The Cox maze procedure, also known as maze procedure, is a type of

heart surgery Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease (for example, with coronary artery bypass grafting); to corr ...

for atrial fibrillation. "Maze" refers to the series of incisions arranged in a

maze A maze is a path or collection of paths, typically from an entrance to a goal. The word is used to refer both to branching tour puzzles through which the solver must find a route, and to simpler non-branching ("unicursal") patterns that lea ...

-like pattern in the atria. Today, various methods of minimally invasive maze procedures, collectively named

minimaze procedure The mini-maze procedures are cardiac surgery procedures intended to cure atrial fibrillation (AF), a common disturbance of heart rhythm. They are procedures derived from the original maze procedure developed by James Cox, MD. The origin of the ...

s, are used. __TOC__

History

James Cox is an American cardiothoracic surgeon. Cox received his medical degree at

University of Tennessee Medical Center The University of Tennessee Medical Center (UTMC) is an academic medical center located in Knoxville, Tennessee and serves as a referral center for East Tennessee and regions in Kentucky and North Carolina. The University of Tennessee Graduate Sch ...

and completed his training in both General and Cardiothoracic Surgery at

Duke University Hospital Duke University Hospital is a 957-acute care bed academic tertiary care facility located in Durham, North Carolina. Established in 1930, it is the flagship teaching hospital for the Duke University Health System, a network of physicians and hosp ...

. Cox and his associates at Duke, and later at

Washington University School of Medicine Washington University School of Medicine (WUSM) is the medical school of Washington University in St. Louis in St. Louis, Missouri. Founded in 1891, the School of Medicine has 1,260 students, 604 of which are pursuing a medical degree with or ...

developed the "maze" or "Cox maze" procedure, an "open-heart"

cardiac surgery Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease (for example, with coronary artery bypass grafting); to corr ...

procedure intended to eliminate atrial fibrillation (AF). Incidence of stroke in patients with AF who are anticoagulated is still around 2-5% per year. The first such procedure was performed by Dr. Cox at St. Louis' Barnes Hospital—now

Barnes-Jewish Hospital Barnes-Jewish Hospital is the largest hospital in the U.S. state of Missouri. Located in the Central West End neighborhood of St. Louis, it is the adult teaching hospital for the Washington University School of Medicine and a major component of ...

—in 1987. The intention was to eliminate AF by using incisional scars to block abnormal electrical circuits (atrial macroreentry) that initiate and perpetuate the abnormal electrical waves of AF. This required an extensive series of full-thickness incisions through the walls of both atria, a median sternotomy (vertical incision through the sternum), and cardiopulmonary bypass (heart-lung machine;

extracorporeal circulation An extracorporeal is a medical procedure which is performed outside the body. Extracorporeal devices are the artificial organs that remain outside the body while treating a patient. Extracorporeal devices are useful in hemodialysis and cardiac surg ...

). After the introduction of the initial procedure, a series of improvements were made, culminating in 1992 in the Cox maze III procedure, which is now considered to be the "gold standard" for effective surgical cure of AF. It was quite successful in eliminating AF but had drawbacks as well. The Cox maze III is sometimes referred to as the "traditional maze", the "cut-and-sew maze", or simply the "maze." Damiano and colleagues have described a Cox-Maze IV procedure in 2002 in which they modified the Cox-Maze III technique using a combination of bipolar radiofrequency and cryothermal ablation lines. Since then, the Cox-Maze IV procedure is the gold standard surgical treatment for AF with conversion to normal sinus rhythm and freedom from AF at 1 year postoperatively of 93%. During the past 10 years, several energy sources, such as unipolar radiofrequency, bipolar radiofrequency, microwave, laser, high-intensity focused ultrasound, and cryothermia, were incorporated into various devices in order to create some of the lesions of the Cox maze III procedure without actually cutting into the atrial walls. Microwave and laser therapy have both been withdrawn from the market, but the other devices continue to be utilized to treat AF surgically.

References

{{Cardiac surgery Cardiac procedures