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Concomitant atrial fibrillation
It has been 21 years since the first description of the maze procedure by James Cox.1 At that time the hypothesis of multiple independent wavelets propagating randomly through both atria was the most accepted dominant atrial fibrillation (AF) mechanism; there was no knowledge of the importance of focal triggers within the pulmonary veins, the influence of different local activation rates, frequency gradients, the autonomic nervous system, or genetics in the genesis of AF. The Cox maze procedure was designed basically with two aims: to reconduct the electrical impulse into dead-end paths, and to avoid its rotation on round structures like the mitral and tricuspid annuli, both venae cavae and atrial appendages. Interestingly, it still is the most successful therapy for controlling AF, with over 90% of sinus rhythm (SR) recovery in patients with lone AF,2 but the aggressiveness of the original procedure limited its implementation by most surgeons.
The introduction in the last decade of surgical devices with different energies to produce scars less aggressively has expanded the use of this therapy remarkably, basically in the field of AF concomitant to other surgical pathology. With this new technology, a maze procedure can be performed with no increase in operative risk,3 and the efficacy is comparable with the cut-and-sew technique.4 Moreover, in patients with a successful concomitant Cox maze procedure versus patients with heart surgery alone, recent data indicate better long term survival,5 reduced incidence of stroke,6 and better ventricular function.7 The last consensus statement of the International Society of Minimally Invasive Cardiothoracic Surgery in 2009 recommended concomitant surgical ablation in patients with persistent and longstanding persistent AF undergoing cardiac surgery to increase the incidence of SR at short and long term follow-up (class I, level A), to improve ejection fraction and exercise tolerance (class …