted in Table 1. The patients did not differ among the groups regarding demographic characteristics. Overall, the average left atrial diameter, as measured on an M-mode tracing taken from a two-dimensional parasternal long-axis view, was 70.1 ± 11.6 mm (range, 47 to 120 mm), and 81.6% of the patients had a preoperative left atrial diameter greater than 60 mm. The left atrial volume was assessed by planimetry and averaged 112 ± 61 mL. A significant number of patients in both groups had a history of stroke. The operative risk was predicted according to the full logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) [18]: the Maze group patients tended to have a higher logistic EuroSCORE. A higher proportion of control group patients were receiving anticoagulant therapy.

Regarding the arrhythmia surgery technique, the first 16 patients underwent the Cox Maze III procedure as described by Cox and associates [19]. Some incisions were replaced by linear lines of ablation, as described by Sie and coworkers [20], using monopolar radiofrequency (RF) ablation in 7 cases and bipolar RF in 14 cases (Cardioblate; Medtronic, Minneapolis, MN). The basic lesion set remained unchanged, however. All the lesions were realized on the arrested heart. Reproducing the Cox Maze III pattern of ablation was straightforward with unipolar radiofrequency probe. However, the use of bipolar probes required adaptations. Pulmonary vein isolation and left appendage electrical ablation were achieved from the epicardial surface of the heart by clamping the opposing atrial walls between the jaws of the radiofrequency probe. Left atrial connection lesions required placement of one jaw on the endocardium and one jaw on the epicardium, after realization of a left atriotomy. Likewise, the ablation of the mitral isthmus was created by transmural application of the probe from the inferior end of the atriotomy to the mitral annulus. That lesion was completed by two cryothermic spots placed on the mitral annulus and on the coronary sinus. Finally, the right isthmus ablation was achieved by a monopolar probe that was applied endocardially from the ostium of the inferior vena cava to the ostium of the coronary sinus and from the ostium of the coronary sinus to the tricuspid annulus. No atrial size reduction was performed in our patients.

The patients who needed anticoagulation therapy were treated with acenocoumarol.

Statistical Analysis
Values are presented as mean ± standard deviation (SD). Numerical and categorical variables were compared between both groups by unpaired Student t test and ² test, respectively. Cox regression analysis using a forward stepwise (Wald) method was used to test the variables independently influencing survival. The variables included in the analysis were age, sex, body mass index, logistic EuroSCORE, ejection fraction, presence of pacemaker, aortic cross-clamp duration, Maze procedure, and surgeon. Postoperative death at any time was the target variable. Univariate and multivariate analysis of outcome of atrial volume indexes was performed by regression analysis using a generalized estimating equation, as described by Liang and Zeger [21]. The hazard function was used to estimate the relative risk of failure. The hazard function is a rate representing an estimate of the potential for death per unit time at a particular instant, given that the case has survived until that instant. A high hazard function indicates a high rate of mortality. The hazard function is not a probability and can take any value from 0 to infinity.

Statistical analyses were performed using SPSS for Windows (SPSS, Chicago, Il) and STATA 10 (Stata Corp, College Station, TX) software. The repeated-measures generalized estimating equation program [22] was used for the generalized estimating equation analysis.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Hospital mortality did not differ between the groups: 2 patients died in the Maze group and 6 in the control group (p = 0.50). In-hospital major complications, including all degrees of neurologic events, were not significantly different between the two groups.

The follow-up was 100% complete. The mean duration of follow-up of patients leaving hospital was 45.7 ± 28.4 months in the Maze group and 55.3 ± 29.5 months in the control group (p = 0.127). The Kaplan–Meier survival estimate was significantly higher in the Maze group (p = 0.008), with a 5-year survival of 89% ± 5% in the Maze group and 60% ± 7% in the control group (Fig 1). A higher proportion of heart failures and sudden deaths in the control group (Table 3) characterized the causes of death, including in-hospital mortality. Left appendage exclusion was associated with a better survival in control group patients, as the 5-year survival was 58.6% ± 6.9% in the control group without exclusion versus 90.0% ± 9.5% in the control group with exclusion (log rank p = 0.066).

View larger version (10K): [in this window] [in a new window]   Fig 1. Kaplan-Meier estimate of postoperative survival including hospital mortality in the Maze group (solid line) and control group (broken line). The log rank comparison shows markedly superior survival in the Maze group (p = 0.008).

View larger version (25K): [in this window] [in a new window]   Fig 2. Three-dimensional representation of the combined influence of age (x-axis) and logistic EuroSCORE (y-axis) on hazard function (z-axis) in the control and Maze groups.

View larger version (9K): [in this window] [in a new window]   Fig 3. Survival estimate of patients in the Maze group (solid line) and control group (broken line) having enlarged left atria (larger than 60 mm). The log rank comparison shows better survival in the Maze group (p = 0.012). The estimate includes in-hospital mortality.

View larger version (9K): [in this window] [in a new window]   Fig 4. Cumulative frequencies of sinus rhythm after surgery in the Maze group (solid line) and control group (broken line [log rank p < 0.001]).

View larger version (35K): [in this window] [in a new window]   Fig 5. Rhythm status of patients in the Maze group (shaded bars) and control group (open bars) during follow-up. The proportions are significantly different at the various control intervals (Pearson 2 p < 0.001).

There was no difference between the groups regarding postoperative anticoagulant administration: 67.6% in the Maze group and 68.2% in the control group (p = 0.418). Likewise, antiarrhythmic drug intake (bisoprolol, digoxin, sotalol, flecainide, or amiodarone) did not differ among the groups at the final assessment. The need for postoperative antiarrhythmic drugs is biased, however, as the policy among our cardiologists is to reduce antiarrhythmic drug intake of patients who are expected to stay in chronic AF postoperatively and to keep only the anticoagulation drug. Nevertheless, at final examination, freedom from AF and flutter and antiarrhythmic drugs was 39.4% in the Maze group and 7.6% in the control group (P < 0.001). Freedom from external electrical shock to treat supraventricular arrhythmia was 70% ± 11% in the Maze group and 79% ± 5% in the control group at 60 months (log rank p = 0.987). The mean New York Heart Association functional class was 1.60 ± 0.91 in the Maze group and 1.94 ± 0.92 in the control group (p = 0.104) at final examination. Sixty-month freedom from neurologic events was 94% ± 4% in the Maze group and 94% ± 3% in the control group (log rank p = 0.598).

The left atrial volume indexes were followed postoperatively, as described in Figure 6. The influence of preoperative volume index, treatment modality (Maze or control), and time interval were assessed by generalized estimating equation repeated measures analysis. Only the preoperative volume indices influenced left atrial volume outcome (p < 0.001).

View larger version (17K): [in this window] [in a new window]   Fig 6. Box plots representing the outcome of left atrial volume (LAV) index for the Maze group (shaded boxes) and the control group (open boxes). Only the preoperative LAV indexes influenced outcome (p < 0.001). (Preop. = preoperative).

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

One could consider that the survival rates of our Maze group were overestimated. Therefore, the survival rates of the present series were compared with the results of three large comparative studies [1, 11, 14], the observational study of Sie and colleagues [23], and the international registry of Melo and associates [24]. Among the large comparative studies, the study of Bando and associates [14] includes patients in chronic AF undergoing mitral valve surgery. In the group of mitral valve replacement plus Maze (n = 147, aged 58.8 years), the 5-year survival is 95%. In the group of mitral valve repair plus Maze (n = 111, aged 59.4 years), the 5-year survival is 97%. In the group of mitral valve replacement alone (n = 61, aged 62.9 years), the 5-year survival is 94%. In our series, the 5-year overall survival rate is 89% in the Maze group and 60% in the control group. Obadia and coworkers [1] studied patients undergoing mitral valve repair. The preoperative rhythm status was the following: sinus, 49.5%; permanent AF, 35.4%; and intermittent AF, 15.1%. The 5-year survival was similar in the sinus rhythm group and AF group, and reached 86%. These results are thus globally superior to our results regarding the control group. Raanani and associates [11] matched 47 patients undergoing the Maze plus mitral valve surgey with 47 patients undergoing mitral valve surgery alone. All patients were in chronic AF preoperatively. The 3-year survival was 96% for the Maze group and 85% for the control group. These results are thus superior to those of the present series.

In the study of Sie and colleagues [23] including 200 patients (mean age, 68 years) with mainly structural heart disease undergoing radiofrequency ablation of both atria, the 5-year survival was in the range of 80%. This time, the results of our Maze group are slightly better, but the difference can be explained by a higher age in the study by Sie and coworkers [23]. Finally, in the international registry of Melo and colleagues [24], including all sorts of atrial approaches, type of ablations, and concomitant surgeries, the 5-year survival was in the range of 95% for stable sinus rhythm and 78% for the stable atrial fibrillation on their figures. In that study, mean age was 63 years and mean size of of the left atrium was 57 mm. These results are superior to ours.

Therefore, the majority of these reports show superior survival rates for the Maze groups, demonstrating that the results of the present series are not overestimated.

The present series has several unique characteristics: (1) there were a variety of primary cardiac procedures mixing mitral valve surgery, aortic valve surgery, and coronary artery bypass grafting; (2) only patients having persistent preoperative AF were considered; (3) the influence of postoperative (not preoperative) AF on survival was assessed; and (4) the series combined a longer follow-up and a large number of patients.

Despite their higher EuroSCOREs, the Maze group patients had no increased operative morbidity or mortality. Interestingly, survival was markedly better in the Maze group, and the improvement was related to a reduced incidence of heart failure and sudden death.

Given the nonrandomized nature of the study, Cox regression analysis was used, which confirmed the independent influence of the concomitant Maze procedure on survival. That the Maze patients had a higher preoperative risk confirms these results. Indeed, the EuroSCORE can be used to predict not only in-hospital mortality, for which it was originally designed, but also long-term mortality in the whole context of heart valve surgery [25].

As the Maze group patients were more likely to have a pacemaker implanted postoperatively, possible pacemaker protection against sudden death could be suspected. However, by multivariate analysis, our data demonstrated better survival in the Maze group independent of the presence of a pacemaker as a covariate.

This series includes elderly patients with long-standing permanent AF and predominantly enlarged left atria (81.6% greater than 60 mm), variables beyond the published and accepted values for Maze operation "success" and falling within the predicted range of failure. Nevertheless, the Maze procedure was effective, as 78% of the patients reviewed at 6 months postoperatively were in sinus rhythm versus 13% in the control group (Fig 5); the cumulative frequency of sinus rhythm restoration at 60 months was 91% ± 7% in the Maze group and 33% ± 7% in the control group (Fig 4). These data compare with studies including a majority of patients with preoperative chronic AF preexisting at least 1 year [4, 9, 10, 13, 23].

The success rate of the Maze procedure can be significantly lower in a subgroup of patients with enlarged atria [26–30]. The cutoff value of preoperative left atrial diameter for predicting success ranges from 60 mm [31] to 65 mm [28, 29]. Conversely, atria larger than 50 mm [32] are not predictors of Maze failure. Nevertheless, we demonstrated in our series that even in the subgroup of patients with a preoperative left atrial diameter more than 60 mm, the Maze procedure improved survival significantly (Fig 3). Regarding the postoperative outcome of atrial dimensions, the left atrial volume index did not differ among the groups, as shown in Figure 6. This finding corroborates the study by Jessurun and colleagues [33] who demonstrated that the unmodified Cox Maze III operation does not affect atrial volume. The success rate of the Maze procedure could be improved, however, particularly in the subgroup of patients with enlarged atria, by using techniques of atrial reduction plasty [26, 34, 35]. These techniques aim to limit the critical mass liable to create a recurrence of AF. Moreover, these techniques help restore contraction and compliance of the left atrium and facilitate left atrial reverse modeling [35].

The absence of randomization is a major limitation of our study. There was a trend toward higher EuroSCORE in the Maze group; however, despite this trend, the operative mortality was not increased in the Maze group, and multivariate analysis confirmed the independent influence of the Maze procedure on survival. The modification of the Maze procedure from the standard cut-and-sew technique to radiofrequency ablation during the study span represents a further limitation. Only patients having the complete Cox Maze III ablation pattern on both atria were included in the study, however, and the two groups of patients were operated on within the same period.

Thus, within the limitations of this study, we conclude that the Maze procedure in combination with heart surgery markedly improves long-term survival in comparison with a control group of patients receiving heart surgery alone. The effect is related to a reduction in the incidence of heart failure and sudden death. This improved survival is linked to restoration of sinus rhythm, and the impact on survival was maintained even in a subgroup of patients who had markedly enlarged atria.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We are very grateful to Christophe Lecocq and Anne Monseur for data collection.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

1. Obadia JF, El Farra M, Bastien OH, et al. Outcome of atrial fibrillation after mitral valve repair J Thorac Cardiovasc Surg 1997;114:179-185.[Abstract/Free Full Text]
2. Ngaage DL, Schaff HV, Mullany CJ, et al. Does preoperative atrial fibrillation influence early and late outcomes of coronary artery bypass grafting? J Thorac Cardiovasc Surg 2007;133:182-189.[Abstract/Free Full Text]
3. Ngaage DL, Schaff HV, Barnes SA, et al. Prognostic implications of preoperative atrial fibrillation in patients undergoing aortic valve replacement: is there an argument for concomitant arrhythmia surgery? Ann Thorac Surg 2006;82:1392-1399.[Abstract/Free Full Text]
4. Khargi K, Deneke T, Haardt H, et al. Saline-irrigated, cooled-tip radiofrequency ablation is an effective technique to perform the maze procedure Ann Thorac Surg 2001;72(Suppl):1090-1095.
5. Deneke T, Khargi K, Grewe PH, et al. Efficacy of an additional MAZE procedure using cooled-tip radiofrequency ablation in patients with chronic atrial fibrillation and mitral valve disease. A randomized, prospective trial. Eur Heart J 2002;23:558-566.[Abstract/Free Full Text]
6. Akpinar B, Guden M, Sagbas E, et al. Combined radiofrequency modified maze and mitral valve procedure through a port access approach: early and mid-term results Eur J Cardiothorac Surg 2003;24:223-230.[Abstract/Free Full Text]
7. Jessurun ER, van Hemel NM, Defauw JJ, et al. A randomized study of combining maze surgery for atrial fibrillation with mitral valve surgery J Cardiovasc Surg (Torino) 2003;44:9-18.[Medline]
8. de Lima GG, Kalil RA, Leiria TL, et al. Randomized study of surgery for patients with permanent atrial fibrillation as a result of mitral valve disease Ann Thorac Surg 2004;77:2089-2094.[Abstract/Free Full Text]
9. Handa N, Schaff HV, Morris JJ, et al. Outcome of valve repair and the Cox maze procedure for mitral regurgitation and associated atrial fibrillation J Thorac Cardiovasc Surg 1999;118:28-635.
10. Jatene MB, Marcial MB, Tarasoutchi F, et al. Influence of the maze procedure on the treatment of rheumatic atrial fibrillation—evaluation of rhythm control and clinical outcome in a comparative study Eur J Cardiothorac Surg 2000;17:117-124.[Abstract/Free Full Text]
11. Raanani E, Albage A, David TE, et al. The efficacy of the Cox/maze procedure combined with mitral valve surgery: a matched control study Eur J Cardiothorac Surg 2001;19:438-442.[Abstract/Free Full Text]
12. Chen MC, Chang JP, Guo GB, Chang HW. 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]
13. Guang Y, Zhen-jie C, Yong LW, et al. Evaluation of clinical treatment of atrial fibrillation associated with rheumatic mitral valve disease by radiofrequency ablation Eur J Cardiothorac Surg 2002;21:249-254.[Abstract/Free Full Text]
14. Bando K, Kobayashi J, Kosakai Y, et al. Impact of Cox maze procedure on outcome in patients with atrial fibrillation and mitral valve disease J Thorac Cardiovasc Surg 2002;124:575-583.[Abstract/Free Full Text]
15. Ngaage DL, Schaff HV, Mullany CJ, et al. Influence of preoperative atrial fibrillation on late results of mitral repair: is concomitant ablation justified? Ann Thorac Surg 2007;84:434-443.[Abstract/Free Full Text]
16. Reston JT, Shuhaiber JH. Meta-analysis of clinical outcomes of maze-related surgical procedures for medically refractory atrial fibrillation Eur J Cardiothorac Surg 2005;28:724-730.[Abstract/Free Full Text]
17. Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines and the European Society of Cardiology committee for practice guidelines (writing committee to revise the 2001 guidelines for the management of patients with atrial fibrillation) J Am Coll Cardiol 2006;48:854-906.[Free Full Text]
18. Michel P, Roques F, Nashef SA. Logistic or additive EuroSCORE for high-risk patients? Eur J Cardiothorac Surg 2003;23:684-687.[Abstract/Free Full Text]
19. Cox JL, Jaquiss RD, Schuessler RB, Boineau JP. 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]
20. Sie HT, Beukema WP, Misier AR, et al. Radiofrequency modified maze in patients with atrial fibrillation undergoing concomitant cardiac surgery J Thorac Cardiovasc Surg 2001;122:249-256.[Abstract/Free Full Text]
21. Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models Biometrika 1986;73:13-22.[Abstract/Free Full Text]
22. Davis CS. A computer program for regression analysis of repeated measures using generalized estimating equations Comput Meth Progr Biomed 1993;40:15-31.
23. Sie HT, Beukema WP, Elvan A, Ramdat Misier AR. Long-term results of irrigated radiofrequency modified maze procedure in 200 patients with concomitant cardiac surgery: six years experience Ann Thorac Surg 2004;77:512-516.[Abstract/Free Full Text]
24. Melo J, Santiago T, Aguiar C, et al. Surgery for atrial fibrillation in patients with mitral valve disease: results at five years from the International Registry of Atrial Fibrillation Surgery J Thorac Cardiovasc Surg 2008;135:863-869.[Abstract/Free Full Text]
25. Toumpoulis IK, Anagnostopoulos CE, Toumpoulis SK, et al. EuroSCORE predicts long-term mortality after heart valve surgery Ann Thorac Surg 2005;79:1902-1908.[Abstract/Free Full Text]
26. Gillinov AM, Sirak J, Blackstone EH, et al. The Cox maze procedure in mitral valve disease: predictors of recurrent atrial fibrillation J Thorac Cardiovasc Surg 2005;130:1653-1660.[Abstract/Free Full Text]
27. Kim YH, Lee SC, Her AY, et al. Preoperative left atrial volume index is a predictor of successful sinus rhythm restoration and maintenance after the maze operation J Thorac Cardiovasc Surg 2007;134:448-453.[Abstract/Free Full Text]
28. Kobayashi J, Kosakai Y, Nakano K, et al. Improved success rate of the maze procedure in mitral valve disease by new criteria for patients' selection Eur J Cardiothorac Surg 1998;13:247-252.[Abstract/Free Full Text]
29. 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]
30. Kim KC, Cho KR, Kim YJ, et al. Long-term results of the Cox-Maze III procedure for persistent atrial fibrillation associated with rheumatic mitral valve disease: 10-year experience Eur J Cardiothorac Surg 2007;31:261-266.[Abstract/Free Full Text]
31. Halkos ME, Craver JM, Thourani VH, et al. Intraoperative radiofrequency ablation for the treatment of atrial fibrillation during concomitant cardiac surgery Ann.Thorac Surg 2005;80:210-215.[Abstract/Free Full Text]
32. Ad N, Barnett S, Lefrak EA, et al. Impact of follow-up on the success rate of the cryosurgical maze procedure in patients with rheumatic heart disease and enlarged atria J Thorac Cardiovasc Surg 2006;131:1073-1079.[Abstract/Free Full Text]
33. Jessurun ER, van Hemel NM, Kelder JC, et al. The effect of maze operations on atrial volume Ann Thorac Surg 2003;75:51-56.[Abstract/Free Full Text]
34. Romano MA, Bach DS, Pagani FD, et al. Atrial reduction plasty Cox maze procedure: extended indications for atrial fibrillation surgery Ann Thorac Surg 2004;77:1282-1287.[Abstract/Free Full Text]
35. Marui A, Saji Y, Nishina T, et al. Impact of left atrial volume reduction concomitant with atrial fibrillation surgery on left atrial geometry and mechanical function J Thorac Cardiovasc Surg 2008;135:1297-1305.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yves Louagie Michel Buche Philippe Eucher Jean-Claude Schoevaerdts Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Louagie, Y. Articles by Blommaert, D. Search for Related Content PubMed PubMed Citation Articles by Louagie, Y. Articles by Blommaert, D. Related Collections Electrophysiology - arrhythmias Related Article