1. Introduction

a. Perform Median Sternotomy

2. Incision

a. Expose the Chest Wall

b. Identify the Left Internal Mammary Artery

c. Expose the Internal Mammary Artery

d. Heparinize

e. Divide the Conduit

f. Place a Bull-Dog at the End of the Artery

3. Left Mammary Artery Harvest with Skeletonization Technique

a. Expose and Open Pericardium to Access Heart

b. Suspend the Edges of Pericardium

c. Perform Aortic Ultrasound

d. Synchronize Cardio-Version

e. Place Purse-string Sutures

f. Mobilize Superior Vena Cava

4. Preparation for Bypass and MAZE

a. Cannulate the Aorta

b. Connect the Aortic Cannula to the Bypass Machine

c. Cannulate Superior and Inferior Vena Cava

d. Connect Bicaval Cannulas to Venous Limb of Pump

e. Go On Pump

5. Cardiopulmonary Bypass

a. Isolate Right Pulmonary Veins, En-Bloc Using Bipolar Radiofrequency Energy

b. Ablate Right Pulmonary Veins Circumferentially

c. Open the Right Atrium

d. Use Bipolar Radiofrequency Clamps to Create Right Atrial Lesion

e. Use Cryoprobe to Create Right Atrial Lesion

f. Close Right Atrium

g. Use Cryoprobe to Create Left Isthmus Lesion

h. Isolate Left Pulmonary Veins

i. Create Left Atrial Lesion

6. Cox-MAZE IV

a. Assess LIMA

b. Identify and Assess the LAD

c. Perform End to Side Anastomosis

7. Coronary Artery Bypass Grafting

a. Perform Left Atriotomy

b. Excise Anterior Leaflet of Mitral Valve

c. Size the Valve

d. Lower Connecting Lesion (MAZE)

e. Create Left Isthmus Lesion (MAZE)

f. Create Roof Lesion (MAZE)

g. Place Interrupted, Everted, Pledgeted Mattress Sutures

h. Give Cardioplegia

i. Implant Valve

j. Tie Down Sutures

k. Close Left Atriotomy

8. Mitral Valve Replacement

a. Place AV Pacing Wires

b. Start Temporary Pacing

c. Go Off Pump

d. Decannulate

9. Wean from Cardiopulmonary Bypass

a. Ensure Hemostasis

b. Place Sternal Wires

c. Close Subcutaneously

d. Close Superficially with Staples

10. Closure

11. Debrief

Cardiovascular disease is a leading cause of morbidity and mortality in the United States and abroad, manifesting as shortness of breath, exercise intolerance, palpitations, and chest pain. Common cardiovascular diseases include coronary artery disease (5.6% of U.S. population), atrial fibrillation (0.95% of U.S. population), and diseases affecting the heart valves (2.5% of the U.S. population). While the majority of cases are treated medically, more advanced or severe cases are treated surgically or endovascularly, warranting an open discussion between the provider and the patient to decide the most appropriate treatment modality given the specific characteristics and preferences of the procedure and the patient. 
The Cox-MAZE IV is a surgical procedure to treat atrial fibrillation that utilizes mainly applied radiofrequency and cryothermal energy (as opposed to the “cut-and-sew” techniques in prior iterations) to treat atrial fibrillation. Coronary Artery Bypass Grafting (CABG) allows for the bypass of stenotic or occluded coronary arteries through the use of arterial or venous conduits. Mitral valve repair, or replacement, can be used for correcting mitral valve disease. Though the aforementioned procedures address different pathologies of the heart, some or all may be necessary at the same time due to concomitant disease.      
The Cox-MAZE IV combined with Coronary Artery Bypass Graft and Mitral Valve Replacement is a singular surgical procedure that is carefully planned and executed to address arrhythmic, coronary, and valvular disease while minimizing time on cardiopulmonary bypass (CPB) with an arrested heart.


VA Boston Healthcare System

Cox-MAZE IV Combined with Coronary Artery Bypass Graft and Mitral Valve Replacement

0175 - MAZE - Preprint v5 20170911

0175 - Zenati - MAZE

Cardiovascular disease is a leading cause of morbidity and mortality in the United States and abroad, manifesting as shortness of breath, exercise intolerance, palpitations, and chest pain. Common cardiovascular diseases include coronary artery disease (5.6% of U.S. population), atrial fibrillation ...

Cox-MAZE IV Combined with Coronary Artery Bypass Graft and Mitral Valve Replacement | Journal of Medical Insight

DOI
Publication Date	N/A
Article ID	175
Production ID	0175
Volume	N/A
Issue	175
https://doi.org/10.24296/jomi/175

Procedure Outline