Low Mortality and Low Rate of Perceived and Documented Arrhythmias after Cox Maze III Surgery for Atrial Fibrillation

BACKGROUND: To report a long-term single-site experience of the cut-and-sew Cox maze III procedure for atrial fibrillation (AF). METHODS: A total of 232 consecutive patients underwent the Cox maze III procedure for symptomatic therapy-refractory AF, with concomitant surgery in 34 patients. Follow-up data were obtained from electrocardiograms, patient visits, questionnaires, and medical files. RESULTS: There were 103 patients (44%) with paroxysmal AF during 8.8 ± 6.5 years and 129 patients (56%) with nonparoxysmal AF for 7.3 ± 6.7 years. The preoperative New York Heart Association class was better in patients with paroxysmal AF (P < 0.0001); the left ventricular ejection fraction was 59 ± 7% versus 56 ± 8%, P = 0.003, and the left atrial area 24 ± 6 versus 27 ± 6 cm(2) , P = 0.01. Early and late postoperative adverse events occurred at similar rates. Four patients from each group died of reasons unrelated to surgery. The mean follow-up was 66 ± 42 (5-155) months. In total, 184/229 (80%) patients were free of documented AF/atrial flutter/atrial tachycardia (AF/AFl/AT) off antiarrhythmic drugs (AA) and 189/229 (83%) on or off AA. The hazard ratio (HR) for paroxysmal versus nonparoxysmal AF patients regarding documented AF/AFl/AT was 0.8 (95% confidence interval [CI] 0.4-1.4; P = 0.40). For patients without versus with concomitant surgery, the corresponding HR was 0.4 (95% CI 0.2-0.8; P = 0.008). Of 197 patients (89%) responding to the questionnaire, 41 had sought care for symptoms of arrhythmia, 29 of whom had documented AF/AFl/AT, whereas another six had other arrhythmias. CONCLUSION: Cut-and-sew Cox maze III surgery provided long-lasting high efficacy, also in patients with nonparoxysmal AF of long duration and/or concomitant surgery, and was associated with low rates of subsequent adverse events.