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The surgical treatment of atrial fibrillation began in 1987, when Dr. James Cox introduced the maze procedure. This operation proved to be extremely effective in curing atrial fibrillation and preventing its most dreaded complication, stroke. However, many surgeons found the operation to be too difficult and invasive. Over the last 5 to 10 years, various groups have tried to develop less invasive approaches using a number of different energy sources to create linear lines of ablation to replace the surgical incisions. This has led to a plethora of new operations for this arrhythmia. There is significant confusion in the literature at the present time as to what is the best lesion pattern and what is the best energy source. It is our feeling that a great deal of this confusion is due to our lack of understanding of the mechanisms of atrial fibrillation and the effect of ablation technology on atrial hemodynamics and electrophysiology. Future progress will require a better understanding of this arrhythmia and continued research into the safety and efficacy of ablation devices.

At our center we have encouraged consideration of the Maze procedure over noncurative therapies for atrial fibrillation, particularly in patients who have other indications for cardiac surgical intervention. As a result, 78 of the 99 Maze procedures we have performed since 1993 have involved combined procedures. These combined operations included procedures on 1 or more valves in 69 of 78 patients (88%). The unmodified "cut-and-sew" Maze-III technique was used in all patients. There has been no operative mortality, and the median postoperative stay has been 7 days. Cure of atrial fibrillation has been observed in 97% of patients, and pacemaker implantation was required for sick sinus syndrome in 6%. Our results favor broader use of the Maze procedure for symptomatic atrial fibrillation and support use of the original Maze-III technique as the procedure of choice.

The minimally invasive partial sternotomy "J" incision can be used for most isolated mitral valves, tricuspid valves, aortic valves, atrial septal defects, maze procedures, aortic repairs, and aortic valve reoperations. This article reviews the technical approaches and outcomes for various procedures. For 2,004 mitral valve repairs, our 30-day in-hospital mortality was 0.2% and for 1,103 aortic valve procedures, it was 0.8%. In addition to both a better cosmetic result and earlier return to work, the benefits include less blood loss, less pain, better respiratory function, and better 1-year survival for mitral valve procedures. Similar results have been obtained for aortic valve procedures. Thus, all patients undergoing isolated aortic or mitral valve repairs are offered a minimally invasive operation.

The Cox-Maze procedure was designed to address the consequences of atrial fibrillation, tachycardia, hemodynamic impairment, and thromboembolism. From 1991 until June 1999, 100 patients underwent the Maze operation at the Cleveland Clinic Foundation. The group included 72 men with a mean age of 58 +/- 11 years (range, 23 to 78 years). Initially, the Maze-I procedure was performed primarily for patients with lone atrial fibrillation. However, since 1995, the Maze-III procedure has been performed exclusively, and it is typically combined with mitral valve repair. Twenty-three patients had only a Maze procedure, 60 patients had the Maze procedure/mitral valve repair, 10 patients had Maze procedure/coronary artery bypass, 6 had Maze procedure/mitral valve replacement, and 1 had Maze procedure/atrial septal defect repair. Chronic atrial fibrillation was present in 78% of patients for a mean of 8 +/- 9 years. There was a 1% perioperative mortality and 5% late mortality rate. Median hospital stay was 9 +/- 5 days. Six patients required new early permanent pacemaker insertion. With a mean follow-up of 3 years, 90.4% of patients are in sinus rhythm (or atrial pacing). Preoperative symptoms were reduced: 24% had preoperative syncope; none had syncope in follow-up; 14% of patients preoperatively had cerebral or systemic emboli; and there were no perioperative or late embolic events. The Maze procedure effectively addressed the major complications of atrial fibrillation and was associated with low perioperative and late morbidity rates.

Since the first patient underwent the Maze procedure on September 25, 1987, 346 patients have undergone this operation for the treatment of atrial fibrillation. The procedure was designed as an open-heart operation performed through a median sternotomy. It underwent 2 major modifications relatively early in the series, evolving into the so-called Maze-III procedure, which has been used exclusively since April 16, 1992. Since that time, the Maze-III procedure has been adapted to allow it to be done by minimally invasive techniques. In addition, we recently performed the entire procedure in 2 patients without the use of cardiopulmonary bypass. The operative mortality rate has remained at 2% to 3%. This includes patients undergoing concomitant high-risk cardiac surgical procedures and all re-do cases. The overall success rate in curing atrial fibrillation has been 99%. The procedure itself has been shown to cause no permanent damage to the sinus node. The left atrium has been documented to function long-term postoperatively in 93% of patients and the right atrium functions in 99% of patients. The Maze-III procedure remains the surgical procedure of choice for the treatment of medically refractory atrial fibrillation.

The Cox-Maze procedure corrects atrial fibrillation in 90% of patients, and successful operation restores sinus rhythm, thereby reducing risks of thromboembolism and anticoagulant-associated hemorrhage. Symptoms such as palpitation and fatigability also improve with restoration of atrioventricular synchrony. At the Mayo Clinic, 221 Cox-Maze procedures were performed from March 1993 through March 1999. Over 75% of patients had associated cardiac disease and concomitant operations. Overall, early mortality was 1.4%, and the incidence of postoperative pacemaker implantation was 3.2%. Limiting incisions to the right atrium simplifies the operation for patients who primarily have tricuspid valve disease, and in early follow-up, outcome appeared to be as good as that achieved with biatrial incisions. The Cox-Maze procedure has proved particularly useful for patients with preoperative atrial fibrillation who require valvuloplasty for acquired mitral valve regurgitation; 87 patients have had this combined procedure, and there have been no early deaths. Further, our experience indicates that ventricular dysfunction is not a contraindication for operation and that restoration of sinus rhythm after the Cox-Maze procedure improves left ventricular ejection fraction in most patients.