Randomized study of surgery for patients with permanent atrial fibrillation as a result of mitral valve disease

Background. The Cox Maze procedure has been used to treat atrial fibrillation in patients with mitral valve disease. Recently, ectopic foci, originating in the pulmonary veins, were demonstrated in patients with atrial fibrillation, and the indication was that their arrhythmia could have a focal origin. In the light of this new evidence, a simplified surgical technique to isolate the pulmonary veins was developed to eliminate permanent atrial fibrillation in patients undergoing mitral valve surgery. This study compares three surgical procedures proposed to maintain sinus rhythm after mitral valve surgery. Methods. A prospective clinical trial of 30 patients with mitral valve disease and permanent atrial fibrillation who had undergone mitral valve surgery were randomized in accordance with the type of surgery used on each: (1) associated en bloc isolation of pulmonary veins, (2) the Maze procedure, or (3) mitral valve correction alone. The preoperative clinical characteristics were similar in the three groups. Results. The overall postoperative complications were similar in all three groups. The cardiopulmonary bypass time and the aortic cross-clamping time were shorter in the control group, but this factor bore no relation to increased morbidity in the intervention groups. The relative risk of atrial fibrillation after surgery was 0.08 in the group undergoing isolation of pulmonary veins (p = 0.010; 95% confidence interval, 0.01 to 0.71) and 0.20 in the Maze group (p = 0.044; 95% confidence interval, 0.04 to 1.02) compared with the control group. Conclusions. En bloc isolation of pulmonary veins associated with mitral valve surgery appears to be safe and just as effective as the Maze procedure in maintaining sinus rhythm in patients with permanent atrial fibrillation. (C) 2004 by The Society of Thoracic Surgeons.