Cox Maze Procedure - History

History

James Cox, MD, and associates developed the "maze" or "Cox maze" procedure, an "open-heart" cardiac surgery procedure intended to eliminate atrial fibrillation (AF), and performed the first one at St. Louis' Barnes Hospital—now Barnes-Jewish Hospital -- in 1987. The intention was to eliminate AF by using incisional scars to block abnormal electrical circuits (atrial macroreentry) that AF requires. 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). 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".

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 Microwave and Laser therapy have both been withdrawn from the market but the other devices continue to be utilized to treat atrial fibrillation surgically. Most of them, however, are used to create lesion patterns that are not as extensive as those of the Cox Maze-III procedure and have not proven to be as successful. Whether the failures when using these devices are due to a failure of the energy source or to the fact that an incomplete lesion set was employed remains an unresolved matter.