1. 1/ Incidence of AF: 5% of the population > 60 years, - 600 000 candidates for AF surgery in USA 2/ Etiologies: among patients applying for a life insurance: 40% lone AF, 60% with cardiopathy 3/ Restoration of sinus rhythm after valve repair depends upon the duration of AF (> 1year) and left atrium dimensions (>60mm) 4/ The presence of preoperative AF does not influence the operative risk Specific surgical procedures aiming at treating atrial fibrillation must add minimal morbidity SURGICAL TREATMENT OF ATRIAL FIBRILLATION Chua JTCS 1993 & Obadia JTCS 1997

2. 1/ Original Cox-Maze III procedure 2/ Hemicox: left maze procedure 3/ Exclusion of the pulmonary veins (+ left appendage exclusion) ATRIAL EXCLUSION LINES which tracing?

3. CLASSICAL COX-MAZE III left appendageright appendage inf. veina cava sup. veina cava pulmonary veins septal incision mitral tricuspid

4. LEFT COX-MAZE PROCEDURE left appendage pulmonary veins mitral

5. EXCLUSION OF THE PULMONARY VEINS left appendage pulmonary veins

6. COX-MAZE PROCEDURE associated to mitral valve surgery N = 40 AGE: 15-71 YRS (49+16 YRS) ETIOLOGIES OF MITRAL VALVE DISEASE: degenerative20 rheumatic17 others 3 Indications: Chronic AF > 6 months35 Intermittent AF (left maze)5

7. MITRAL VALVE PROCEDURE associated to the Cox-maze MAZE DURATION complete: 52 min left: 23 min

8. RESULTS complete maze = left maze mortality: 1 (2,5%) (septic shock) reoperation for bleeding: 3 coronary bypass for circumflex stenosis 1 pace maker (complete maze) 1 fluid retention (complete maze)4 –lower limbs edema : 4 –pericardial effusion: 2 –pleural effusion: 2

9. POSTOPERATIVE EKG complete maze = left maze immediate1 month AT 1 MONTH, FREEDOM FROM AF: 75% n = 39

10. LATE EKG 1 month AT ONE YEAR: FREEDOM FROM AF: 69% 18 pts with complete maze 1 year

11. POSTOPERATIVE TREATMENT Transient stroke at 10 mths, sinus with AC : 1 anticoagulantsantiarhythmics

12. tricuspid flowmitral flow DOPPLER following COX-MAZE PROCEDURE evidence for atrial transport a e e a

13. ATRIAL WALL in chronic atrial fibrillation muscular hypertrophyfat transformation C. Guiraudon in La fibrillation auriculaire JY Le Heuzey 1997 p51

14. COX-MAZE PROCEDURE INDICATIONS AF indication N intermit. / chroniclone AF other Cox World Heart Foundation Schaff 221 20% 80% 25% 75% Mayo Clinic Mc Carthy 100 22%78% 23% 77% Cleveland Clinic Izumoto 104 0%100% 0% 100% Iwate, Japon 308 58%42%56% 44%

15. COX-MAZE OPERATION RESULTS CPB mortality fluid ret. pace maker Cox - 2,9%6%15% World Heart Foundation Schaff 122 mn 1,4%-3,2% Mayo Clinic Mc Carthy 120 mn 1%yes6% Cleveland Clinic Izumoto 177 mn 2%-6% Iwate, Japon

16. 99% 38% 99% World Heart Foundation Schaff 90% 38% 70% 3 yrs Mayo Clinic Mc Carthy - 33% 90% 3yrs Cleveland Clinic Izumoto 72% - 65% 5yrs Iwate, Japon free from AF free from AF postop. intermittent AF late COX-MAZE OPERATION RESULTS

17. COX-MAZE OPERATION RECENT ADVANCES 1/ Results of patients with rheumatic vs degenerative MV disease are identical Lee, Annals 2003:75:57-61 2/ Right sided maze does not arrythmogenic substrate of lone AF and may not be necessary Jessurun, Europace 2003;5:39-46 3/ The maze operation does not influence atrial volumes in patients with lone AF / mitral surgery reduces LA volume Jessurun, Annals 2003;75:51-6 4/ The left maze can be performed through a minimally invasive approach Akpinar, Eur J Card Surg 2003;24:223-30

18. 1/ Surgical cut and sew =GOLD STANDARD 2/ Radiofrequency 3/ Cryogenic injuryTRANSMURALITY ? 4/ Microvawe ENERGY SOURCES which ablation technique?

19. RADIOFREQUENCY ABLATION technical approach endocardialepicardial

20. epicardial & endocardial probes histology showing transmural lesion RADIOFREQUENCY ABLATION

21. RADIOFREQUENCY PROCEDURE INDICATIONS 98% 2% 8% 92%132 Benussi Eur JCS 2003:17;524 81% 19% 0% 100%200 Sie Eur Soc Card 2003 100% -19% 50%69 Le Tourneau Eur Soc Card 2003 Surgery mitral aortic/ CABG AF Intermit. chronic N

22. RADIOFREQUENCY PROCEDURE RESULTS 77% 79%- - Benussi Eur JCS 2003:17;524 73% Sie Eur Soc Card 2003 67% 21% 12% Le Tourneau Eur Soc Card 2003 3 years AF free 6 months AF free Intermit. Chronic

23. RADIOFREQUENCY ABLATION RECENT CONCEPTS 1/ No transmurality when atrial wall thickness > 4 mm 2/ The epicardial is less efficient than the endocardial approach (epicardial fat + circulating blood) Thomas, Annals 2003:75:543-8 3/ Atrioesophageal fistula is a potential complication: cachectic patient, LA ectasia, TEE probe Mohr, J Thorac CVS 2002;123:919-27 4/ Circumflex coronary stenosis is a potential complication Fayad, Annals 2003;76:1291-3 5/ Age at surgery and postop arrhytmias are predictive factors of a negative outcome Benussi, Eur J Card Surg 2003;17:524-9

24. CONCLUSIONS 1/ The Cox-Maze operation is very efficient in restoring normal sinus rhythm in chronic or intermittentAF and remains the gold standard 2/ The left maze seems to be as efficient as the complete maze in pts with mitral valve disease 3/ Radiofrequency ablation could be an important adjunct in pts with lone/non-mitral related AF 4/ Antiarrhythmics are often necessary to maintain a good long term results 5/ The TE risk is decreased but not eliminated