Page 6 - CBAC Newsletter 2017

The Surgical Treatment of Atrial
Fibrillation at Washington University:

Three Decades of Progress

By Ralph J. Damiano Jr., M.D.*

The Evarts A. Graham Professor of Surgery
Chief, Division of Cardiothoracic Surgery
Co-Chair, Heart & Vascular Center, Barnes Jewish Hospital
Washington University School of Medicine, St. Louis, MO

Introduction

Atrial fibrillation (AF) is the most common cardiac preoperative planning for the CM IV, to describe the
arrhythmia and the treatment options include medical operative technique, and to review the outcomes both
treatment, catheter-based ablation, or surgical in our institution and others. Finally, this review explores
interventions. AF is a major cause of stroke, and its future directions for the surgical treatment of patients
prevalence is increasing.[1] The surgical treatment of with AF.
AF has been revolutionized over the past two decades The first experimental surgical therapies for AF were
through surgical innovation and improvements in developed in the early 1980s. Several procedures were
endoscopic imaging, ablation technology, and surgical developed, including the left atrial isolation procedure
instrumentation. The Cox-Maze (CM) procedure, which [4], the corridor procedure [5], and the atrial transection
was developed by Dr. James Cox and introduced procedure [6]. However, those procedures were
clinically in 1987, [2, 3] is a procedure in which multiple abandoned because they failed to prevent AF and/or
incisions are created in both the left and right atria to restore normal sinus rhythm.
eliminate AF, while allowing the sinus impulse to reach Based on extensive animal studies, Cox and colleagues
the atrioventricular (AV) node.[2] This procedure became went on to develop the Cox-Maze (CM) procedure and
the gold standard for the surgical treatment of atrial first performed it on a patient with long standing
fibrillation. Its latest iteration is termed the CM IV, and persistent lone AF at Barnes Hospital in St. Louis in
was introduced in 2002. The CM IV replaced the previ- September 1987.[7] The procedure involved making
ous cut-and-sew method (CM III) by replacing most of multiple left and right atrial incisions that formed a
the incisions with a combination of bipolar set of scars which isolated the pulmonary veins and
radiofrequency (RF) and cryoablation. By employing posterior left atrium and also interrupted putative
ablation technology, the CM IV was technically easier, macro-reentrant circuits thought to be responsible
faster, and more amenable to minimally invasive ap- for AF. The initial procedure, the CM I, resulted in
proaches. occasional left atrial dysfunction and had a high
This review will show how the basic research done over incidence of pacemaker implantation due to the
the last three decades in the Cardiothoracic Surgery inability to generate an adequate sinus node
Research Laboratory has been translated into clinical response to exercise and other forms of stress.[8]
practice, and how that has impacted patient care. The A second iteration, the CM II, preserved normal sinus
aims of this article are to review the indications and

* Corresponding Author: Ralph J. Damiano, Jr., MD, 660 S. Euclid Ave., Campus Box 8234, St. Louis, MO 63110
Tel: (314)362-7327, Email: damianor@wustl.edu

1 | CBAC Center Heartbeat