Long-term Outcomes of Stand-Alone Maze IV for Persistent or Long-standing Persistent Atrial Fibrillation

Background. The study sought to assess the long-term outcomes of the stand-alone Cox-Maze IV procedure in symptomatic patients with refractory, persistent, or long-standing persistent atrial fibrillation (AF). Methods. Fifty-nine consecutive patients (mean age 52 +/- 10.5 years, previous catheter ablation 80%, left ventricular ejection fraction 55% +/- 3.4%, median left atrial volume index 41 [interquartile range, 34-47] mL/m(2)) with symptomatic, refractory, persistent (56%), or long-standing persistent (44%) AF, underwent stand-alone Cox-Maze IV procedure. Biatrial ablations were performed with bipolar radiofrequency and cryoenergy. Left atrial appendage was excluded in 56 of 59 (95%) patients. Results. No hospital deaths occurred and 1 (1.7%) patient required postoperative pacemaker implantation. Follow-up was 97% complete (median 5.8 [interquartile range, 3.92-7.11] years). The overall survival at 7 years was 97% +/- 2.3%. The 7-year cumulative incidence function of AF recurrence and of AF recurrence off class I or III antiarrhythmic drugs (AADs), with death as competing risk, was 14.2% +/- 5.6% (95% confidence interval [CI], 5.5%-26.8%) and 26.5% +/- 6.9% (95% CI, 14.2%-40.4%), respectively. Multivariate analysis identified the duration of AF as the only predictor of AF recurrence (hazard ratio, 1.01; 95% CI, 1.01-1.02; P < .001). At 7 years, the proportion of patients in sinus rhythm was 84%, of whom 74% were off class I or III AADs. At the last follow-up, 75% of patients were in European Heart Rhythm Association functional class I, no stroke and thromboembolic events were documented, and 70% of patients were off anticoagulation therapy. Left ventricular ejection fraction improved from 53% +/- 3.4% at baseline to 59% +/- 3.4% at follow-up (P = .003). Conclusions. This study confirmed the safety and efficacy in the long term (7 years) of the stand-alone Cox-Maze IV surgical procedure for persistent or long-standing persistent AF. Indeed, more than 70% of the patients were in sinus rhythm off class I or III AADs and off oral anticoagulation.