Long-term outcomes of Cox-Maze IV in patients undergoing multiple concomitant cardiac procedures - Is a complex surgery a barrier to rhythm success?

Sep 29, 2026

Long-term rhythm outcomes of the Cox-Maze IV procedure were assessed in patients undergoing complex cardiac surgery with atrial fibrillation ablation delivered as a second, third, or fourth-and-beyond concomitant operation. Records from 71 patients (October 2018 to February 2025) with complete Cox-Maze IV lesion sets and at least six months of rhythm follow-up were retrospectively analyzed. Patients were stratified by the number of concomitant procedures and rhythm monitoring used 24-h Holter and pacemaker interrogation. Overall freedom from atrial tachyarrhythmias was 88.7% at a mean 26±2 months; freedom at 36 months was 100%, 80.0%, and 87.5% for Groups 1–3.

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CategoryHealthcare

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Abstract

Background

Methods

Results

Conclusion

Keywords

Turkish Journal of Thoracic and Cardiovascular Surgery 2025;33(4):442-450 Orıgınal Artıcle / Özgün Makale Long-term outcomes of Cox-Maze IV in patients undergoing multiple concomitant cardiac procedures: Is a complex surgery a barrier to rhythm success? Birden fazla eş zaman lı kardiyak cer rahi uygulanan hastalarda Cox-Maze IV işleminin uzun dönem son uçları: Kompleks cer rahi, ritim başarısına engel mi? Taylan Adademir1􀀬, Fatih Yiğit1􀀬, Fuat Büyükbayrak1􀀬, Kaan Kırali1􀀬, Ralph J. Damiano2􀀬 Institution where the research was done: Koşuyolu High Specialization Training and Research Hospital, İstanbul, Türkiye Author Affiliations: 1Department of Cardiovascular Surgery, Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul, Türkiye 2Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, Missouri, USA ABSTRACT Background: This study aims to evaluate the long-term rhythm outcomes of the Cox-Maze IV procedure in patients undergoing complex cardiac surgery, where atrial fibrillation ablation was performed as a second, third, or fourth-and-beyond concomitant operation. Methods: Between October 2018 and February 2025, a total of 71 patients (24 males, 47 females; mean age: 59±10 years; range, 36 to 80 years) who underwent a complete Cox-Maze IV lesion set and achieved at least six months of rhythm follow-up were retrospectively analyzed. The patients were grouped by the number of concomitant cardiac procedures performed: Group 1 (one procedure, n=16), Group 2 (two procedures, n=43), and Group 3 (≥3 procedures, n=12). Rhythm monitoring included 24-h Holter and pacemaker interrogation. Results: At a mean follow-up of 26±2 months, overall freedom rate from atrial tachyarrhythmias was 88.7% . Group-specific freedom rate from atrial tachyarrhythmias at 36 months was as follows: 100% in Group 1, 80.0% in Group 2, and 87.5% in Group 3. No significant intergroup differences were observed. Pacemaker implantation was needed in 7.0% of the patients. Higher procedural complexity did not adversely affect rhythm outcomes. Conclusion: Our study results suggest that Cox-Maze IV provides excellent long-term rhythm control even in complex cardiac surgeries involving multiple concomitant procedures. The effectiveness of the procedure appears to be preserved across increasing surgical complexity, supporting its broader application. Keywords: Atrial fibrillation, cardiac surgery, Cox-Maze IV, rhythm outcomes, surgical ablation. ÖZ Amaç: Bu çalışmada atriyal fibrilasyon ablasyonununikinci, üçüncü veya dört ve üzeri eş zamanlı girişimolarak uygulandığı kompleks kardiyak cerrahi hastalarında Cox-Maze IV işleminin uzun dönem ritim sonuçları değerlendirildi. Çalışma planı: Ekim 2018 - Şubat 2025 tarihleri arasında tam Cox-Maze IV lezyon seti uygulanmış ve en az altı ayritim takibi sağlanmış toplam 71 hasta (24 erkek, 47 kadın; ort. yaş: 59±10 yıl; dağılım, 36-80 yıl) retrospektif olarak incelendi. Hastalar, uygulanan eş zamanlı kardiyak işlem sayısına göre gruplandırıldı: Grup 1 (bir işlem, n=16), Grup 2 (iki işlem, n=43) ve Grup 3 (≥3 işlem, n=12) . Ritim takibi 24 saatlik Holter ve pacemaker kontrolü ile yapıldı . Bulgular: Ortalama 26±2 aylık takipte, genel atriyaltaşiaritmisiz olma oranı %88.7 idi. Otuz altı ay sonundagruplara göre atriyal taşiaritmisiz olma oranı sırasıyla şöyleydi: Grup 1 için %100, Grup 2 için %80.0 ve Grup 3 için %87.5 . Gruplar arasında anlamlı fark gözlenmedi. Hastaların %7.0’sine kalp pili implantasyonu gerekli oldu. Artan işlem kompleksitesiritim sonuçlarını olumsuz etkilemedi. Sonuç: Çalışma sonuçlarımız Cox-Maze IV işleminin birden fazla eş zamanlı işlemi içeren kompleks kardiyak cerrahilerdedahi mükemmel uzun dönem ritim kontrolü sağladığını göstermektedir. İşlemin etkinliği artan cerrahi kompleksiteyerağmen korunmuş görünmekte olup, bu durum daha geniş bir alanda uygulanabilmesini desteklemektedir. Anahtar sözcükler: Atriyal fibrilasyon, ka

FAQs

What was the main aim of this study?

To evaluate long-term rhythm outcomes of the Cox-Maze IV procedure in patients undergoing complex cardiac surgery with atrial fibrillation ablation as a concomitant operation.

How were patients grouped in the analysis?

Patients were grouped by the number of concomitant cardiac procedures performed: Group 1 (one procedure), Group 2 (two procedures), and Group 3 (≥3 procedures).

What did the results show about rhythm freedom and procedural complexity?

Overall freedom from atrial tachyarrhythmias was 88.7% with no significant differences between groups; higher procedural complexity did not adversely affect rhythm outcomes.

Sep 29, 2026

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