This article has Open Peer Review reports available.
Preoperative risk factor analysis of postoperative stroke after Cox-maze procedure with mitral valve repair
© Kim et al.; licensee BioMed Central Ltd. 2014
Received: 22 March 2013
Accepted: 20 August 2014
Published: 11 September 2014
Atrial fibrillation (AF) is a life-threatening arrhythmia that carries the high risk of thromboembolic complication. Stroke often develops in patients who undergo successful Cox Maze procedure, despite the fact that the procedure has shown a high rate of success in sinus conversion from AF. This study examined the preoperative risk factors predictive of stroke following Cox Maze procedure in patients with mitral valve disease.
240 patients with the mean age of 57 years underwent Cox-Maze IV procedure with mitral valve repair from November 2007 through December 2010. All patients were available during the follow-up period with the mean duration of 23.6 months. This study excluded those patients who had undergone mitral valve replacement because of maintenance of warfarin medication
Sixteen patients had an ischemic stroke. Of these sixteen patients, six had a transitional ischemic accident while the remaining ten had cerebral infarction. Twelve of sixteen showed sustained sinus rhythm, three showed AF and one had pacing rhythm. Univariate analysis showed that only preoperative stroke history was associated with postoperative stroke (p = 0.03). High CHA2DS2-VASc score, rheumatic etiology, large left atrium (LA), preoperative or postoperative LA thrombus, age, sex, hypertension, and concomitant surgery were not associated with predictive risks for stroke.
In the group of patients who underwent the Cox-Maze procedure with mitral valve repair, having a stroke history was the only preoperative risk factor that could lead to a stroke event after surgery. Accordingly, patients with affliction of ischemic stroke, albeit sustained sinus rhythm, may require prophylactic anticoagulation.
Atrial fibrillation (AF) is the most significant arrhythmia that may cause thromboembolic complications. AF under any circumstance causes reduction of cardiac output and thrombus formation that may provide the grounds for systemic embolism. AF increases the risk of death by nearly twice and ischemic stroke by about five folds . In particular, AF occurs in 30~50% from the group of patients with mitral valve disease [2, 3]. With respect to the reason for a hospital visit in these patients, there are more cases with symptoms associated with stroke than there are cases with symptoms related to cardiac disease. AF would not largely disappear by surgical modality with mitral valve repair alone in such group of patients.
Advances in the Cox-Maze procedure have made it the most valid method in AF treatment. Its complex techniques have continuously been modified and advanced  to the point of achieving 90% success rate in surgery [5–7].
The success rate of having sinus conversion of the heart rhythm after Cox-Maze procedure is considerable in patients with a mitral valve disease. Nevertheless, ischemic stroke occurs quite often in patients with successful sinus conversion. The reason may be that patients have either transient reversion to AF or a cerebral arterial disease. However, a recent study revealed that the incidence rate of postsurgical stroke had been high in patients with a large left atrium devoid of contractile function in the left atrium .
This study examined the incidence rate of stroke following mitral valve surgery and Cox-Maze procedure in AF patients with mitral valve disease. This study retrospectively analyzed various preoperative parameters and investigated risk factors that could cause stroke after surgery.
Demographic data and operative profiles
Number of patients
56.9 ± 12.1
HTN, n (%)
History of preoperative stroke
Prior cardiac surgery, n (%)
Paroxysmal, n (%)
Persistent, n (%)
Rheumatic, n (%)
Degenerative, n (%)
Others, n (%)
Presence of left atrial thrombus, n (%)
59.7 ± 7.4
LA dimension, mm
51.0 ± 11.7
MV repair, n (%)
Concomitant cardiac surgery
AV repair, n (%)
TV repair, n (%)
CABG, n (%)
ASD or PFO closure, n (%)
Other, n (%)
All surgeries were carried out under cardiopulmonary bypass after reaching moderate hypothermia and cardioplegia-induced cardiac arrest by infusing a cardioplegic solution. An antegrade approach was only used for cardioplegic solution in isolated mitral valve surgery, while a retrograde approach was used in mitral valve surgery with concomitant aortic valve surgery. Generally, the cardioplegic solution was infused every 35 minutes. Intraoperative transesophageal echocardiogram was inserted for all patients. The mitral valve was exposed by making incision on the interatrial groove for all patients, and cryothermy ablation was performed using the left-sided Cox-Maze IV procedure (Figure 1). In cases of mitral regurgitation, patch obliteration technique  for posterior leaflet prolapsed and artificial chordae formation techniques for anterior leaflet prolapse were employed. Annuloplasty was performed by using the Mitra-strip (ScienCity, Inc. Seoul, Korea), which had been newly developed for the posterior supraannular plication .
For the repair of rheumatic mitral disease, in which mitral stenosis due to leaflet calcification would be the primary lesion, 1) thickened calcified leaflet was removed by slicing, then, 2) commissurotomy was performed, followed by 3) making extension of the posterior leaflet by using a bovine pericardial patch, and then 4) annuloplasty incorporating the Mitra-strip was carried out.
The concomitant procedures included tricuspid valve repair, aortic valve repair, coronary artery bypass grafting, ASD closure or others.
Overall postoperative care was similar to that of patients with routine cardiac surgery. Amiodarone was infused to all patients except for patients who developed bradycardia (pulse rate < 60beats/min). A saturation dose of 300 mg adiodarone was slowly injected after surgery. Thereafter, an oral dose of 200 ~ 400 mg/day was administered after extubation. Amiodarone was prescribed for all other patients who did not develop bradycardia during the hospital day, and was maintained for three months after discharge from our institute. Anticoagulation therapy was also maintained for three months after discharge in patient with successful Cox-Maze procedure due to the application of annuloplasty ring. After discharge, all patients were followed-up at the outpatient clinic once every three months on the average. On each visit at the outpatient clinic, patients underwent 12-lead ECG for check-up. Amiodarone and anticoagulation were continued for patients with AF recurrence after hospital discharge. When patients developed stroke, anticoagulation therapy along with neurology consultation was immediately started again, albeit no recurrence of AF.
Continuous variables were expressed as the mean and standard deviation while discrete variables were expressed in frequency and percentage. The Cox proportional hazards regression model as well as univariate analyses were used to determine the risk factors. SPSS Korean version 18.0 (SPSS Inc, Chicago, IL USA) was used for the statistical process and the p values less than 0.05 were considered statistically significant.
The characteristics of the patients
Of these two 240 patients who underwent the left-sided Cox Maze IV procedure with mitral valve repair, 91 were males, 39 had hypertension and 28 had a history of thromboembolic event before surgery. Eight patients had a history of prior heart surgery. Permanent AF type was overwhelmingly numerous with the number of patients showing 235 (97.9%). Preoperative echocardiography confirmed the left atrial enlargement suggestive of a mitral valve disease in the most patients. 22 patients (9.2%) were confirmed as having a thrombus in the left atrium during surgery (Table 1).
The primary indications for surgery and pathologic findings revealed that 94 patients had degenerative mitral valve regurgitation while 139 patients had a rheumatic disease with the evidence of mitral valve stenosis with insufficiency (Table 1).
All of 240 patients underwent mitral valve repair with Cox-Maze procedure. The most frequently performed concomitant surgery was aortic valve repair (80 cases). This was followed by 64 cases of tricuspid valve repair, eight cases of coronary artery bypass grafting and nine cases of either atrial septal defect or persistent foramen ovale closure (Table 1).
All of 240 patients who underwent the left-sided Cox-Maze procedure with mitral valve repair were followed-up for the mean duration of 23.6 ± 7.9 months. Among these 240, sixteen subjects (6.7%) developed thromboembolic event(s) during the follow-up period. Of these sixteen patients, six suffered with mild transitional ischemic accident (TIA) but recovered symptomatically within a day. The rest of the patients were diagnosed as having cerebral infarction by neurologists as well as brain computed tomographic scan confirmation. Eight patients fully recovered with anticoagulation and rehabilitative treatment. One patient recuperated after right middle cerebral artery thrombectomy while the remaining one patient expired from pneumonia during the neurologic treatment after development of stroke. All sixteen patients were treated in the hospital at the time of thromboembolic event, and left atrial thrombus was not found for all of them in echocardiography which was performed on admission.
The time it took to development of thromboembolic event after surgery was 227.6 ± 333.6 days on the average. The ECG results of sixteen patients on admission showed that sinus rhythm was found in twelve patients (75%), AF in three patients (18.8%) and pacing rhythm in one patient (6.3%).
Predictive risk factors of thromboembolic events after Cox-Maze procedure
Preoperative risk factors of thromboembolic events
OR (95% CI)
Preoperative giant LA (>60 mm)
Concomitant cardiac surgery
Warfarin stop at 3 M postoperatively
Preoperative LA thrombus
Postoperative LA thrombus
Preoperative stroke history
The present study showed that preoperative history of stroke would increase the risk of postoperative stroke after Cox-Maze procedure with mitral valve repair. Buber et al. suggested left atrial mechanical contraction and left atrial size as the postoperative risks of stroke after Cox-Maze procedure . However, there were few studies that analyze the risk factors for postoperative stoke. Many studies focused on the factors influencing the outcome of Cox-Maze procedure itself [13–17], but few studies focused on postoperative stroke . Owing to the fact that AF increases stroke incidence by five folds , previous studies have focused on either restoring sinus rhythm or analysis of the risk factors that lead to failure of Cox-Maze procedure. Furthermore, the incidence of postoperative stroke is a mere 1-3% [13, 18, 19], making it difficult to analyze the risk factors of postoperative stroke. On the other hand, having the incidence rate of postoperative stroke of 6.7% in this study is considerably higher than that of other previous studies. However, heterogeneous population, witnessed in this investigation, involving a large numbers of rheumatic mitral valve and double valve diseases, may affect the incidence rate of stroke. It was remarkable that twelve of sixteen patients (75%) with postoperative stroke demonstrated sinus rhythm while eight of the twelve (67%) patients had left atrial mechanical contraction in echocardiography at the onset of stroke. This result did not concur with that of Buber et al. study . Buber et al. reported fifteen cases of stroke (10% in patients with normal sinus rhythm or 6.4% of the entire Cohort) in patients with sinus rhythm following successful Cox-Maze procedure, and also demonstrated that restoration of sinus rhythm would not enough to avoid the stroke . Furthermore, they concluded that the absence of left atrial mechanical contraction would be a strong independent risk factor for the postoperative stroke. The consideration is that a history of preoperative stroke is closely related with postoperative stroke regardless of left atrial mechanical contraction, albeit only univariate analysis which had been carried out. Meanwhile, the CHA2DS2-VASc score for stroke prediction  was analyzed as a risk factor. Univariate analysis showed that high CHA2DS2-VASc score (score ≥2) appeared not to be related with postoperative stroke (p = 0.08). This was consistent with the result of Buber and colleague . This outcome was unexpected due to the fact that stroke risk score took account of history of stroke, transient ischemic attack and thromboembolism, which would be considered high risk in these cases. Such finding might have resulted from the aspect that the CHA2DS2-VASc score consisted of the combination of several risk factors.
Postoperative rhythm status
AF or A flat
This study had a number of limitations. Having conducted a retrospective study with observational data, albeit all subjects were followed up for observations, these subjects were not homogenous and follow-up duration was relatively short. Only 142 of 240 patients underwent isolated mitral valve surgery including mitral valve repair, repair of function tricuspid regurgitation as well as Cox-Maze procedure, and others had surgery of double valve diseases or of the concomitant coronary artery surgery. This might have affected the success rate of the Cox-Maze procedure and the incidence rate of the stroke. A long-term study is necessary to confirm the results of this investigation. The results of this study were reported with rhythm statuses at intervals, and this might have overestimated the success rate of the Cox-Maze procedure . A large scaled multi-center study is needed to overcome several limitations of which limited sample size and a single-center study.
A history of preoperative stroke would increase the postoperative risk of stroke, following the Cox-Maze procedure concomitantly with mitral valve repair, in the group of patients with permanent AF accompanied by a structural mitral valve disease. Therefore, patients who had experienced ischemic strokes might require preventive anticoagulation even in cases with sustained sinus rhythm.
- Kannel WB, Wolf PA, Benjamin EJ, Levy D: Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol. 1998, 82: 2N-9N.View ArticlePubMedGoogle Scholar
- Cox JL, Ad N, Palazzo T, Fitzpatrick S, Suyderhoud JP, DeGroot KW, Pirovic EA, Lou HC, Duvall WZ, Kim YD: Current status of the Maze procedure for the treatment of atrial fibrillation. Semin Thorac Cardiovasc Surg. 2000, 12: 15-19.View ArticlePubMedGoogle Scholar
- Lim E, Barlow CW, Hosseinpour AR, Wisbey C, Wilson K, Pidgeon W, Charman S, Barlow JB, Wells FC: Influence of atrial fibrillation on outcome following mitral valve repair. Circulation. 2001, 104: I59-I63.View ArticlePubMedGoogle Scholar
- Ad N: The Cox-Maze procedure: history, results, and predictors for failure. J Interv Card Electrophysiol. 2007, 20: 65-71.View ArticlePubMedGoogle Scholar
- Gammie JS, Laschinger JC, Brown JM, Poston RS, Pierson RN, Romer LG, Schwartz KL, Santos MJ, Griffith BP: A multi-institutional experience with the CryoMaze procedure. Ann Thorac Surg. 2005, 80: 876-880.View ArticlePubMedGoogle Scholar
- Gaynor SL, Diodato MD, Prasad SM, Ishii Y, Schuessler RB, Bailey MS, Damiano NR, Bloch JB, Moon MR, Damiano RJ: A prospective, single-center clinical trial of a modified Cox maze procedure with bipolar radiofrequency ablation. J Thorac Cardiovasc Surg. 2004, 128: 535-542.View ArticlePubMedGoogle Scholar
- Gillinov AM, McCarthy PM: Advances in the surgical treatment of atrial fibrillation. Cardiol Clin. 2004, 22: 147-157.View ArticlePubMedGoogle Scholar
- Buber J, Luria D, Sternik L, Raanani E, Feinberg MS, Goldenberg I, Nof E, Gurevitz O, Eldar M, Glikson M, Kuperstein R: Left atrial contractile function following a successful modified Maze procedure at surgery and the risk for subsequent thromboembolic stroke. J Am Coll Cardiol. 2011, 58: 1614-1621.View ArticlePubMedGoogle Scholar
- Shemin RJ, Cox JL, Gillinov AM, Blackstone EH, Bridges CR: Guidelines for reporting data and outcomes for the surgical treatment of atrial fibrillation. Ann Thorac Surg. 2007, 83: 1225-1230.View ArticlePubMedGoogle Scholar
- Sakamoto Y, Takakura H, Onoguchi K, Hachiya T, Sasaki T, Yoshitake M, Hashimoto K: Cryosurgical left-sided maze procedure in patients with valvular heart disease: medium-term results. Ann Thorac Cardiovasc Surg. 2011, 17: 148-152.View ArticlePubMedGoogle Scholar
- Chung JW, Shin JK, Song MG, Chee HK, Kim JS: Patch valvuloplasty in patients with posterior chordae rupture. Int J Cardiol. 2012, 154: 206-207.View ArticlePubMedGoogle Scholar
- Choi JB, Kim KH, Kim MH, Kim WH: Improvement of mitral valve coaptation with supraannular plication of the posterior annulus–a newly designed strip for posterior annular plication. Ann Thorac Cardiovasc Surg. 2012, 18: 95-100.View ArticlePubMedGoogle Scholar
- Kim JB, Yun TJ, Chung CH, Choo SJ, Song H, Lee JW: Long-term outcome of modified maze procedure combined with mitral valve surgery: Analysis of outcomes according to type of mitral valve surgery. J Thorac Cardiovasc Surg. 2010, 139: 111-117.View ArticlePubMedGoogle Scholar
- Nakamura T, Izutani H, Sawa Y: Mid-term outcomes of the modified Cox-maze procedure for elderly patients: a risk analysis for failure. Interact Cardiovasc Thorac Surg. 2011, 12: 924-928.View ArticlePubMedGoogle Scholar
- Gillinov AM, Sirak J, Blackstone EH, McCarthy PM, Rajeswaran J, Pettersson G, Sabik FJ, Svensson LG, Navia JL, Cosgrove DM, Marrouche N, Natale A: The Cox maze procedure in mitral valve disease: predictors of recurrent atrial fibrillation. J Thorac Cardiovasc Surg. 2005, 130: 1653-1660.View ArticlePubMedGoogle Scholar
- Kosakai Y, Kawaguchi AT, Isobe F, Sasako Y, Nakano K, Eishi K, Tanaka N, Kito Y, Kawashima Y: Cox maze procedure for chronic atrial fibrillation associated with mitral valve disease. J Thorac Cardiovasc Surg. 1994, 108: 1049-1054.PubMedGoogle Scholar
- Stulak JM, Sundt TM, Dearani JA, Daly RC, Orsulak TA, Schaff HV: Ten-year experience with the Cox-maze procedure for atrial fibrillation: how do we define success?. Ann Thorac Surg. 2007, 83: 1319-1324.View ArticlePubMedGoogle Scholar
- Kim JB, Bang JH, Jung SH, Choo SJ, Chung CH, Lee JW: Left atrial ablation versus biatrial ablation in the surgical treatment of atrial fibrillation. Ann Thorac Surg. 2011, 92: 1397-1404.View ArticlePubMedGoogle Scholar
- Baek MJ, Na CY, Oh SS, Lee CH, Kim JH, Seo HJ, Park SW, Kim WS: Surgical treatment of chronic atrial fibrillation combined with rheumatic mitral valve disease: Effects of the cryo-maze procedure and predictors for late recurrence. Eur J Cardiothorac Surg. 2006, 30: 728-736.View ArticlePubMedGoogle Scholar
- Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ: Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010, 137: 263-272.View ArticlePubMedGoogle Scholar
- Gehi AK, Adams DH, Salzberg SP, Filsoufi F: Outcomes and predictors of success of a radiofrequency- or cryothermy-simplified left-sided maze procedure in patients undergoing mitral valve surgery. J Heart Valve Dis. 2006, 15: 360-367.PubMedGoogle Scholar
- Barnett SD, Ad N: Surgical ablation as treatment for the elimination of atrial fibrillation: A meta-analysis. J Thorac Cardiovasc Surg. 2006, 131: 1029-1035.View ArticlePubMedGoogle Scholar
- Fukada J, Morishita K, Komatsu K, Sato H, Shiiku C, Muraki S, Tsukamoto M, Abe T: Is Atrial Fibrillation Resulting From Rheumatic Mitral Valve Disease a Proper Indication for the Maze Procedure?. Ann Thorac Surg. 1998, 65: 1566-1569.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/14/116/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.