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The Surgical Treatment for Atrial Fibrillation: Should the Maze be Modified?

Ad, Niv MD

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: September-October 2009 - Volume 4 - Issue 5 - p 238-239
doi: 10.1097/IMI.0b013e3181bc93da

From the Department of Cardiac Surgery Research, Inova Heart and Vascular Institute, Falls Church, VA USA.

Accepted for publication August 17, 2009.

Disclosure: Niv Ad, MD is on the scientific advisory board and speaking bureau for ATS Medical, Inc., Minneapolis, MN USA and a consultant for ArtiCure, Inc., West Chester, OH USA.

Address correspondence and reprint requests to Niv Ad, MD, Inova Heart and Vascular Institute, 2921 Telestar Court, Falls Church, VA 22042 USA. E-mail:

The maze procedure was first introduced by Dr. James Cox in September of 1987. This unique surgical approach was the result of extensive research. Despite its relative complexity, the results of the cut and sew maze procedure are still considered excellent, when assessing the morbidity and the long-term success rate.

This issue’s review article provides the reader an excellent overview of the development and current state of the surgical treatment for atrial fibrillation. The authors also share information regarding current research on surface mapping in Washington University that may assist us in tailoring the procedure to the patient.

The current surgical approaches available for patients are:

  1. The full Cox-Maze lesion set using either the cut and sew technique or ablation energy.
  2. Limited lesion set that can be less defined.

See accompanying article on page 248

On the basis of the current literature, it is clear that lesions limited to the pulmonary veins have acceptable results only in patients with paroxysmal atrial fibrillation and not in patients with persistent or long-term persistent atrial fibrillation.

I would like to underscore the importance of minimally invasive surgery; our ability to simplify procedures and improve safety is critical and would dictate our future role in treating cardiovascular diseases. However, we should only adopt procedures that would provide excellent results. On the basis of the current review, it is clear that the Cox-Maze procedure performed using ablation technology should provide the same excellent results as the original cut and sew procedure. Dr. James Cox pioneered the use of cryoablation technology to apply the full lesion set successfully. His experience with hundreds of patients using cryoablation led to a unique minimally invasive approach using a single right minithoracotomy incision.1 To date, it is clear that the cut and sew technique should be performed only in cases in which ablation devices can not be applied or their impact is questionable, especially when the atrial is thick and scarred.

We may all find it extremely interesting that while we surgeons were working on simplifying the procedure by applying less lesions, our fellow electrophysiologists worked deliberately on mapping and catheter platforms that would enable them to mimic the left-sided Maze procedure lesion set. Currently, catheter ablation limited to the pulmonary veins are performed only on patients with paroxysmal atrial fibrillation and small left atrium.2,3

Future research should focus on understanding the practical differences between patients that may assist us to understand and predict success and failure. Our ability to comprehend atrial remodeling remains limited and this may be very important. Until we have better answers to the multiple challenges, we should be very careful in modifying the Cox-Maze procedure altogether. In turn, we should focus on selecting patients for more extensive or less extensive lesion set. I am still treating the majority of my patients using the Cox-Maze procedure, however a significant amount of our patients were treated with a limited lesion set, almost always for paroxysmal atrial fibrillation.

In summary, we are in the middle of a very exciting era. The surgical treatment for atrial fibrillation is being researched in more depth. Guidelines were published to standardize the reporting process of the results and new devices and concepts are being adopted readily. If we manage all the changes and elevate the scientific discussion, this surgical field is going to thrive.

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1. Ad N, Cox JL. The Maze procedure for the treatment of atrial fibrillation: a minimally invasive approach. J Card Surg. 2004;19:196–200.
2. Knecht S, Hocini M, Wright M, et al. Left atrial linear lesions are required for successful treatment of persistent atrial fibrillation. Eur Heart J. 2008;29:2359–2366.
3. Wright M, Haïssaguerre M, Knecht S, et al. State of the art: catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2008;19:583–592.
© 2009 Lippincott Williams & Wilkins, Inc.