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• W2587156780 abstract "Central MessageChaos has been defined as freedom with better lighting. Cox and Boineau found structure in apparently random atrial impulses. This article puts the Cox-maze IV procedure under a magnifying glass.See Article page 1087. Chaos has been defined as freedom with better lighting. Cox and Boineau found structure in apparently random atrial impulses. This article puts the Cox-maze IV procedure under a magnifying glass. See Article page 1087. We all like to think that we make progress—incremental improvements in standard diagnoses and therapy. It is rare, however, for one of us to achieve the orbital leap of identifying a therapeutic pattern within apparent randomness. In the mid 1980s, Jim Cox and Jack Boineau began exploring atrial activation patterns with 156 epicardial electrodes, and they recognized patterns—even within atrial fibrillation.1Boineau J.P. Canavan T.E. Schuessler R.B. Cain M.E. Corr P.B. Cox J.L. Demonstration of a widely distributed atrial pacemaker complex in the human heart.Circulation. 1988; 77: 1221-1237Crossref PubMed Scopus (247) Google Scholar In sinus rhythm, with age, the sinoatrial node appeared to sag down into the lateral right atrium. Maybe all the anatomy books were wrong. Extranodal atrial escape impulses originated from as many as 4 widely distributed atrial pacemaker sites.2Ferguson Jr., T.B. Schuessler R.B. Hand D.E. Boineau J.P. Cox J.L. Lessons learned from computerized mapping of the atrium. Surgery for atrial fibrillation and atrial flutter.J Electrocardiol. 1993; 26: 210-219PubMed Google Scholar Perhaps the apparent causes of atrial fibrillation could also be mapped.3Cox J.L. Schuessler R.B. Boineau J.P. The surgical treatment of atrial fibrillation. I. Summary of the current concepts of the mechanisms of atrial flutter and atrial fibrillation.J Thorac Cardiovasc Surg. 1991; 101: 402-405Abstract Full Text PDF PubMed Google Scholar, 4Cox J.L. Canavan T.E. Schuessler R.B. Cain M.E. Lindsay B.D. Stone C. et al.The surgical treatment of atrial fibrillation. II. Intraoperative electrophysiologic mapping and description of the electrophysiologic basis of atrial flutter and atrial fibrillation.J Thorac Cardiovasc Surg. 1991; 101: 406-426Abstract Full Text PDF PubMed Google Scholar If atrial fibrillation revealed mappable patterns, this common arrhythmia was not a large group of isolated, angry cardiomyocytes firing independently and unpredictably (automatic arrhythmia). A mappable circuit rhythm had to be reentrant. For a reentrant rhythm to be sustained, 3 characteristics are obligatory: (1) areas of slow conduction, (2) rapid refractoriness, and (3) zones of unidirectional block. Conceptually, then, the larger the area of “at-risk” atrial muscle, the longer it should take the reentrant impulse to course the length of the pathway. This delay would permit the origin of the impulse to repolarize before the reentrant impulse returned to stimulate it again. This hypothesis should confer 2 clinically observable and testable outcomes. (1) Antiarrhythmic drugs that slow impulse conduction velocity should prove to be proarrhythmic (we all now know this to be true). (2) By cutting the atrium into strips too narrow to sustain a reentrant arrhythmia, atrial fibrillation should be surgically curable (thus the Cox-maze procedure). In an attempt to guarantee success, Jim Cox designed the early Cox-maze procedure to slice the entire right and left atria into narrow ribbons—leaving an errant reentrant impulse with no chance of success. This early procedure resulted in atrial remnants with all the anatomic characteristics of a lawnmower accident. For most of us, pasting the atria back together proved to be a time-consuming surgical challenge. Continued refinement of the procedure at Washington University in St Louis with radiofrequency probes has simplified the repair. These ablative reentrant impulse barriers have permitted the Cox-maze procedure to be routinely tacked on to other standard surgical procedures. The study in this issue of the Journal by Schill and colleagues5Schill M.R. Musharbash F.N. Hansalia V. Greenberg J.W. Melby S.J. Maniar H.S. et al.Late results of the Cox-maze IV procedure in patients undergoing coronary artery bypass grafting.J Thorac Cardiovasc Surg. 2017; 153: 1087-1094Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar presents superb surgical results of 83 patients who, in addition to coronary artery bypass grafting, benefited from a concurrent arrhythmia ablation. At 1 year, 98% of these patients were free of arrhythmia, and 88% were no longer receiving any arrhythmia medications. The surgical results of this combined Cox-maze IV and coronary artery bypass grafting procedure are superior to the recent meta-analysis of more than 6000 patients treated with a single catheter ablative procedure. During the period of this study, the Washington University surgical group performed coronary artery bypass grafting alone on 586 patients with atrial fibrillation.5Schill M.R. Musharbash F.N. Hansalia V. Greenberg J.W. Melby S.J. Maniar H.S. et al.Late results of the Cox-maze IV procedure in patients undergoing coronary artery bypass grafting.J Thorac Cardiovasc Surg. 2017; 153: 1087-1094Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar One wonders why only 135 patients were offered the concurrent, formidably successful arrhythmia therapy. I guess they are still learning. That's good. Late results of the Cox-maze IV procedure in patients undergoing coronary artery bypass graftingThe Journal of Thoracic and Cardiovascular SurgeryVol. 153Issue 5PreviewMost patients with atrial fibrillation (AF) undergoing cardiac surgery do not receive concomitant ablation. This study reviewed outcomes of patients with AF undergoing Cox-maze IV (CMIV) procedure with radiofrequency and cryoablation and coronary artery bypass grafting (CABG) at our institution. Full-Text PDF Open Archive" @default.
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• W2587156780 title "Order out of chaos" @default.
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