loading page

Comparing Mid-Term Outcomes of Cox-Maze Procedure and Pulmonary Vein Isolation for Atrial Fibrillation After Concomitant Mitral Valve Surgery: A Systematic Review
  • +2
  • Davorin Sef,
  • Vladimir Trkulja,
  • Shahzad Raja,
  • Joanne Hooper,
  • Marko Turina
Davorin Sef
Royal Brompton and Harefield Hospitals

Corresponding Author:[email protected]

Author Profile
Vladimir Trkulja
Department of Pharmacology Zagreb University School of Medicine Zagreb Croatia EU
Author Profile
Shahzad Raja
Royal Brompton and Harefield Hospitals
Author Profile
Joanne Hooper
University Hospitals Bristol and Weston NHS Foundation Trust
Author Profile
Marko Turina
UniversitatsSpital Zurich
Author Profile


Background: Although concomitant pulmonary vein isolation (PVI) is used more frequently than the Cox-maze procedure, which is currently the gold standard treatment for AF, data on the comparative effectiveness of the two procedures after concomitant mitral valve (MV) surgery are still limited. Objective: We conducted a systematic review to identify randomized controlled trials (RCT) and observational studies comparing the mid-term mortality and recurrence of atrial fibrillation (AF) after concomitant Cox-Maze and PVI in patients with AF undergoing MV surgery based on 12-month follow-up. Methods: Medline, EMBASE databases, and the Cochrane Library were searched from 1987 up to March 2022 for studies comparing concomitant Cox-Maze and PVI. A meta-analysis of RCTs was performed to compare the mid-term clinical outcomes between these two surgical ablation techniques. Results: Three RCTs and 3 observational studies meeting the inclusion criteria were included with 790 patients in total (532 concomitant Cox-Maze and 258 PVI during MV surgery). Regarding AF recurrence, estimate pooled across the 3 RCTs indicated large heterogeneity and high uncertainty. In the largest and highest quality RCT, 12-month AF recurrence was higher in the PVI arm (RR=1.58, 95%CI 0.91-2.73). In 2 out of 3 higher quality observational studies, 12-month AF recurrence was higher in PVI than in Cox-Maze arm (estimated adjusted probabilities 11% vs. 8% and 35% vs. 17%, respectively). RCTs demonstrated comparable 12-month mortality between concomitant Cox-Maze and PVI, while observational studies demonstrated survival benefit of Cox-Maze. Conclusions: Concomitant Cox-Maze in AF patients undergoing MV surgery is associated with better mid-term freedom from AF when compared to PVI with comparable mid-term survival. Large observational studies suggest that there might be a mid-term survival benefit among patients after concomitant Cox-Maze. Further large RCTs with longer standardized follow-up are required in order to clarify benefits of concomitant Cox-Maze in AF patients during MV surgery.
28 Apr 2022Submitted to Journal of Cardiac Surgery
29 Apr 2022Submission Checks Completed
29 Apr 2022Assigned to Editor
07 May 2022Reviewer(s) Assigned
16 May 2022Review(s) Completed, Editorial Evaluation Pending
11 Jun 2022Editorial Decision: Revise Minor
14 Jun 20221st Revision Received
14 Jun 2022Assigned to Editor
14 Jun 2022Submission Checks Completed
14 Jun 2022Reviewer(s) Assigned
17 Jun 2022Review(s) Completed, Editorial Evaluation Pending
04 Jul 2022Editorial Decision: Revise Minor
09 Jul 20222nd Revision Received
09 Jul 2022Submission Checks Completed
09 Jul 2022Assigned to Editor
09 Jul 2022Reviewer(s) Assigned
18 Jul 2022Review(s) Completed, Editorial Evaluation Pending
18 Jul 2022Editorial Decision: Accept
Nov 2022Published in Journal of Cardiac Surgery volume 37 issue 11 on pages 3801-3810. 10.1111/jocs.16888