title: A systematic review of minimally invasive surgical treatment for atrial fibrillation: a comparison of the Cox-Maze procedure, beating-heart epicardial ablation, and the hybrid procedure on safety and efficacy.
abstract: There is a growing trend to perform off-bypass surgical ablation for atrial fibrillation (AF) because it is perceived to be safer and more effective than the Cox-Maze procedure with cardiopulmonary bypass (CPB) support. In this systematic review, we compared three minimally invasive stand-alone surgical ablation procedures for AF: the endocardial Cox-Maze procedure, epicardial surgical ablation and a hybrid epicardial surgical and catheter-based endocardial ablation procedure (hybrid procedure). Relevant studies were identified in MEDLINE and the Cochrane Database of Systematic Reviews according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. From 565 initial studies, 37 were included in this review. The total number of patients across all studies was 1877 (range 10-139). Two studies reported on endocardial Cox-Maze procedures (n = 145), 26 reported on epicardial surgical ablation (n = 1382) and 9 reported on hybrid surgical ablation (n = 350). For minimally invasive Cox-Maze, epicardial and hybrid groups, operative mortality rates were 0, 0.5 and 0.9%, perioperative permanent pacemaker insertion rates were 3.5, 2.7 and 1.5%, incidence of conversion to median sternotomy was 0, 2.4 and 2.5%, and reoperation for bleeding was 1.0, 1.5 and 2.2%, with mean length of stay (days) of 5.4, 6.0 and 4.6, respectively. At 12 months, rates of sinus rhythm restoration were 93, 80 and 70%, and sinus restoration without anti-arrhythmic medications was 87, 72 and 71%, for Cox-Maze, epicardial and hybrid procedures, respectively. Of the three procedures, the minimally invasive Cox-Maze procedure with CPB support was most effective for the treatment of stand-alone AF and had important safety advantages in conversion to sternotomy and major bleeding. The minimally invasive Cox-Maze procedure with CPB support also demonstrated the potential for a higher success rate 12 months following the procedure.
authors.affiliation: Inova Heart and Vascular Institute, Falls Church, VA, USA.
authors.forename: Hyung Gon
authors.initials: HG
authors.lastname: Je
authors.affiliation: Inova Heart and Vascular Institute, Falls Church, VA, USA.
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Shuman
authors.affiliation: Inova Heart and Vascular Institute, Falls Church, VA, USA niv.ad@inova.org.
authors.forename: Niv
authors.initials: N
authors.lastname: Ad
mesh_terms: D001281:Atrial Fibrillation / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D002315:Cardiopulmonary Bypass / Q000379:methods / Q000401:mortality; D017115:Catheter Ablation / Q000379:methods* / Q000401:mortality; D004562:Electrocardiography / Q000379:methods; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D061646:Operative Time; D061214:Patient Safety; D010496:Pericardium / Q000601:surgery*; D011379:Prognosis; D018570:Risk Assessment; D012720:Severity of Illness Index; D015996:Survival Rate; D016896:Treatment Outcome
keywords: Atrial fibrillation; Minimally invasive procedures; Surgical ablation