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39. The Cox-Maze Procedure in Mitral Valve Disease: Predictors of Failure
A. Marc Gillinov, Jon Sirak, Eugene H Blackstone, Jeevanantham Rajeswaran, Patrick M Mccarthy, Gosta Pettersson, Joseph F Sabik, III, Lars G Svensson, Delos M Cosgrove; Cleveland, OH

Objective:
The Cox-Maze procedure is the gold standard for ablation of atrial fibrillation (AF) in patients having mitral valve surgery, and new approaches to AF ablation must be compared to it. Therefore, we sought to determine time-related prevalence of AF and its risk factors, and ablation failure and its risk factors, after combined Cox-Maze and mitral valve surgery.
Methods:
From 1991 to 2004, 262 patients underwent combined mitral valve (repair-71%) and Cox-Maze procedures for AF (permanent-74%, persistent-7%, paroxysmal-16%). Rhythm documented on 1,601 postoperative electrocardiograms was used to estimate prevalence of AF across time. Maze failure was defined as occurrence of AF any time beyond 6 months after operation.
Results:
Hospital mortality was 1.9%. Postoperative AF prevalence peaked at 37% at 1 month, declining to 9% at 5 years (Figure). Risk factors included older age (P=.005) and earlier date of operation (P<.0001) for early AF return; longer duration of preoperative AF (P<.0001) and lower ejection fraction (P<.0001) for late return; and larger left atrial volume for increased AF prevalence across the entire time span (P=.0002). Freedom from ablation failure was 83% at 1 year and 66% at 3 years. Longer duration of preoperative AF (P=.001) and lower ejection fraction increased risk of ablation failure (P=.003).
Conclusions:
Cox-Maze procedures can be applied safely in patients with mitral valve disease and AF. In these patients, type of AF does not affect results. However, earlier surgery and left atrial size reduction should be considered in patients with longstanding AF and left atrial enlargement, respectively.

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