title: A minimally invasive Cox maze IV procedure is as effective as sternotomy while decreasing major morbidity and hospital stay.
abstract: OBJECTIVE
  The Cox maze IV procedure has the best results for the surgical treatment of atrial fibrillation. It has been traditionally performed through sternotomy with excellent outcomes, but this has been considered to be too invasive. An alternative approach is to perform a less invasive right anterolateral minithoracotomy. This series compared these approaches at a single center in consecutive patients.
  
  
  METHODS
  Patients undergoing a Cox maze IV procedure (n = 356) were retrospectively reviewed from January 2002 to February 2014. Patients were stratified into 2 groups: right minithoracotomy (RMT; n = 104) and sternotomy (ST; n = 252). Preoperative and perioperative variables were compared as well as long-term outcomes. Patients were followed up for 2 years and rhythm was confirmed with an electrocardiogram or prolonged monitoring.
  
  
  RESULTS
  Freedom from atrial tachyarrhythmias off antiarrhythmic drugs was 81% and 74% at 1 and 2 years, respectively, using an RMT approach and was not significantly different from the ST group at these same time points. The overall complication rate was lower in the RMT group (6% vs 13%, P = .044) as was 30-day morality (0% vs 4%, P = .039). Median length of stay in the intensive care unit was lower in the RMT group than in the ST group (2 days [range, 0-21 days] vs 3 days [range, 1-61 days]; P = .004) as was median hospital length of stay (7 days [range, 4-35 days] vs 9 days [range, 1-111 days]; P < .001).
  
  
  CONCLUSIONS
  The Cox maze IV procedure performed through a right minithoracotomy is as effective as sternotomy in the treatment of atrial fibrillation. This approach was associated with fewer complications, decreased mortality and decreased length of stay in the intensive care unit and hospital length of stay.
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Lawrance
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
authors.forename: Matthew C
authors.initials: MC
authors.lastname: Henn
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
authors.forename: Jacob R
authors.initials: JR
authors.lastname: Miller
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
authors.forename: Laurie A
authors.initials: LA
authors.lastname: Sinn
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
authors.forename: Richard B
authors.initials: RB
authors.lastname: Schuessler
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
authors.forename: Hersh S
authors.initials: HS
authors.lastname: Maniar
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo. Electronic address: damianor@wustl.edu.
authors.forename: Ralph J
authors.initials: RJ
authors.lastname: Damiano
mesh_terms: D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D012189:Retrospective Studies; D012307:Risk Factors; D056346:Sternotomy / Q000009:adverse effects / Q000401:mortality; D013908:Thoracotomy / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000889:Anti-Arrhythmia Agents