eComment. The modifed maze procedure as concomitant surgery: the impact of left atrial size

I read with great interest the paper by Bakker et al [1]. The Cox-maze III procedure achieved high curative rates and has become the surgical gold standard for the treatment of atrial fibrillation (AF). There are multiple risk factors for recurrent AF after a Cox-maze procedure: age, ejection fraction, duration of preoperative AF, surgical techniques, mitral valve disease, and left atrial size. The authors reported risk factors of recurrent AF but did not mention left atrial size. Duration of preoperative AF, age and ejection fraction were identified as risk factors for recurrent AF in several studies [1-3], but this is not all [4].

To our knowledge, there have been no studies denouncing the effect of left atrial size on the recurrence of AF. Increasing left atrial size was a significant risk factor for failure after a Cox-maze procedure [3,4]. Romano et al. [5] have demonstrated that combining atrial reduction plasty for a left atrial size >60 mm with a Cox-maze III procedure resulted in 89% of patients being in sinus rhythm at a mean follow-up of 19 months. Damiano et al. [4] suggest performing a more aggressive left atrial reduction or a more extensive ablation lesion set in patient with left atria ≤70 mm. We believe that in groups of patients with large left atria, the risk of recurence of AF should be strongly considered, and in this group, the value of concomitant atrial fibrillation ablation remains unclear. Surgeons must be careful for not increase the operative risk by adding a concomitant procedure of AF ablation.

Conflict of interest: none declared