Cryoablative Cox Maze Procedure and Pulmonary Vein Isolation for Treatment of Atrial Fibrillation in Rheumatic Heart Disease Undergoing Mitral Valve Surgery

Introduction: The cox-maze procedure (CMP) is considered the gold standard surgical therapy for atrial fibrillation (AF), however, cryosurgical ablations are changing daily practice. The aim of this study was to assess the safety and efficacy of the cryosurgical ablation in rheumatic mitral valve (MV) patients with chronic AF undergoing MV surgery with or without concomitant cardiac surgeries and to compare cryoablative CMP with surgical cryoablative pulmonary vein isolation (cryo-PVI). Methods: In a prospective observational study, a total of 65 patients with long-standing persistent AF who had MV surgeries as the main procedure and underwent either biatrial cryoablative CMP-IV or surgical cryo-PVI were evaluated. Results: The patients’ mean age was 49.6 ± 10.6 years, and they were followed for a median of 16 months (ranging from 3 to 60 months). The rates of sinus rhythm were 60.9% in the CMP-IV and 74.3% in the surgical cryo-PVI groups at follow-up period. The preoperative LA size of > 4.5 cm discriminated late AF with a sensitivity of 89% and a specificity of 45% (area under receiver operating characteristics curve = 0.733, 95% confidence interval [CI] = 0.602 - 0.863). No in-hospital mortality and permanent pace-maker implantation were developed. In Cox regression analysis, the preoperative LA size (Hazard ratio [HR] 1.962, 95% CI 1.175 - 3.276, P = 0.010) and AF duration (HR 1.028, 95% CI 1.002 - 1.054, P = 0.032) predicted late AF. Conclusions: Cryoablative CMP-IV or surgical cryo-PVI for long-standing persistent AF are safe, efficacious, and cost-effective at restoring sinus rhythm in the setting of rheumatic MV surgery combined with or without other cardiac surgeries.