The Cox-Maze III procedure for atrial fibrillation associated with rheumatic mitral valve disease

Background. The surgical results of the Cox-Maze III procedure (CM-III) for atrial fibrillation (AF) associated with rheumatic mitral valve (MV) disea se are not as good as the results from surgery for AF alone. Methods. To assess the efficacy and safety of the CM-III in AF associated w ith rheumatic MV disease, we retrospectively analyzed 75 patients who under went the CM-III combined with a rheumatic MV procedure between April 1994 a nd December 1997. Fourteen cases were reoperations because of prosthetic va lve failure. Results. Mean aortic cross-clamp (ACC) times and cardiopulmonary bypass (CP B) times were 151 +/- 43 and 251 +/- 73 min, respectively. Concomitant proc edures were mitral valve replacement (MVR) in 25 patients, MVR and aortic v alve replacement (AVR) in 14 patients, MV repair in 10 patients, MVR and tr icuspid annuloplasty (TAP) in 6 patients, MVR and AV repair in 3 patients, MVR and coronary artery bypass grafting (CABG) in 2 patients, MVR and AVR a nd CABG in 1 patient, redo-MVR in 8 patients, redo-MVR and TAP in 4 patient s, and redo-MVR and redo-AVR in 2 patients. There were two in-hospital mort alities (2 of 75, 2.7%). Seventy-three survivors were followed for a mean d uration of 30 +/- 13. months (12-56 months). Normal sinus rhythm was restor ed in 90.4% (66 of 73). Three patients remained in AF and 2 patients were i n junctional rhythm. Permanent pacemakers were implanted in 2 patients due to sick sinus syndrome. Right atrial (RA) contractility was demonstrable in 100% (66 of 66) and left atrial (LA) contractility in 62.1% (41 of 66) of the patients in the latest follow-up echocardiography. RA and LA contractil ities were restored a mean 69 +/- 93 and 126 +/- 136 days after the operati on, respectively. LA contractility was restored significantly later at a lo wer rate than RA contractility in rheumatic MV disease. There were no diffe rences in ACC time, CPB time, incidence of postoperative bleeding complicat ions, and sinus conversion rates between non-redo and redo cases in spite o f the significantly longer duration of preoperative AF in redo cases (p < 0 .05). Conclusions. The CM-III for AF associated with rheumatic MV disease demonst rated a high sinus conversion rate with acceptable operative risk even in c ases of reoperation. (Ann Thorac Surg 1999;68:799-804) (C) 1999 by The Soci ety of Thoracic Surgeons.