The maze procedure in atrial fibrillation: An evolution of rhythm surgery

The Cox-Maze procedure is the cornerstone of surgical rhythm-control therapy for atrial fibrillation (AF). Developed to interrupt macro-reentrant conduction while preserving physiological atrial activation. It has evolved from the original cut-and-sew Maze I-III Operations, based on earlier strategies like a corridor surgery to today's energy-based Cox-Maze IV (CM-IV) and minimal invasive operations. Contemporary surgical ablation can be performed concomitantly with valve or coronary surgery, as a stand-alone operation, or via minimally invasive or hybrid strategies integrating electrophysiologic mapping. Numerous works is done by Cox, providing the understanding, development and acceptance for this surgery. Later, early work was done by Ad and Damiano. The minimal invasive approach, originally developed by Wolff and later performed through VATS by van Boven was based on combining the work of Cox, with the landmark paper of Haissageurre in 1998, showing that the origin of AF is mostly situated in the PVI's. This was further developed in a Hybrid approach. Providing evidence, in diverse ways, from the groups of Maastricht and Amsterdam. In concomitant operation, performing a Maze or a PVI beside another cardiac operation, current evidence shows durable sinus-rhythm restoration and survival benefit without added operative risk. Future directions center on advanced imaging, patient tailored lesion design and new energy sources like non-thermal pulsed-field ablation (PFA) next to combining surgical and catheter-based therapies in hybrid operating rooms. This review traces the evolution, evidence, technical refinements, and forward trajectory of Maze surgery.