Efficacy of the Stand-Alone Cox-Maze IV Procedure in Patients with
Longstanding Persistent Atrial Fibrillation
Introduction: Atrial fibrillation (AF) is the most common sustained
cardiac arrhythmia, and results in significant morbidity and mortality.
The Cox-Maze IV procedure (CMP-IV) has been shown to have excellent
efficacy in returning patients to sinus rhythm, but there have been few
reports of late follow-up in sizable cohorts of patients with
longstanding persistent AF, the most difficult type of AF to treat.
Methods & Results: Between May 2003 and March 2020, 174 consecutive
patients underwent a stand-alone CMP-IV for longstanding persistent AF.
Rhythm outcome was assessed postoperatively for up to 10 years,
primarily via prolonged monitoring (Holter monitor, pacemaker
interrogation, or implantable loop recorder). Fine-Gray regression was
used to investigate factors associated with atrial tachyarrhythmia (ATA)
recurrence, with death as a competing risk. Median duration of
preoperative AF was 7.8 years (interquartile range [IQR] 4.0-12.0
years), with 71% (124/174) having failed at least one prior
catheter-based ablation. There were no 30-day mortalities. Freedom from
ATAs was 94% (120/128), 83% (53/64), and 88% (35/40) at 1, 5, and 7
years, respectively. On regression analysis, preoperative AF duration
and early postoperative ATAs were associated with late ATAs recurrence.
Conclusion: Despite the majority of patients having a long-duration of
preoperative AF and having failed at least one catheter-based ablation,
the stand-alone CMP-IV had excellent late efficacy in patients with
longstanding persistent AF, with low morbidity and no mortality. We
recommend consideration of stand-alone CMP-IV for patients with
longstanding persistent AF who have failed or are poor candidates for