The effect of ablation technology on surgical outcomes after the Cox-maze procedure: A propensity analysis

Shelly C. Lall, Spencer J. Melby, Rochus K. Voeller, Andreas Zierer, Marci S. Bailey, Tracey J. Guthrie, Marc R. Moon, Nader Moazami, Jennifer S. Lawton, Ralph J. Damiano

Research output: Contribution to journalArticlepeer-review

143 Scopus citations


Objectives: Since its introduction in 1987, the Cox-maze procedure has been the gold standard for the surgical treatment of atrial fibrillation. At our institution, this procedure has evolved from the cut-and-sew technique (Cox-maze III procedure) to one using bipolar radiofrequency energy and cryoablation as ablative sources to replace most incisions (Cox-maze IV procedure). This study compared surgical outcomes of patients undergoing the Cox-maze III procedure versus those of patients undergoing the Cox-maze IV procedure by using propensity analysis. Methods: From April 1992 through July 2005, 242 patients underwent the Cox-maze procedure for atrial fibrillation. Of these, 154 patients had the Cox-maze III procedure, and 88 had the Cox-maze IV procedure. Logistic regression analysis was used to identify covariates among 7 baseline patient variables. Using the significant regression coefficients, each patient's propensity score was calculated, allowing selectively matched subgroups of 58 patients each. Operative outcomes were analyzed for differences. Late follow-up was available for 112 (97%) patients. Freedom from atrial fibrillation recurrence and survival was calculated at 1 year by using Kaplan-Meier analysis. Results: The Cox-maze III procedure had significantly longer crossclamp times. There was no significant difference in intensive care unit and hospital stay, 30-day mortality, permanent pacemaker placement, early atrial tachyarrhythmias, late stroke, and survival. Freedom from atrial fibrillation recurrence was greater than 90% in both groups at 1 year. Conclusions: The use of bipolar radiofrequency ablation has simplified the Cox-maze procedure, making it applicable to virtually all patients with atrial fibrillation undergoing concomitant cardiac surgery. The Cox-maze IV procedure produces similar surgical outcomes to the Cox-maze III procedure at 1 year of follow-up.

Original languageEnglish
Pages (from-to)389-396
Number of pages8
JournalJournal of Thoracic and Cardiovascular Surgery
Issue number2
StatePublished - Feb 2007


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