Clinical Outcome and Safety of Cox-Maze IV Pro-cedure for Atrial Fibrillation Associated with Con-genital Heart Disease: A Case Report and Literature Review

Introduction: Atrial Fibrillation in adult patients presenting with congenital heart disease (ACHD) is the prime cause of morbidity and mortality. In this sub group of people, the majority of hospital admissions are caused by atrial fibrillation and according to some studies, it represents about 20-25% of late mortalities1. Because the need for further cardiac operations is frequent in ACHD, the Cox-maze IV procedure (CM4) performed together with other cardiac procedures has shown to be successful in the restoration of normal sinus rhythm (NSR). The aim of this case report is to evaluate the Maze operation's safety and early clinical outcomes in the treatment of symptomatic and medically recurrent AF and also assess the advantage and risks of concomitant congenital heart surgery (Atrial Septal defect ASD) with the Cox-Maze procedure. Case presentation: Presenting a 58 year old male with congenital atrial septal defect with associated atrial fibrillation who successfully underwent a COX MAZE 4 procedure with complete cessation of atrial fibrillation. The patient had no complications after surgery and was discharged 22 days post-operative. He underwent ASD closure and left atrial appendage (LAA) closure 3 years prior indicated for atrial fibrillation and stroke. Discussion: AF is frequently seen in patients with ASD, the high incidence of AF in patients with ASD is linked to chronic volume overload as a result of a left-to-right atrial shunt, resulting in geometrical and electrical remodeling of both upper chambers of the heart (atria) and the incidence of ASD-associated AF is also firmly related with age2. Although a standalone closure of ASD may lead to restoring of normal sinus rhythm, it is widely agreed upon that surgical intervention for AF should be performed on ASD closure, this is particularly so in elderly patients with chronic AF and enlarged right atrium2. The ablation-assisted Cox-maze IV procedure (CM4), established severalyears back, has dramatically reduced and made easy the operation and has led to a reduction in morbidity and mortality attributed with the Cox Maze Procedure. The CM4 currently is the gold standard surgical treatment for AF, with a 93% freedom from AF and 85% freedom from AF andantiarrhythmic drugs (AAD) at 1year, and a 78% freedom from AF and 66% freedom from AF and AAD at 5years3. Conclusion: Cox Maze 4 operation for the treatment of Afib in ACHD is a safe and an effective procedure. The Cox Maze 4 has an excellent efficacy at maintaining normal sinus rhythm.