Evolution of the Cox Maze Procedure for Atrial Fibrillation — Video Interview with Dr. James Cox

Evolution of the Cox Maze Procedure for Atrial Fibrillation — Video Interview with Dr. James Cox

By Mellanie True Hills

February 20, 2013

  • Summary: Dr. James Cox, creator of the Cox Maze procedure for atrial fibrillation, discusses the 25-year history of the procedure
  • Reading and watching time is approximately 5 minutes

In this video interview commemorating the 25th anniversary of the Cox Maze procedure for atrial fibrillation, Dr. James Cox discussed the history of the procedure, including the first surgery. In talking about the evolution of the procedure, he mentioned that few surgeons still do the cut-and-sew Maze procedure, and that today there are various energy sources that can be used. There are also now minimally invasive versions of the maze procedure, making it less traumatic for the patient. It was an honor to be able to thank Dr. Cox for his pioneering contributions on behalf of afib patients.

View the video interview with Dr. Cox (approximately 4½ minutes)

About James L. Cox, MD

Emeritus Evarts A. Graham Professor of Surgery, Washington University School of Medicine, St. Louis, MO, and Chairman and Chief Executive Officer, World Heart Foundation


Video Transcript:

Mellanie True Hills: Dr. Cox, it’s really an honor to be with you today, and to have you share with the patient community about the history of the Cox Maze procedure.

Dr. Cox: Well, it actually started quite a few years before the Maze procedure, but I appreciate your asking about it and giving me the opportunity. Prior to the development of the Maze procedure, we’d spent almost thirty years operating on other cardiac arrhythmias—WPW syndrome, AV node reentry, and that sort of thing. So we didn’t just sort of stumble onto this, because we’d had a lot of interaction with electrophysiologists in our group, and other surgeons, and so on.

So, we had pretty much developed operations for every other arrhythmia, other than atrial fibrillation, so we started focusing on atrial fibrillation in the early 80s, and we were working on almost nothing but that. We developed actually one operation for it that didn’t work very well, there were some other surgeons who developed an operation or two that didn’t work well. And our initial objective was to be able to map atrial fibrillation and use the maps to guide what we did, just as we had done with the other procedures.

We realized shortly that that was not going to be possible, because of the fleeting nature of the re-entrant circuits and so on. So at that point we decided to just develop an operation that would preclude the ability of the reentry to occur; if the reentry could not occur in the atrium, then by definition, the atrium could not fibrillate. We still needed, after having ablated the arrhythmia, we needed to leave the atrium capable of beating in a sinus rhythm, and so the combination of those two requirements ended up with us placing a maze pattern on the atrium, and it worked very well.

We studied it for several years in the lab—we had some animal models of it. We were still operating on a lot of people with WPW syndrome—about 30% of them had atrial fibrillation. So, we went through our Investigational Review Board at the hospital and were allowed to record with multiple electrodes on the surface of the heart, maybe five seconds of data, which would take about a month to interpret what it meant. But this was in the mid-eighties, so this all led up to doing the first operation.

I remember the morning that I had the first operation scheduled, my chairman called and said, “What is this procedure you have scheduled today?” I told him, and he said, “Is that the one you’ve been working on these years?” I said yes. He said, “Is this the first one you’ve ever done?” I said yes. And he said, “What if it doesn’t work?” I said, “Well, what if it does?” And so we did it, and fortunately it worked.

It was actually done on an airline pilot from Cyprus, who was a very persistent man. We’d actually done the original operation that didn’t work on him, a year before, but he’d kept in touch with us about every day, or at least every week, so we ended up operating on him again later, and fortunately it worked.

MTH: That’s great. So how has the procedure evolved over these years? It’s been over 25 years now.

Dr. Cox:  The first procedure was done the 25th of September, 1987, so we just passed the 25th anniversary, and it’s evolved enormously. The biggest change is that there are very few people who still do the cut and sew Maze procedure; I had breakfast with one of them today, from California, and there are about four or five surgeons who still prefer to do it that way because the results are better.

The main way it has evolved, or devolved, is that a lot of the lesions have been left out, and the results when you leave the lesions out are not quite as good as the original one. The other major development, of course, is that we have other energy sources, and we can do it minimally invasively, and lots of things like that, that make it a lot less traumatic for the patient.

MTH: Right. So, on behalf of all the patients who have been cured of their afib by the Cox Maze procedure, or any of the other things that have been spawned by that procedure, I want to thank you for the great pioneering work that you did, and for giving so many of us our lives back. Thank you so much, Dr. Cox.