1. Introduction
The first maze procedure (Cox-Maze I) was performed by James Cox on
September 25, 1987 8. The procedure evolved into the
Cox-Maze III and became the gold standard surgical treatment of AF3,9. In 2002, Damiano and associates have modified the
Cox-Maze III technique and replaced the majority of the incisions with a
combination of bipolar radiofrequency (RF) and cryothermal ablation
lines in a procedure termed the Cox-Maze IV, which has shortened and
simplified the operation and has decreased morbidity and mortality10. The Cox-Maze IV is currently the gold standard
surgical treatment for AF, with estimated freedom from AF and from
antiarrhythmic drugs (AAD) at 1 year postoperatively of 93% and 85%,
respectively 11. However, concomitant pulmonary vein
isolation (PVI) is still being used more frequently than the Cox-Maze
procedure as it is the simplest and most rapidly completed set of
ablation lesions 12. In addition, PVI can be performed
without cardiopulmonary bypass in coronary artery bypass graft surgery13.
In the attempt to evaluate mid-term efficacy and safety of concomitant
Cox-Maze relative to PVI in patients with AF undergoing MV surgery, we
conducted a systematic review to critically evaluate randomized
controlled trials (RCTs) and non-randomized studies directly comparing
the two procedures in this setting with additional subgroup
meta-analysis of RCTs.