Comparing Mid-Term Outcomes of Cox-Maze Procedure and Pulmonary Vein
Isolation for Atrial Fibrillation After Concomitant Mitral Valve
Surgery: A Systematic Review
Abstract
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.