1. Successful Cox Maze Procedure During Mitral Valve Surgery Restores Patient Survival Without Increasing Operative Risk
Niv Ad, MD
Chief, Cardiac Surgery
Inova Heart and Vascular Institute

2. I have no real or apparent conflicts of interest to report.
Niv Ad, MD
I have no real or apparent conflicts of interest to report.

3. STS Data-Surgical ablation for AF 2005-2010

4. Introduction
Recent reports indicated that patients experiencing significant atrial fibrillation (AF) at the time of mitral valve (MV) surgery have decreased survival compared to patients in sinus rhythm (NSR).
The purpose of this study was to determine the impact of Cox Maze III/IV (CM) for AF on patient outcomes and survival following MV surgery.

5. Why should we treat AF? AF
If left untreated
TE/Stroke/Bleeding
Survival
Quality of life
Mitral Disease and AF
No AF AF
Years

6. Introduction
Recent reports indicated that patients experiencing significant atrial fibrillation (AF) at the time of mitral valve (MV) surgery have decreased survival compared to patients in sinus rhythm (NSR).
The purpose of this study was to determine the impact of Cox Maze III/IV (CM) for AF on patient outcomes and survival following MV surgery.

7. Methods 489 patients were included:
Isolated MV and were in NSR (n=373)
MV surgery plus Cox Maze III procedure (n=116)
All patients followed prospectively.
CM III patients enrolled in a unique AF registry.
Rhythm was verified by 24-hour holter.
Kaplan-Meier analysis compared cumulative survival between the two surgery groups, plus a third group with isolated MV and untreated AF (n=47).

8. Results
The isolated MV group was younger (p<0.001) and lower risk (euroSCORE, p=0.001) compared to the MV plus CM group.
Isolated MV patients were similar to MV plus CM patients on many characteristics, including chronic pulmonary disease (p=0.29), proportion of females (p=0.09), elective status (p=1.00), and diabetes (p=1.00).
Although bypass time (p<0.001) and length of stay were longer for MV plus CM patients (p<0.001), the groups were comparable on perioperative complications including stroke, prolonged ventilation, renal failure, and operative mortality (1% in both groups).

9. Preoperative Characteristics

10. Selected Postoperative Outcomes

11. Rhythm Status Over Time for CM Patients

12. Results
MV plus CM patients (88.8%) had similar 5-year survival as isolated MV patients in NSR (89.1%; Log Rank=0.01, p=0.92).
Cumulative survival in patients with isolated MV and untreated AF (81.4%) was lower than in MV plus CM (88.8%; Log Rank=2.77, p=0.10), but only marginally significant.

13. No AF
Patient Survival AF

14. Conclusions
Patients with mitral valve disease and atrial fibrillation should expect similar outcomes when compared to patients presenting to surgery in sinus rhythm when the CM procedure was added.
The addition of the Cox Maze procedure did not negatively impact perioperative outcomes.
Consideration should be given to addressing atrial fibrillation at the time of mitral valve surgery.

15. Thank You