Immediate and long-term results of the simultaneous rhythm-converting procedure Cox-Maze IV in multivalvular correction

Evseev EP, Botashev AA, Aidamirov IA, et al. Immediate and long-term results of the simultaneous rhythm-converting procedure Cox-Maze IV in multivalvular correction. Pirogov Russian Journal of Surgery. 2024;(12‑2):25‑34. (In Russ.)
https://doi.org/10.17116/hirurgia202412225

Подписка 2026 Хирургия. Журнал им. Н.И. Пирогова (Pirogov Russian Journal of Surgery)

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OBJECTIVE

This study aimed to investigate the immediate and long-term outcomes of the Cox-Maze IV procedure in patients undergoing surgical treatment for multivalvular heart disease with atrial fibrillation. It also sought to identify predictors of atrial fibrillation recurrence in the long-term period.

MATERIALS AND METHODS

We conducted an analysis of 92 patients who underwent multivalvular heart defect correction and simultaneous Cox-Maze IV procedure between 2017 and 2023. The mean age of the patients was 65.5 years (57.5; 69), 43 males (46.7%) and 49 females (53.3%). Sixty-six patients (71.7%) were classified as functional class III heart failure according to NYHA, while 3 (3.3%), 14 (15.2%), and 9 (9.8%) were classified as functional classes I, II, and IV, respectively. The types of atrial fibrillation were: paroxysmal in 15.2%, persistent in 22.8%, and long-standing persistent in 62%. The mean duration of atrial fibrillation prior to surgery was 15.5 months (10; 45.8) for those with paroxysmal form, 7 months (4; 9) for persistent form, and 60 months (22; 84) for long-standing persistent form. Mitral-aortic valve replacement was performed in 9 cases (9.8%), mitral-tricuspid correction in 69 cases (75%), and combined mitral-aortic-tricuspid correction in 14 cases (15.2%).

RESULTS

During the hospital stay, there were 3 fatalities. In the long-term follow-up, 8 deaths were recorded, with 3 attributed to cardiac causes. Permanent pacemaker implantation was required in just one case during the long-term postoperative period. The freedom from atrial fibrillation was 61.4% in patients with paroxysmal form at follow-up of up to 46 months, 58.1% in those with persistent form at up to 63 months, and 32.5% in those with long-standing persistent form at up to 82 months. Three predictors of arrhythmia recurrence were identified: early postoperative atrial fibrillation paroxysms, a duration of atrial fibrillation exceeding 60 months, and enlarged left atrial size.

CONCLUSIONS

The Cox-Maze IV rhythm-conversion procedure designed to restore sustained sinus rhythm is most effective in patients with paroxysmal and persistent forms of atrial fibrillation, achieving success rates of 61.4% and 58.1%, respectively. This procedure is not associated with a high rate of pacemaker implantation. An enlarged left atrium should not deter the use of the Cox-Maze IV procedure in patients with atrial fibrillation; however, atrioplasty is recommended if the left atrium is significantly enlarged. Episodes of rhythm disturbance during the early postoperative period and a history of atrial fibrillation lasting more than 60 months prior to surgery are associated with an increased risk of recurrence postoperatively. Therefore, careful monitoring of these patients after discharge is essential for early detection and management of recurrences.

Keywords:

multivalvular heart disease

mitral valve

aortic valve

tricuspidal valve

atrial fiblillation

Cox-Maze IV

Authors:

Evseev E.P.

B.V. Petrovsky Russian Research Center of Surgery

ORCID: 0000-0002-3806-9658

Botashev A.A.

B.V. Petrovsky Russian Research Center of Surgery

ORCID: 0000-0002-1224-3224

Aidamirov I.A.

B.V. Petrovsky Russian Research Center of Surgery

ORCID: 0000-0003-3870-1040

Balakin E.V.

B.V. Petrovsky Russian Research Center of Surgery

ORCID: 0000-0002-9658-6725

Fomin M.A.

B.V. Petrovsky Russian Research Center of Surgery

ORCID: 0000-0002-7555-3633

Fazylov A.O.

Sechenov First Moscow State Medical University

ORCID: 0000-0002-4275-0534

Ivanov V.A.

B.V. Petrovsky Russian Research Center of Surgery

ORCID: 0000-0001-6277-0375

Belov Yu.V.

B.V. Petrovsky Russian Research Center of Surgery;
Sechenov First Moscow State Medical University

SPIN RSCI: 2740-1439
Scopus AuthorID: 7101862336
ResearcherID: 7101862336
ORCID: 0000-0002-9280-8845

Received:

26.08.2024

Accepted:

10.09.2024

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References:

Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL; ESC Scientific Document Group. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European association for cardio-thoracic surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European society of cardiology (ESC) developed with the special contribution of the European heart rhythm association (EHRA) of the ESC. European Heart Journal. 2021;42(5):373498. https://doi.org/10.1093/eurheartj/ehaa612
Adderley NJ, Nirantharakumar K, Marshall T. Risk of stroke and transient ischaemic attack in patients with a diagnosis of resolved atrial fibrillation: retrospective cohort studies. British Medical Journal. 2018;361:k1717. https://doi.org/10.1136/bmj.k1717
Iung B, Vahanian A. Epidemiology of valvular heart disease in the adult. Nature Reviews Cardiology. 2011;8:162-172. https://doi.org/10.1038/nrcardio.2010.202
Gammie JS. Atrial fibrillation correction surgery: lessons from the Society of Thoracic Surgeons National Cardiac Database. The Annals of Thoracic Surgery. 2008;85(3):909-914. https://doi.org/10.1016/j.athoracsur.2007.10.097
Cox JL, Ad N, Palazzo T, Fitzpatrick S, Suyderhoud JP, DeGroot KW, Pirovic EA, Lou HC, Duvall WZ, Kim YD. The Maze-III procedure combined with valve surgery. Seminars in Thoracic and Cardiovascular Surgery. 2000;12(1):53-55. https://doi.org/10.1016/s1043-0679(00)70017-7
Cox JL. A brief overview of surgery for atrial fibrillation. Annals of Cardiothoracic Surgery. 2014;3(1):80-88. https://doi.org/10.3978/j.issn.2225-319X.2014.01.05
McGilvray MMO, Bakir NH, Kelly MO, Perez SC, Sinn LA, Schuessler RB, Zemlin CW, Maniar HS, Melby SJ, Damiano RJ Jr. Efficacy of the stand-alone cox-maze iv procedure in patients with longstanding persistent atrial fibrillation. Journal of Cardiovascular Electrophysiology. 2021;32(10):288-294. https://doi.org/10.1111/jce.15113
Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Bärwolf C, Levang OW, Tornos P, Vanoverschelde JL, Vermeer F, Boersma E, Ravaud P, Vahanian A. A prospective survey of patients with valvular heartdisease in Europe: The Euro Heart Survey on Valvular Heart Disease. European Heart Journal. 2003;24:1231-1243. https://doi.org/10.1016/s0195-668x(03)00201-x
Iung B, Vahanian A. Epidemiology of valvular heart disease in the adult. Nature Reviews Cardiology. 2011;8(3):162-172. https://doi.org/10.1038/nrcardio.2010.202
Ivanov VA, Aidamirov YaA, Evseev EP, Nikityuk TG, Ivanova LN, Balakin EV, Voropaeva VI, Botashev AA. Immediate results of surgery for multiple valve disease. Kardiologiya i serdechno-sosudistaya xirurgiya. 2024;17(3):294-300. (In Russ.). https://doi.org/10.17116/kardio202417031294
Weimar T, Schena S, Bailey MS, Maniar HS, Schuessler RB, Cox JL, Damiano RJ Jr. The cox-maze procedure for lone atrial fibrillation: a single-center experience over 2 decades. Circulation. Arrhythmia and Electrophysiology. 2012;5(1):8-14. https://doi.org/10.1161/CIRCEP.111.963819
Ad N, Damiano RJ Jr, Badhwar V, Calkins H, La Meir M, Nitta T, Doll N, Holmes SD, Weinstein AA, Gillinov M. Expert consensus guidelines: Examining surgical ablation for atrial fibrillation. The Journal of Thoracic and Cardiovascular Surgery. 2017;153(6):1330-1354.e1. https://doi.org/10.1016/j.jtcvs.2017.02.027
Korchazhkina NB, Mikhailova AA, Kovalev SA, Portnov VV, Rzhevsky VS. Effectiveness of early rehabilitation techniques in programs of accelerated recovery of patients after surgical interventions. Fizioterapiya, bal`neologiya i reabilitaciya. 2019;18(6):408-411. (In Russ.).
Kotenko KV, Mikhailova AA, Badimova AV, Reshetova IV, Dymova OV, Eremin II, Korchazhkina NB. Determination of prognostically significant markers of prenosological detection of predictors of obesity and metabolic disorders. Voprosy` kurortologii, fizioterapii i lechebnoj fizicheskoj kul`tury. 2023;100(5-2):21. (In Russ.).
Bezrukova OV, Kotenko KV, Vasilyeva ES, Korchazhkina NB. Evaluation of the effectiveness of complex physical therapy and SIS-therapy in the treatment of cervical disc herniation in the cervical spine. Fizioterapiya, bal`neologiya i reabilitaciya. 2023;22(3):209-218. (In Russ.). https://doi.org/10.17816/625476
Korchazhkina NB, Mikhailova AA, Reshetova IV, Dymova OV, Kotenko KV. Modern approaches to the development of a system of valid methods for monitoring individual health and maintaining active longevity. Voprosy` kurortologii, fizioterapii i lechebnoj fizicheskoj kul`tury. 2023;100(6):6-13. (In Russ.).
Korchazhkina NB, Mikhailova AA, Badimova AV, Reshetova IV, Dymova OV, Eremin II, Kotenko KV. Methods and markers of prenosological diagnosis and monitoring of individual health and maintenance of active longevity. Voprosy` kurortologii, fizioterapii i lechebnoj fizicheskoj kul`tury. 2023;100(5-2):20-21. (In Russ.).
Frolova YuV, Polozkova IG, Rybachenko MS, Evseev EP, Korchazhkina NB. The role of cryoballoon ablation of the pulmonary vein orifices in the treatment of chronic heart failure with reduced left ventricular ejection fraction against the background of tachycardia-induced cardiomyopathy. Kardiologiya i serdechno-sosudistaya xirurgiya. 2024;17(2):222-227. (In Russ.). https://doi.org/10.33978/2307-3586-2024-20-31-88-94
Polozkova IG, Frolova YuV, Rybachenko MS, Evseev EP, Korchazhkina NB. Clinical case of cryoballoon ablation of the pulmonary vein orifices in the treatment of chronic heart failure with reduced left ventricular ejection fraction against the background of tachycardia-induced cardiomyopathy. Rossijskij kardiologicheskij zhurnal. 2024;29(S8):18-20. (In Russ.).
Ad N, Suri RM, Gammie JS, Sheng S, O’Brien SM, Henry L. Surgical ablation of atrial fibrillation trends and outcomes in North America. The Journal of Thoracic and Cardiovascular Surgery. 2012;144(5):1051-1060. https://doi.org/10.1016/j.jtcvs.2012.07.065
Ad N, Henry L, Hunt S, Holmes SD. Impact of clinical presentation and surgeon experience on the decision to perform surgical ablation. Annals of Thoracic Surgery. 2013;96(3):763-768; discussion 768-769. https://doi.org/10.1016/j.athoracsur.2013.03.066
Wang CT, Zhang L, Qin T, Xi ZL, Sun L, Wu HW, Li DM. Cox-maze III procedure for atrial fibrillation during valve surgery: a single institution experience. Journal of Cardio-Thoracic Surgery. 2020;15(1):111. https://doi.org/10.1186/s13019-020-01165-4
Cherniavskiĭ AM, Pak IA, Rakhmonov SS, Kareva IuE. Predictors of recurrent atrial fibrillation after radiofrequency ablation and coronary artery bypass grafting. Kardiologiya i serdechno-sosudistaya xirurgiya. 2015;8(4):50-55. (In Russ.). https://doi.org/10.17116/kardio20158450-55
Yang S, Wang C, Zhang B, Hou J, Huang S, Wang K, Wu Z. Clinical Effects of Surgical Left Atrial Reduction and Concomitant Mitral Valve Replacement in Patients with Giant Left Atrium. Brazilian Journal of Cardiovascular Surgery. 2023;38(5):e20220469. https://doi.org/10.21470/1678-9741-2022-0469
Baudo M, Rosati F, Di Bacco L, D’Alonzo M, Benussi S, Muneretto C. Left Atrium Volume Reduction Procedure Concomitant With Cox-Maze Ablation in Patients Undergoing Mitral Valve Surgery: A Meta-Analysis of Clinical and Rhythm Outcomes. Heart, Lung and Circulation. 2023;32(11):1386-1393. https://doi.org/10.1016/j.hlc.2023.09.009
Sunderland N, Nagendran M, Maruthappu M. In patients with an enlarged left atrium does left atrial size reduction improve maze surgery success? Interactive Cardiovascular and Thoracic Surgery. 2011;13(6):635-641. https://doi.org/10.1510/icvts.2011.275511
Bogachev-Prokophiev AV, Ovcharov MA, Lavinykov SO, Pivkin AN, Sharifulin RM, Afanasyev AV, Sapegin AV, Zheleznev SI. Surgical Atrial Fibrillation Ablation With and Without Left Atrium Reduction for Patients Scheduled for Mitral Valve Surgery: A Prospective Randomised Study. Heart, Lung and Circulation. 2021;30(6):922-931. https://doi.org/10.1016/j.hlc.2020.10.027
Trofimov NA, Medvedev AP, Babokin VE, Efimova IP, Kashin VYu, Sobolev YuA, Egorov DV. Impact of pulmonary hypertension on the effectiveness of Cox Maze IV procedure in patients with mitral valve disease and concomitant atrial fibrillation. Kardiologiya i serdechno-sosudistaya xirurgiya. 2020;13(3):230-238. (In Russ.). https://doi.org/10.17116/kardio202013031230