96. Ten-Year Outcomes Following the Cox-Maze IV Procedure for Atrial Fibrillation
Ali J. Khiabani, Robert M. MacGregor, Laurie A. Sinn, *Hersh S. Maniar, *Marc R. Moon, Richard B. Schuessler, Spencer J. Melby, *Ralph J. Damiano, Jr.
Washington University, St. Louis, MO
Invited Discussant: *Vinay Badhwar
Post-Presentation Commentary by *Patrick M. McCarthy and *Niv Ad
Objective: Surgical ablation (SA) of atrial fibrillation (AF) is indicated in patients with symptomatic AF undergoing other cardiac surgical procedures and in patients with lone AF who have failed medical and/or catheter-based ablation therapy. This study examined the 10-year outcomes following Cox-Maze IV procedure (CMP-IV).
Methods: Between January 2001 and March 2018, 1044 patients underwent SA for refractory AF. Cox-Maze III procedures, redo-SA, as well as any other SA techniques that did not completely isolate the posterior left atrium (LA) were excluded (n=191). The remaining patients underwent either biatrial CMP-IV (n=765) or a left-sided Cox-Maze (n=88) lesion set. Freedom from atrial tachyarrhythmias (ATAs) was determined by electrocardiography, Holter, or pacemaker interrogation at 3, 6, and 12 months and yearly thereafter. At 5 years, 72% (252/348), and at 10 years, 43% (51/120) of patients were available for follow up. Recurrence was defined according to the consensus statement as any documented ATAs lasting ≥30 seconds. Preoperative and procedural characteristics and outcomes were compared in multiple subgroups. Predictors of recurrence were determined by analyzing 35 variables using univariable and if significant, multivariable logistic regression.
Results: The mean age was 64.2±11.5 years, and the mean LA size was 5.1±1.0 cm. The majority of patients (513/853, 60%) had non-paroxysmal AF. Twenty-four percent of patients (201/853) had failed at least one catheter-based ablation. The majority of patients (647/853, 76%) underwent prolonged monitoring during their follow up. Eighty-seven percent (744/853) of patients were discharged home in sinus rhythm. Freedom from ATAs on or off antiarrhythmic drugs (AADs) were 92% (551/597) and 84% (504/597) at 1 year; 84% (212/252) and 71% (179/252) at 5 years; and 73% (37/51) and 57% (29/51) at 10 years (Figure). There was no difference in freedom from ATAs on or off AADs at 5 and at 10 years between patients with paroxysmal AF and those with non-paroxysmal AF (p>0.4). Being in AF at the time of hospital discharge, and lower preoperative ejection fraction were the two predictors of failure at 5 years by multivariable analysis. No predictor of failures were found at 10 years, including age, LA size, and type or duration of preoperative AF.
Conclusions: At 10 years following a CMP-IV, most patients were still free from ATAs on or off AADs. In long-term follow up, the results of the CMP-IV remained superior to those reported for catheter ablation and other forms of SA of AF, especially for patients with persistent or long-standing AF. There did not appear to be any predictors of late recurrence in this cohort of patients.