ABOUT 'BEAT YOUR A-FIB'...


"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

Dr. Wilber Su Cavanaugh Heart Center, Phoenix, AZ

"Your book [Beat Your A-Fib] is the quintessential most important guide not only for the individual experiencing atrial fibrillation and his family, but also for primary physicians, and cardiologists."

Jane-Alexandra Krehbiel, nurse, blogger and author "Rational Preparedness: A Primer to Preparedness"



ABOUT A-FIB.COM...


"Steve Ryan's summaries of the Boston A-Fib Symposium are terrific. Steve has the ability to synthesize and communicate accurately in clear and simple terms the essence of complex subjects. This is an exceptional skill and a great service to patients with atrial fibrillation."

Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School

"I love your [A-fib.com] website, Patti and Steve! An excellent resource for anybody seeking credible science on atrial fibrillation plus compelling real-life stories from others living with A-Fib. Congratulations…"

Carolyn Thomas, blogger and heart attack survivor; MyHeartSisters.org

"Steve, your website was so helpful. Thank you! After two ablations I am now A-fib free. You are a great help to a lot of people, keep up the good work."

Terry Traver, former A-Fib patient

"If you want to do some research on AF go to A-Fib.com by Steve Ryan, this site was a big help to me, and helped me be free of AF."

Roy Salmon Patient, A-Fib Free; pacemakerclub.com, Sept. 2013


The Hybrid: Surgery+Catheter Ablation

Helping Doctors Understand A-Fib from the Patients’ Point-of-View

ssr-lake-zurich-400-x-300-pix-at-96-res

Steve Ryan in Zurich, Switzerland

Have you ever wished you could give your doctors an episode of Atrial Fibrillation, just so they would understand what you are going through? That’s what I did in Zurich last week (well, sort of).

I’m back from Zurich, Switzerland, where I was the only patient speaking at the 2-day 2016 Multidisciplinary Arrhythmia Meeting (MAM), a gathering of cardiologists and surgeons from leading institutions in Europe, the US and Asia who treat Atrial Fibrillation.

The Patient’s Point of View

After dinner on the first night, I spoke to a room of 200+ cardiac electrophysiologists (EPs) and surgeons. I was there to help them better understand A-Fib from the patient’s point of view. I focused on the psychological and emotional impact of A-Fib on patients―how the anxiety, fear and stress of the disease can be as bad (or worse) as the physical symptoms.

My Wish: Let Doctors Experience A-Fib for 60-Seconds

I shared my own journey with A-Fib and described my own stress, fear and frustration; then how I did extensive research and found my cure in Bordeaux by a catheter ablation (one of my Bordeaux doctors, Dr. Dipen Shah, was in the audience).

With Dr. Stefano Benussi, my host in Zurich

With Dr. Stefano Benussi, my host in Zurich

I next shared my wish that each of them could experience an episode of A-Fib for just 60-seconds―it would change their perspective of A-Fib forever. They wouldn’t soon forget the fear (am I going to die?) and anxiety (God, please stop this!).

My Challenge: Be a Resource for Your Patients

Then, I challenged them to go beyond the physical symptoms and help patients deal with their anxiety and fear. Knowledge is empowering so I recommended they personally check out and be ready to recommend at least two books and 2 websites about Atrial Fibrillation. In addition, I suggested they vet at least three psychiatrists who understand A-Fib and who could help patients in need of counseling and medication to address their anxiety.

Being Back in Normal Sinus Rhythm: Life Changing

And finally, I thanked them, on behalf of all the patients they have made A-Fib-free. There are few medical procedures as transformative and life changing as going from A-Fib to Normal Sinus Rhythm. For me, it was getting my life back.

I think I really made an impression. I don’t think anyone had ever talked to these doctors like that before. I hope my efforts will trickle down to helping others with A-Fib.

MAM 2016 300 x 100 pix at 96 resMultidisciplinary Arrhythmia Meeting 2016

The goal of MAM was to improve interaction between cardiac electrophysiologists (EPs) and surgeons who treat difficult A-Fib cases through a new Hybrid approach. Both a surgeon and an EP work together, one from inside the heart, the other from outside the heart. (Note: In the past, it’s been a rare occurrence for a surgeon to work with a cardiac electrophysiologist.) To learn more about the hybrid approach, see THE HYBRID SURGERY/ABLATION.

I want to thank my host, Dr. Stefano Benussi, University Hospital, Zurich, Switzerland, for his personal invitation to attend and speak at MAM 2016.

Look For My Reports

I’ll soon be writing reports on the key presentations. Just look for 2016 MAM.

Hybrid Surgery/Ablation Topic of the Multidisciplinary Arrhythmia Meeting (MAM)

Background: The Hybrid approach is an unusual team effort and is complementary in nature: the Surgeon works on the outside of the patient’s heart and the Electrophysiologist on the inside of the same patient’s heart.
Hybrid Surgery/Ablation is becoming an increasingly important and effective strategy for highly symptomatic patients with persistent atrial fibrillation or longstanding persistent atrial fibrillation who have failed one or two catheter ablations, and for the patient with a significantly enlarged left atrium. (Read more: Hybrid Surgery/Ablation.)

Multidisciplinary Arrhythmia Meeting (MAM)

Multidisciplinary Arrhythmia Meeting (MAM) GFXThe goal of MAM is to improve interaction between cardiologists and surgeons through multiple examples of cooperation in dealing with Atrial Fibrillation. [Note: In the past, it’s been a rare occurrence for a surgeon to work with a cardiac electrophysiologist.]

Zurich stamp GFX

Reporting for A-Fib.com

Cardiologists and surgeons from leading institutions in Europe, the US and Asia will discuss their experiences with hybrid simultaneous, hybrid stages, and multidisciplinary sequential approaches, and report their results.

Reporting from Zurich in September: I’ve been invited to attend this first Multidisciplinary Arrhythmia Meeting (MAM) by the organizers. I’ll be reporting on the key presentations and writing summary reports for our A-Fib.com readers.

Alert: Patients with Lariat Device for Left Atrial Appendage Closure

By Steve S. Ryan, PhD, February 2015

If you’ve had your Left Atrial Appendage (LAA) closed off using the Lariat device from SentreHeart, Inc., you must schedule follow-up tests at 3 months and one year intervals to check for total LAA closure with no gaps or leakage. Talk to your doctor about a TEE (Trans-esophageal Echocardiogram) or preferably a 3-D TEE. In a small number of reported cases the Lariat failed to fully seal off the LAA allowing tissue remnants to loosen, enter the blood stream and cause clot and stroke. (See Shannon Dickson’s first-hand story below.)

The Lariat Device

The Lariat device from SentreHeart, Inc.

The Lariat device from SentreHeart, Inc.; open and closed

When closing off the Left Atrial Appendage (LAA), surgeons may use the Lariat II device, a noose-like device which is slipped around this small pocket of heart tissue. The ‘lasso’ is then tightened, and eventually the tissue dies and shrivels up like a grape. In effect, the Lariat II chokes off the LAA and eliminates it as a source of A-Fib signals. (For more on the Lariat see my article: Tech & Innovations: Lariat II.)

The Problem: The ‘Gunny-Sack’ Effect

In what is described as “the gunny-sack effect”, the LAA heart tissue between the lariat lasso atrophies and becomes thinner. As with a gunnysack, the multiple tight folds begin to loosen and unravel slightly leaving a hole. If the hole is large enough, blood may flow into and out of the dead LAA possibly carrying with it dead (necrotic) tissue remnants into the blood stream. These dead tissue remnants can cause clots and strokes. Normal blood thinners don’t work on them. Any hole over 2mm can create such leaks. It’s estimated that holes greater than 2mm occur in 6% of Lariat cases, but not all cause clots and strokes. The number of clot/strokes (embolic events) reported so far is very small compared with around 2,500 total Lariat cases worldwide to-date.

Easily Fixed if Discovered

Once this hole or leak is discovered, it’s relatively easy for your surgeon to fix by closing it off with an Amplatzer Atrial Septal Occluder, an Amplatzer Duct Occluder II, or a Gore Helix Septal Occluder.

Lariat II – Should Include Short-Term Anticoagulation

And even when the LAA is completely closed off, there is still a small chance (around 2%) of clots forming inside the heart at the LAA closed off location primarily during the first 4-8 weeks. This is probably related to tissue inflammation and blood platelet “clumping” at the site. It’s therefore important for you and your doctor to consider short term anticoagulation for 6-8 weeks to reduce the risk of clot forming at the closure site. (For those patient who can not take oral anticoagulation or antiplatelet agents, there will be a small temporary risk of stroke at the LAA site while the area heals.)

Shannon W. Dickson: Tells of Clots and a Stroke After Lariat II Installed

If you’d like to read a well-written first-person account of someone who experienced clots and a stroke after having a Lariat occluder installed, Shannon W. Dickson published his experience in The AFIB Report, Number 133, August/September 2014.

(Shannon Dickson says he got the Lariat II because his A-Fib was producing loads of spots in his LAA. Even after an LAA isolation ablation a year earlier (effectively disconnecting electrically from the LAA), Shannon chose the added reassurance a successful Lariat ligation can bring. Permanently removing the LAA from the ‘AFIB/Flutter equation’ insures his LAA could never again reconnect and be a source of more arrhythmia.)

Shannon is the new managing editor of The AFIB Report; a one-year subscription to The AFIB Report is $29.00.

Editor’s Comments:
Don’t let this risk of a leak and stroke scare you away from having a Lariat device installed if you need it. If a hole or leak does form, and it’s discovered, it’s very easily fixed. Just make sure your doctors check for leaks!

Return to Index of Articles: Maze, Mini-Maze, Convergent, LAA Closure Surgeries

Last updated: Friday, August 28, 2015

References for this Article
   

Subject Index to A-Fib.com Articles for Additional Reading

Book of heart 2 Red in box 150 x 96Subject Index to A-Fib.com Articles

This index is a growing list of articles found throughout the A-Fib.com site that augment or supplement the major topics (each subject title is a link). If you have a keyword or topic, you can also use the ‘Search’ feature in the upper right corner of every page. New posts are flagged in Red.

Select a subject to browse articles:

♥  Dealing with Atrial Fibrillation

♥  Diagnosis & Testing

♥  Minerals Deficiencies & Supplements

♥  Drug Therapies & Medications

♥  Catheter Ablation, CyroBalloon and Pulmonary Veins Isolation

♥  Surgeries: Maze/Mini-Maze, Convergent, LAA Closure

  AF Symposium Articles by Year: Steve’s Summary Reports

♥  Research and Innovations


Didn’t find what you’re looking for?
Try the ‘Search our Site’ feature (top right of every page)


Return to A-Fib.com home page
Last updated: Monday, March 2, 2015

Article Index: Surgeries: Maze/Mini-Maze, Convergent, LAA Closure

Book of heart 2 Red in box 150 x 96Article Index

Maze/Mini-Maze Convergent, LAA Closure

2015 International Symposium on Left Atrial Appendage (ISLAA): Brief Reports (Feb 2015) NEW

Alert: Patients with Lariat Device for Left Atrial Appendage Closure NEW

Advantages of the Convergent Procedure by Andy C. Kiser, MD and Paul Mounsey, MD

Role of the LAA & Removal Issues

FAST Trial: Surgical Versus Catheter Ablation―Flawed Study, But Important Results for Patients


Didn’t find what you’re looking for?
Try the ‘Search our Site’ feature (top right of every page)


Return to Subject Index to A-Fib.com Articles
Last updated: Wednesday, February 25, 2015

US Centers Performing the Hybrid Surgery/Ablation – a List from A-Fib.com

Steves List logo 200 pix at 96 resUS Centers performing the Hybrid Surgery/Ablation Procedure

There are very few centers offering the Hybrid Surgery/Ablation approach because it’s relatively new, and because it’s extremely rare to have the tremendous expertise necessary in both catheter ablation and surgical A-Fib ablation at the same institution.

Note: Similar multidisciplinary ablation techniques are called ‘hybrid ablation technique’, ‘convergence process’, ‘Convergent Maze Procedure’ and ‘Convergent Ablation”’.

HOW TO FIND CONTACT INFO

Return to Steve’s Lists of A-Fib Doctors by Specialty

 Medical Center  City/State/Phone  Notes
Allegheny General Hospital’s Cardiovascular Institute Pittsburgh, PA 877-97HEART Informational link
Arrhythmia Center of Florida/FDM PLC/Interventional Cardiac Consultants Hudson, FL (727) 819-2338 Informational Link
Aurora St. Luke’s Heart and Vascular Institute Milwaukee, WI (888) 649-6892 Informational link
Bridgeport Hospital’s Connecticut Cardiac Arrhythmia Center Bridgeport, CT (203) 384-3000 Informational link
Banner Good Samaritan Medical Center/Cavanaugh Heart Center Phoenix, AZ
(602) 839-7393
Informational link
Danbury Hospital/Western Connecticut Health Network Danbury, CT
(203) 739-7000
Informational link
Doylestown Cardiology Assoc. Doylestown, PA
(267) 253-8938
 Informational link
Ellis Medicine/Medical Center of Clifton Park Schenectady, NY (518) 831-8840 Informational link
Florida Institute for Atrial Fibrillation Palm Beach Gardens, FL (561) 630-8570  Informational Link
Georgia Regents University/Medical College of Georgia Augusta, GA
(706) 721-2426
Informational link
Mount Sinai Medical Center/Columbia Un. Division of Cardiology Miami Beach, FL (305) 405-0455 Informational Link
Pinellas Arrhythmia Associates Clearwater, FL (727) 587-6999 Informational Link
Sarasota Memorial Hospital Sarasota, FL
(941) 917-8791
Stanford Hospital & Clinics Palo Alto, CA (650) 723-5771 Informational link
St. Joseph’s Hospital/Advanced Center for Atrial Fibrillation/Bay Heart Group Tampa, FL (813) 877-2342 (AFIB) Informational Link
Tampa Cardiac Specialists Tampa, FL (813) 229-9292 Informational link
TriStar Centennial Heart & Vascular Center Nashville, TN (800) 242-5662 Informational link
UNC Health Care System, Cardiac Surgery & Electrophysiology Services Chapel Hill, NC (866) 862-4327 Informational link
The University of Chicago Medical Center Chicago, IL (888) 824-0200 Informational link
Vanderbilt University Medical Center Nashville, TN (615) 322-5000 Informational link
Washington University & Barnes-Jewish Hospital/Heart & Vascular Center St. Louis, MO (866) 534-8403 Informational link
Virginia Cardiovascular Specialists, The Heart Rhythm Center Richmond, VA (804) 521-5800 Informational link

NOTICE: we offer no preferential listings. We accept no fee, benefit or value of any kind for listing a specific doctor or medical center. A-Fib.com is not affiliated with any practice, medical center or physician.

HOW TO FIND CONTACT INFO: Use the “Search our site” box (upper right on this page) to get to the right Directory page. Then, open your browser’s ‘Find on Page’ feature (‘CTRL+F’) to locate the name on the page.

Disclaimer: this directory is provided for your convenience only.  We make no endorsement of a specific physician or medical facility. Choosing a physician is an important decision and should be based upon your own investigation of each physician’s training, education and experience. This directory offers you the opportunity to locate and contact a healthcare professional directly.

A-Fib.com—your independent source of unbiased information about Atrial Fibrillation, research and treatment options.

♦♦♦

Last updated: Saturday, May 14, 2016

Back to the Top

Return to Steve’s Lists of A-Fib Doctors by Specialty

FAST Trial: Surgical Versus Catheter Ablation―Flawed Study

FAST Trial: Surgical Versus Catheter Ablation―Flawed Study, But Important Results for Patients

FAST Trial: Surgical Versus Catheter Ablation

FAST Trial: Surgical Versus Catheter Ablation―Flawed Study, But Important Results for Patients

By Steve S. Ryan, PhD
December 29, 2011

Not that long ago, surgery was the only way to fix most heart problems including Atrial Fibrillation (the Cox-Maze operation). But thanks to new techniques and discoveries like stents and the Bordeaux Group’s discovery in 1994 that a catheter with an electrode at the end can electrically isolate the pulmonary vein openings making people A-Fib free, electrophysiologists (EPs) became more involved in fixing heart problems. Surgeons had less to do.

The last fifteen years saw a tremendous growth in the number, training and quality of EPs doing Pulmonary Vein Isolations (PVIs). I remember when I could find and list only ten centers doing PVIs. Now there are over a thousand in the US alone. A-Fib is indeed an epidemic, but the medical field has risen to the challenge. Few medical discoveries have been introduced and received such wide-spread acceptance in such a short time as catheter ablation (PVI).

FDA Approves AtriCure Synergy Ablation System

And recently surgeons have gotten back in the game, thanks in no small part to the work of AtriCure, Inc. whose Synergy Ablation System was recently approved by the FDA (December 16, 2011). (The FDA approved the AtriCure system “in patients who have persistent or longstanding persistent Atrial Fibrillation and are also undergoing surgery for coronary artery bypass grafting or valve repair or replacement.” The AtriCure System is and can still be used off-label for paroxysmal A-Fib. It’s probably only a matter of time before the FDA approves AtriCure’s System for paroxysmal, stand-alone operations such as the Wolf Mini-Maze.)

The FDA approval, though limited, is nevertheless a major medical breakthrough for A-Fib patients. A-Fib patients now officially have a choice of treatments.

Catheter or Surgical Ablation?

A small study compared the two treatments head-to-head. AtriCure, Inc. provided funding for the study “Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST).”

 But which is better—catheter or surgical ablation? Over the years there have been many multi-center studies and data developed about the efficacy and safety of catheter ablation. But that’s not the case for the AtriCure system which is a relatively new treatment.

For what is probably the first time, a recent small study compared the two treatments head-to-head. AtriCure, Inc. provided funding for the study “Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST).” 59 patients at St. Antonius Hopital in Nieuwegein, the Netherlands and 64 patients at the Hopital Clinic in Barcelona, Spain were randomized to receive either a catheter ablation (CA) or surgical ablation (SA). Patients were selected who had a prior failed catheter ablation (67%), had a left atrium diameter of 40 to 44 mm and hypertension (28-40 mm is normal), or a left atrium diameter greater than 45 (33%). (At first glance this seems like stacking the deck against a successful catheter ablation. These are more difficult cases requiring more than a simple Pulmonary Vein Isolation ablation.)

Back to top

Catheter Ablation

At St. Antonius Hospital the Pulmonary Veins were re-isolated. No additional lines or ablation strategies were performed regardless of the type of A-Fib. A non-irrigated tip RF catheter was used. (This is surprising as non-irrigated tip catheters are outdated and considered less effective. Irrigated-tip catheters are SOP (Standard Operating Procedure) in most A-Fib centers today.)

At the Hospital Clinic an irrigated tip RF catheter was used. An additional Left Atrium roofline could be made at the discretion of the operator. Sometimes a Mitral Isthmus line was also made.

At either site no mention was made of using current mapping strategies to find and isolate activation sites, or the use of Complex Fractionated Atrial Electrograms, or Dominant Frequency, or step-wise ablation protocols typically used in more complex cases. (See 2007 Boston AF/Bordeaux 5-Step Ablation Treatment for Chronic A-Fib.) According to the study authors, “patients in the CA group may have been undertreated compared with patients in the SA group.” “More than 40% of (the CA) patients had nonparoxysmal AF and may have been undertreated by PVI alone…67% had already failed a prior CA, which may be a more serious predisposition to failure than anticipated.”

Surgical Ablation: AtriCure Synergy Ablation System

The surgical ablation arm used the AtriCure Synergy Ablation System which uses an RF clamp to ablate and isolate the pulmonary veins. In addition, 31% of patients had various additional LA ablation lines at the LA roof, aortic trigone, mitral isthmus, or box lesion around the PVs. “Part of these lines were made without verifying that conduction block had indeed been established.” (In a somewhat surprising observation, the authors concluded “efficacy tended to be a little lower in patients with such lines.”) The Left Atrial Appendage was also removed. And Ganglia areas on the outside of the heart were also ablated. 

Editor’s comment: Ganglia Ablation is a subject of some controversy that deserves its own report. There are over 1000 neurons (nerve signal pathways) in the Ganglia areas. They affect other areas than just A-Fib, such as the ventricles and the GI tract. According to the authors of this study, “So far, no randomized clinical trials have quantified the added effect of surgical ganglia ablation to achieve freedom from AF.”

FAST Study Results

Read our 5-star customer reviews. http://tinyurl.com/amazon-BYA-5-star-reviews

Read our 5-star customer reviews.

Efficacy: (As one would expect), the efficacy of catheter ablation was low—44.4%. What was more surprising was that the efficacy of Surgical Ablation was only 67.2%, far less than the over 90% success rates often reported (in unpublished, self-reported, or single-center, non-controlled series with short duration and lax follow-up). This is all the more surprising in that the surgical arm, in addition to isolating the pulmonary veins, often employed additional extensive lesion sets and burns in the left atrium and elsewhere on the heart. Whereas the catheter ablation arm was limited in ablation strategies it used.

Safety: The procedural adverse event rate for surgery was 23% (approximately 1 out of 4 patients) which was significantly higher than catheter ablation 3.2% (in line with previously published data). The main procedural complications in surgery were pneumothorax (collapsed lung), major bleeding, and the need for a pacemaker. (In surgical ablation the lungs have to be alternately deflated and re-inflated to fit the clamp around the pulmonary veins. Especially in older people whose lungs are no longer as elastic, this may be hard on the lungs.) These complications were caused “mostly from direct mechanical injury during the procedure. About half required additional intervention and/or prolonged hospitalization.”

“The events reported with CA seemed more transient and did not require intervention.” They seemed to center around anticoagulation, with bleeding on the one hand and transient ischemic attack, stroke and hemorrhage stroke on the other. (One of the CA patients died of a hemorrhagic stroke a month after the ablation.)

Catheter Ablation procedure time was shorter, on average 163 minutes versus a Surgical Ablation average of 188 minutes. CA patients tended to stay in the hospital 2.0 days, versus 5.5 days for surgery.

Unlike catheter ablation, “there are no large registries for minimally invasive surgical ablation that provide good insight into safety.”

Editor’s Comments: Though not the fault of the study’s investigators, the deck was obviously stacked against catheter ablation. The success rates were far lower than previously published and documented data. (For example, the Bordeaux Group reports a 95% success rate after two ablations using their step-wise ablation protocol for Persistent A-Fib patients. But what was more surprising was the moderate success rate for the surgical arm which seemed to pull out all the stops and use the newest, most advanced extensive lesion sets and burns to achieve success.
In terms of safety, a 1-in-4 major adverse event rate is huge when one considers that the surgeons were probably under intense scrutiny to perform their best and not make any mistakes, since so much was riding on this study.

Back to top

What the FAST Study means for Patients

Though not the fault of the study’s investigators, the deck was obviously stacked against catheter ablation. The success rates were far lower than previously published and documented data.

This was probably the first study to provide documented, verifiable, non-self reporting data on the safety of Surgical Ablation (Mini-Maze). The results for patients were not good. A 1-in-4 chance of a major adverse event is not acceptable for most patients.

This study did not address simpler cases of Paroxysmal A-Fib. But the surgical Mini-Maze operations are generally the same for Paroxysmal as for more complex cases. Until we get verifiable data to the contrary, anyone going for a Mini-Maze operation should expect a 1-in-4 chance of a major adverse event.

“But what if I’ve had a failed catheter ablation? Shouldn’t I get one of the more advanced types of Mini-Maze ablations?” A 67% success rate is certainly acceptable and is better odds than you’d get in Las Vegas. But one of the more disturbing findings in this study is that with the more advanced surgical approaches using ablation lines on the left atrium and burns on other areas of the heart, “efficacy tended to be a little lower in patients with such lines.” The Mini-Maze operations featuring extensive ablation lines and burns didn’t seem to work, at least in this study.

More important for patients, and disturbing, is the high complication rate and safety of surgical ablation.

And according to the numbers, you have a better (and much safer) chance of being A-Fib free if you go to catheter ablation centers specializing in advanced activation mapping, step-wise protocols, etc. Unfortunately those centers are relatively few and far between. The Bordeaux protocol, for example, is currently used in only a few centers around the world. And catheter ablation strategies for complex cases currently have not been standardized, though most centers’ strategies are very similar (See Comparison of Dr. Pappone’s, Haïssaguerre’s and Reddy’s Stepwise Approaches in Ablating for Chronic A-Fib). The FAST study, though probably the first of its kind, was a relatively small study. A-Fib patients shouldn’t rely entirely on the results of this study for their medical decisions. While the efficacy results for catheter ablation should probably be discounted because of the design bias of the study, the FAST study does raise red flags particularly about the safety, but also about the efficacy, of surgical ablation (Mini-Maze) operations.

Most reports of the FAST study tout the higher success rate of surgical versus catheter ablation, but these results don’t hold up under close scrutiny. More important for patients is the high complication rate and safety of surgical ablation.

Back to top

Return to Index of Articles: Maze, Mini-Maze, Convergent, LAA Closure Surgeries

Last updated: Wednesday, September 2, 2015

Spoiler title

Finding the Right Doctor for You and Your A-Fib

Find the Right Doctor for patients with Atrial Fibrillation, A-Fib, a fib, afib.

Finding the Right Doctor for You and Your A-Fib

When your family doctor first suspects you have A-Fib, they will probably send you to a cardiologist, a doctor who specializes in the heart. The cardiologist will probably put you on different medications (called Drug Therapy) over the next six months to a year or more to see if any of these medications will stop or control your A-Fib.

But current A-Fib medications are not very effective and often have bad side effects. In addition, time is of the essence in treating A-Fib. The longer you wait, the more your A-Fib may “remodel” your heart (i.e., change it physically and electrically). Drug therapy may not be the best option for you.

To seek treatments beyond medications, you may need to change doctors. You should see an Electrophysiologist (EP)—a cardiologist who specializes in the electrical activity of the heart and in the diagnosis and treatment of heart rhythm disorders.

 How to Start Your Search

To be cured of your A-Fib, you need to find the best doctor for you and your treatment goals. You need a doctor who will work with you to create a treatment plan—a path to finding your cure or best outcome.

To find the right doctor for you, start by creating a list of possible doctors to consider. Seek recommendations from your GP and from other A-Fib patients (see Resources/Bulletin Boards for a list of online discussion groups). If you know nurses or support staff who work in the cardiology field or in Electrophysiology (EP) labs, they are often a great resource.

Instead of a cardiologist, you should see an Electrophysiologist (EP)—a cardiologist who specializes in the electrical activity of the heart and in the diagnosis and treatment of heart rhythm disorders.

 And use the internet. To find a local Electrophysiologist yourself, we recommend the Heart Rhythm Society website and their feature called ‘Finding a Heart Rhythm Specialist’. ‘Check’ the box “to limit the results to Fellows of the Heart Rhythm Society (FHRS)”. (EPs with the FHRS designation have been recognized by their peers and are experienced heart rhythm professionals working in the field of electrophysiology and/or pacing; see more about FHRS below).

When you type in a U.S. city and state, (or country) the site gives you a list of Electrophysiologists in your area. Check for their list of specialties (not all EPs perform PVIs; some focus on pacing/pacemakers, or clinical research, for example). Look for additional information such as which medical insurance they accept.

Unfortunately this FHRS list leaves out many younger A-Fib EPs who are doing excellent work. (We haven’t found an unbiased way of identifying these younger A-Fib doctors and welcome suggestions as to how to do this,)

Start your research with a notebook and a three-ring binder…to organize the information you will be collecting.

Steves List - Doctors by Specialty for Atrial Fibrillation, A-Fib, a fib, afib

Doctors by Specialty

 Our A-Fib.com Directory

This A-Fib.com Directory of Doctors and Facilities is an evolving list of the physicians and medical centers in the U.S. and internationally treating patients with atrial fibrillation. It is offered as a service and convenience to A-Fib patients.

In addition, I’ve compiled several rosters of doctors by specialty called Steve’s Lists’.

For a list of EPs with the FHRS credential listed by state and city, see Steve’s Lists: Doctors by Specialties and more specifically, US EPs with FHRS-designation Performing A-Fib Ablations by US State/City.

We strongly encourage you to get in the habit of keeping a copy of every test result you get in your three-ring binder. Don’t leave your doctor’s office or hospital without a copy of every test they perform. Or if the test result isn’t immediately available, have them mail it to you.

 Organize Your Research

Keep your medical records and notes handy

To find the right doctor to cure your A-Fib, start your research with a notebook and a three-ring binder or a file folder.

You need to organize the information you will be collecting: printouts of information from the internet, copies of documents from your local public library or medical center library, notes from phone calls, and answers to “interview” questions during doctor consultations.

Obtain Copies of Your Medical Records, Tests, and Images

Your 3-ring binder, or file folder is also where to collect copies of all your lab tests, doctor visits, etc.

We strongly encourage you to get in the habit of keeping a copy of every test result you get in your three-ring binder. Don’t leave your doctor’s office or hospital without a copy of every test they perform. Or if the test result isn’t immediately available, have them mail it to you.

If you need to request copies of some medical records, read our article, How to Request Copies of your Medical Records. We give you three ways to request your medical records from your doctors and medical providers.

Later, when you are ready to interview new doctors, you will want to send each office a packet with your medical records, test results, and images or X-rays. When you arrive at the EP’s office, make sure they have indeed received your up-to-date medical records. As a back-up, bring your own three-ring binder with the originals.

Back to top

 Researching Doctors and Centers

Don’t rely on a single online source when researching and selecting doctors.

Credential Acronyms While researching EPs, you will notice acronyms following a physician’s name. For an explanation of these credentials and acronyms, see our article Physician Credentials.

Be cautious of all doctor informational listings you find on web sites (yes, including this one). Doctors may be listed or appear most prominently because they pay for that privilege (but not so at A-Fib.com).

Don’t depend entirely on the typical doctor informational websites or online directories. A doctor with a good lawyer can keep their name free of sanctions and board actions. And the patient surveys on these sites aren’t very scientific and lend themselves to manipulation (one can get friends or paid people to respond to the survey). Consult several sites.

Please bear in mind than not all EPs perform and have sufficient experience in Pulmonary Vein Ablation. See my “Choosing the Right Doctor: 7 Questions You’ve Got to Ask” page and my list  Doctors/Facilities/Steve’s Lists/EPs Performing Pulmonary Vein Ablation to help find the right Electrophysiologist for you.

Over the last several years there has been an astounding and welcome growth of US centers and doctors who do Pulmonary Vein Isolation (PVI) procedures. But some are low volume centers with limited facilities and training who may do as little as 20 PVAs a year.

It’s tough to quantify experience with specific numbers. But if a doctor only does 20 PVAs a year, that may not be enough to maintain and develop ablation skills. A typical experienced EP does over 50 PVIs a year. For more see our article, Considering a Catheter Ablation? Know Complication Rates When Choosing Your Doctor.

 How to Find the Information

You must do your own homework. To narrow down your list of prospective doctors you will want to scrutinize their credentials. You’ll be looking for information such as:

• Where did they attend medical school?
• Where did they do their residency program?
• What board certifications have they received?
• What are their hospital affiliations?
Where and from whom did the doctor receive special training to treat A-Fib?

On the negative side:

• Have they lost privileges with any hospitals?
• Have they been sanctioned by any medical entity?

To research each doctor, consult the internet or your local library. The following online resources may be helpful.

The Heart Rhythm Society ‘Find a Specialist online searchable directory; Also: includes the doctor’s specialties, insurance accepted, and more
The American Board of Medical Specialists (ABMS) Directory of Board Certified Medical Specialists
The American Board of Internal Medicine. http://www.abim.org/services/verify-a-physician.aspx; to check on a doctor’s certification
The Cardiothoracic Surgeon’s Network Directory of Surgeons
HealthGrades, Vitals, and RateMDs: independent healthcare ratings organizations which provides physician’s profile, education, awards & recognition, insurance accepted, hospital affiliations, and malpractice and sanctions. But be aware that these sites usually don’t review a doctor’s competence.
Online discussion groups and forums; read what other A-Fib patients have written about specific doctors. (see Resources/Bulletin Boards.)
FindACase™ http://co.findacase.com

 Create Your ‘Short’ List

Narrow down your list to the top three-to-five doctors. The next step is to get specific information from each doctor or their office personnel (call their physician assistant, nurse practitioner or office manager). Hint: you get better service if you ask for a specific doctor by name or for their physician assistant or nurse. (When you call, sound like you know the doctor.)

Note: some EPs have a “referrals only” policy, which means they won’t talk to you directly. You have to be referred by a cardiologist or a family doctor.

Gather the following Information about each prospective doctor:

  1. How long have you been performing Pulmonary Vein Ablation for my type of A-Fib? How experienced are you with RF and/or Cryo? How many procedures do you perform a year?
  2. What is your success rate with PVI/PVA? How do you define ‘success’? (No A-Fib and drug-free, for example.)
  3. What kind of complications have you had? What kind of precautions do you take to prevent complications like Atrial Esophageal Fistula?
  4. What kind of A-Fib ablation procedures and equipment do you use? What would you use for my type of A-Fib? 
  5. Do you refer patients to surgeons for a Cox Maze or Mini-Maze operation?

Most doctors and centers will welcome these questions and respond frankly to you. If they don’t, that may be a sign you need to look elsewhere. For a list of specific questions to ask doctors and how to interpret their answers, see my Questions for Doctors page.

Be Cautious: information from the doctor or their practice is ‘self-reporting data’. There is no independent entity to verify the doctor’s or their office’s responses to you. If it sounds too good to be true, it probably is.

If the doctor or their office seems reluctant to give you the info you need, it might be wise to talk with another doctor.

Back to top

 Your Consultation Appointments

Select your top three doctors. Now you are ready to set up a consultation appointment with each doctor. Think of this as an interview. Don’t worry, doctors are also ‘interviewing’ you to determine if they can help you.

Send your medical records beforehand

Beforehand, send each doctor a packet with your medical records. When you arrive at the doctors offices’, make sure they have indeed received your medical records. As a back-up, bring your own three-ring binder with the originals.

Take Notes During Your “Interview”

During your interview appointment, take lots of notes. In addition, consider using an audio recorder to help you remember things. (Most doctors don’t mind, but always ask permission beforehand.)

You may want to take along a trusted friend or family member. As needed, your ‘personal advocate’ can question the doctor for you and verify your list of questions have been answered. Afterwards they can help you evaluate the doctor’s answers, discuss anything that’s unclear and comment on the doctor’s demeanor.

Never go to any doctor appointment alone. Always carry notepad and pen to take lots of notes.

Our ‘Questions for Doctors Worksheet’

To help you scrutinize prospective doctors we’ve written a set of 7 interview questions. The questions help you find the right doctor for your treatment goals. Use our Questions for Doctors Worksheetto interview and question each prospective doctor. (Download the FREE PDF and save to your hard drive. Then, print a worksheet for each doctor you interview.) 

After Your Interviews

Back home, compare answers and your notes about each doctor. To ‘interpret’ the doctors’ answers, see our article, “Choosing the Right Doctor: 7 Questions You’ve Got to Ask (And What Their Answers Mean)“.  We’ve included the various responses you might receive, and what each response means to you when searching for the right doctor for you and your treatment goals.

Also Assess the Doctor’s Manner and Personality

You’ll also want to assess the doctor’s manner and personality. Is this someone who will work with you? Someone who listens to how A-Fib makes you feel? Does this doctor inspire confidence? Is this someone you feel comfortable with and trust with your health care? Does he/she respect you? Women in particular should be wary of condescending behavior. “It’s all in your mind.” “Take a Valium.” Women in the US often don’t receive the proper diagnosis and treatment of their A-Fib.

Rudeness, bad temper, boorish behavior, etc. from a doctor, no matter how highly recommended, should be a red flag for you. That kind of behavior is not just personally offensive but can be dangerous for your health.

Does the poor behavior also extend to how the doctor treats his staff? Patients of doctors “who don’t show respect for their medical staff have much higher rates of adverse effects, than patients of their more congenial colleagues.” “As a patient, you’re also a member of the health-care team,” explains Gerald B. Hickson, MD of Vanderbilt University Medical Center.1 If your doctor is condescending or dismisses your concerns, you’re getting poor care. If a doctor is too busy to talk with you and answer your concerns, he’s probably too busy to take care of you properly.

But do give the doctor a break. They may be having a bad day or may have heard your questions too many times before. So, say something, speak up! Or contact the patient-relations representative at the heart center. They want to know if a doctor is rude (those patients are more likely to sue!). Once a doctor’s bad behavior is called to his attention, they are likely to do better. And so will you.

File your worksheets and other notes in your binder for future reference (you might want a second opinion).

 About Catheter Ablation

Caution:A Pulmonary Vein Isolation Ablation PVA/I is the most challenging, demanding and complex catheter ablation an Electrophysiologist performs. But surprisingly, no specific certification is required. Any EP is allowed to do PVIs. When doing your basic research, make sure the EP has obtained “Clinical Cardiac Electrophysiology” Certification. It’s surprising how many EPs never pass this exam but still do PVIs. Certification in “General Cardiology” or “Internal Medicine” are more basic and not what you’re looking for.

Patients are advised to consider the more experienced EPs in the PVI field. One indicator is the credential “FHRS” after a doctor’s name. A Fellow of the Heart Rhythm Society (FHRS), is an EP certified by the American Board of Internal Medicine (ABIM) in clinical cardiac electrophysiology (CCEP), has letters of support from current FHRS members, and has been vetted by the HRS Membership Committee.

According to the Heart Rhythm Society:

“The FHRS designation distinguishes members among health care providers for their specialization in electrophysiology, clarifies the referral process, and serves as a credential for quality care for patients, media and government. FHRS members are characterized by advanced training, certification, and prominence in research.”2

New Article icon - red-heart-negative 75 sq at 96 resSince Pulmonary Vein Ablation (Isolation) is a relatively new procedure, select facilities and doctors who are more experienced with it. For more, see our article, Considering a Catheter Ablation? Know Complication Rates When Choosing Your Doctor.

In this author’s opinion, although certain centers and doctors are more experienced than others, there is no first and second tier of A-Fib doctors. In general, Electrophysiologists performing Pulmonary Vein Ablation (Isolation) are highly trained, experienced and technically gifted. Your chances of being cured by a PVA(I) are very good at most A-Fib medical centers.

Steves List - Doctors by Specialty for Atrial Fibrillation, afib, a fib, A-Fib

EPs & Ablations

 STEVE’S LIST: Electrophysiologists Performing Catheter Ablation Procedures

For a list of cardiologists doing Catheter Ablation procedures, see Steve’s Lists/US EPs with FHRS-designation performing A-Fib ablations by US State/City.

Back to top

 About Maze or Mini-Maze

After your consultation, your Electrophysiologist may recommend a Cox Maze or Mini-Maze operation for your A-Fib. Your EP will probably recommend a short list of surgeons. You will conduct the same research for finding the right surgeon as you did for finding the right EP. Unfortunately, we’re not aware of a database that lists A-Fib Surgeons by geographic area, except for the list on A-Fib.com (see Steve’s Lists/Surgeons Performing Cox-Maze and Mini-Maze Operations).

Caution: Any surgeon is allowed to perform a Maze and Mini-Maze operation, but not all have a great deal of experience doing it. There are currently no training courses or certification exams specifically required for Maze and Mini-Maze surgeries. (The same is true to some extent for catheter ablation.)

A study from the Un. of Michigan found that surgical death rates are directly related to experience with the particular operation being performed. You are four times more likely to die if your surgeon performs your operation only rarely, compared to a surgeon who performs it regularly.3 Ask your surgeon or his office how often he performs the Maze and/or Mini Maze. Call other doctors in this field to see how often they perform Mazes. Be cautious about a surgeon who performs Maze operations far less than the average.

If a surgeon specializes in exactly your condition and if 50% or more of his practice relates to your type of A-Fib, they may be a good choice.

It’s hard to establish a specific number that indicates sufficient experience and skill level, but here’s an example that may help, The death rate after pancreas surgery is 14.7% for surgeons who average fewer than two operations a year. It is 4.6% for those who do four or more. A survey done by the New York State Department of Health found that hospitals with surgeons who did relatively few operations had patient-mortality rates that were four times higher than the state average.4

Steves List - Doctors by Specialty for Atrial Fibrillation, afib, a fib, A-Fib

Surgeons & Maze

 STEVE’S LIST: US Surgeons Performing Maze and Mini-Maze Operations

For surgeons performing Maze/Mini-Maze operations, see Doctors & Facilities/Steve’s Lists Doctors by Specialties and more specifically, US Surgeons performing Maze and Mini-Maze operations.

 Other Considerations

You may also want to consider the mind set and attitudes of Surgeons vs. Electrophysiologists.

Keep in mind: a surgeon’s primary concern is in performing a successful operation, whereas EPs have devoted their careers to dealing with heart rhythm problems. The EP’s primary concern is creating a ‘treatment plan’—an organized path to finding your A-Fib cure or best outcome.

In an ideal world, a surgeon would work with and consult with an EP, especially if the surgery didn’t work. But, with certain exceptions, that generally isn’t the case today.

The Hybrid Surgery/Ablation

For more about surgeons and EPs performing procedures together, see our Treatments/Maze/Mini-Maze/Hybrid Procedures page.

You may also want to read: Advantages of the Convergent Procedure by Kiser/Mounsey, and Boston AF 2011/Edgerton “Hybrid Ablation (Combining Surgery with Catheter Ablation) for Persistent A-Fib“.

 Additional Readings

Physician Credentials and Acronyms: What They Mean for Atrial Fibrillation Patients
How to Request Your Medical Records: Instructions and a sample letter (for US patients)
Pre-visit Appointment Worksheet: From American Heart Association (www.heart.org)

Back to top

 Return to A-Fib.com Where to Start

Last updated: Monday, February 15, 2016

References    (↵ returns to text)
  1. Shannonhouse, R. “Is Your Doctor a Bully?” Bottom Line Health, September 2013, p. 2.
  2. Fellowship in the Heart Rhythm Society (FHRS) Information. Heart Rhythm Society website. Accessed April 8, 2014. URL:http://www.hrsonline.org/Membership/FHRS-Information
  3. Makary, Marty. “7 Things Your Hospital Won’t Tell You (That Could Hurt You)” Bottom Line Personal, Volume 34, Number 2, January 15, 2013. p1.
  4. Makary, Marty 2. “Surprising Dangers in the Hospital.” Bottom Line Health. Volume 27, Number 2. February 2013, p6.

Steve’s Lists of A-Fib Doctors by Specialty

Steve's Lists of Doctors by Specialty - Atrial Fibrillation, afib, a fib, A-Fib

Doctors by Specialty

Steve’s Lists of A-Fib Doctors by Specialty 

Steve has prepared these lists of doctors treating atrial fibrillation patients by specialty to help you find doctors with a particular expertise.

  1. US EPs with FHRS-designation performing A-Fib ablations: Listed by State/City
  2. US EPs Using Cryoballoon Ablation
  3. US EPs Installing the Watchman Device
  4. US Surgeons performing Maze and Mini-Maze operations
  5. US Centers performing the Hybrid Surgery/Ablation procedure
  6. EPs Specializing in Persistent/Long-Standing Persistent A-Fib (US and International)
  7. EPs using Contact Force sensing catheters

Return to Directory of Doctors Treating A-Fib: Medical Centers and Practices

Notice: unlike other directories, A-Fib.com offers no preferential listings or placement. No doctor or facility pays, provides services, etc. to be listed. We accept no fee, benefit or value of any kind for listing a specific doctor or medical center. A-Fib.com is not affiliated with any practice, medical center or physician.

If you know the name of the doctor or practice, use the “Search our site” box (upper right on this page) to get to the right Directory page. Then, open your browser’s ‘Find on Page’ feature (‘CTRL+F’) to locate the name on the page.

Disclaimer: this directory is provided for informational purposes only. We make no endorsement of a specific physician or medical facility. Choosing a physician is an important decision and should be based upon your own investigation of each physician’s training, education and experience. These listings offer you the opportunity to locate and contact a healthcare professional directly. 

A-Fib.com is your independent source of unbiased information about Atrial Fibrillation, resources and treatments.

Last updated: Tuesday, September 6, 2016

Cox Maze, Mini-Maze & Hybrid Surgeries – Atrial Fibrillation

The Cox-Maze & Mini-Maze Surgeries and the Hybrid Surgery/Ablation

Surgical Maze pattern of series of lesions

 Cox-Maze Surgeries

In the Cox-Maze open heart operation the surgeon makes numerous incisions in your atria. This “maze” of incisions divides your atria into electrically isolated segments, thereby blocking the electrical impulses that cause A-Fib from spreading throughout the heart. The atria continue to be activated by a regular signal from the sinus node.

The left atrial appendage is usually removed during this operation.

Dr. Cox developed a successor to the Cox Maze III called a “Radial Maze.” (also see 2006 BAFS: Dr. David Kess Advances in Surgical Therapy for A-Fib.”)

In a later version of the operation, the Cox Maze IV, most of the “cut and sew” incisions are replaced with linear ablation lesions created either with radiofrequency energy or cryothermy (freezing).1,2Access to the heart on pulmonary bypass can be through the sternum (breast bone) or through incisions in the chest. If access is through the chest, Dr. Damiano, Jr. calls it a Minimally Invasive Cox-Maze IV.

The Cox Maze IV operation does work and has a high success rate (“approximately 75% at two years”) but it hasn’t been used often because of the risks of open heart surgery, the danger of bleeding from the incisions, the pain, discomfort and prolonged convalescence from the operation, and the resulting reduced atrial function due to the incisions/lesions. (Voltage mapping of post-Maze patients may show that their left atrium has reduced or is entirely devoid of electrical activity because of the extensive scarring.)

According to Surgeon A. Mark Gillinov of the Cleveland Clinic, having the Maze surgery alone generally should be done only after other therapies have been tried.3

Final thoughts: Maze Surgeries for Atrial Fibrillation, a fib, afib, A-Fib

Cox Maze

However, if you have to undergo open heart surgery for another heart problem, you may want to go to a heart center that can perform the Cox Maze operation at the same time.

Note: If you have a left atrium larger than 6.0 cm or if you’ve been in A-Fib for over five years, the long term success of the “Cut and Sew” Maze operation is lower, under 80%.4

For more about the Cox Maze and Mini-Maze surgeries, you may want to read Boston AFib 2006/Advances in Surgical Therapy for A-Fib by Dr. David C. Kress.

Illustration of the typical Mini-Maze incisions locations - Atrial Fibrillation -A-Fib, afib, a fib

Typical Mini-Maze incisions locations

 Mini-Maze Operations

In newer maze operations (such as the Wolf Mini-Maze and Totally Thoracoscopic [TT] Maze) surgeons do not crack open the breastbone and stop the heart while putting the patient on a heart-lung machine as in the Cox Maze operation.

Instead the surgeons cut keyhole-sized incisions on the sides of the chest to gain access to the heart. Using a tiny video camera the surgeons loop a bipolar clamp catheter around the outside of the heart. Each lung is temporarily deflated in turn to allow the bipolar clamp to be threaded around the pulmonary veins. The bipolar clamp creates lesions around the atrium cuff of the pulmonary veins that scar and block the electrical impulses causing the irregular heartbeat.5

Though not open heart surgery like the Cox Maze III (Radial Maze), the Mini-Maze operations are nevertheless very traumatic for the body and require general anesthesia.

To be effective the ablations (lesions, burns) have to be transmural; i.e., they have to penetrate all the way from the outside of the heart to the inside. But the inside of the heart varies in thickness, has ridges, etc. And epicardial (outside the heart) fat can also prevent transmurality. Even bipolar RF burns cannot guarantee transmural lesions.6 “Transmurality of a lesion set cannot be guaranteed with current ablation catheters on the beating heart.”7 Also, proving or confirming bidirectional block from outside the heart can be challenging.8

If you have a simple case of recent onset A-Fib that requires only the isolation of the Pulmonary Vein openings, the Mini-Maze operation may work for you.

The biggest drawback to Mini-Maze operations is that they can’t currently reach or isolate all areas of the heart where A-Fib signals may originate. If you have a simple case of recent onset A-Fib that requires only the isolation of the Pulmonary Vein openings, the Mini-Maze operation may work for you. But anything more complicated is questionable. Currently surgeons don’t have the ability to map inside the heart to identify sites where A-Fib originates. For example, patients with long-standing persistent (complicated) A-Fib tend to have relatively poor results. One study cites a 46.2% success rate after three months.9(In contrast, Dr. John Sirak, inventor of the Five Box Totally Thorascopic Maze surgery, reports a 91% success rate.)10

One considered advantage of the Mini-Maze operations is that the Left Atrial Appendage is cut out, stapled shut or closed off. Most A-Fib blood clots which cause stroke come from the Left Atrial Appendage (more on this topic further down the page).

VIDEO 1: Inside the O.R. for a Mini-Maze Surgery. Dr William Harris, cardiovascular surgeon, describes what he refers to as a mini-maze procedure, the minimally invasive Lone Atrial Fibrillation Ablation. Posted by Baptist Medical Center in Jackson, Miss. (4:49 min.)

Is Mini-Maze Overkill For Paroxysmal A-Fib?

Patients may ask if a Mini-Maze surgery is overkill for simple cases of Paroxysmal (occasional) A-Fib. Some surgeons would agree.

Surgeon Andy C. Kiser says about his practice, “when a patient has paroxysmal A-Fib and the left atrium is under 4.5-5.0 cm, we recommend percutaneous (through the skin) catheter ablation. In this population, simple pulmonary vein isolation may be effective in over 80% of patients.11,12

Surgeon James Edgerton does not normally perform surgery on Paroxysmal (Occasional) A-Fib patients. “I think they are very well treated with catheter ablation.” (See surgeon James Edgerton’s presentation Boston AF 2011/Hybrid Ablation.)

Maze Surgery is Recommended in Some Cases

In general, Maze surgical treatments for A-Fib are not recommended as a first choice or option by current guidelines. They are generally more invasive, traumatic and risky than catheter ablation.

Surgery, however, is recommended if one can’t tolerate blood thinners or if one is “morbidly obese.” With current imaging systems, it’s more difficult to see a clear image of the heart during a catheter ablation if someone is significantly overweight. Also, a Mini-Maze might be a better option is you’ve already had a stroke and are more in danger of having a stroke during a catheter ablation. And if you have to have a heart operation to, for example, fix a heart valve, the surgeon can often do a Maze operation at the same time.

Mini-Maze Risks

Mini-Maze surgeries “usually have significant risks compared with catheter-based electrophysiology procedures such as catheter ablation.”13 A study comparing catheter versus surgical ablation found that Mini-Maze surgeries had about a one in four chance of a major adverse event.14

Since 2008, there have been at least five U.S. patient deaths reported to an FDA database in A-Fib surgeries using AtriCure devices and one involving a Medtronic device. (That database doesn’t prove that the devices caused the deaths.) According to Thomas M. Burton of the Wall Street Journal, currently (2010) “there are no large studies comparing the safety of surgical ablation to that of other ways to treat A-Fib.”15 

Mini-Maze-type surgeries can also be very painful, including ongoing numbness and phantom pain at chest access sites.

In addition, deflating and re-inflating the lungs can be very difficult particularly for older people whose lungs are no longer very elastic. Possible complications include but are not limited to pericardial effusion, pleural effusion, pneumothorax (collapsed lung), herniated lung, heavy coughing, bronchitis, and pneumonia.

And approximately 6% of patients may require a pacemaker.”16

In a very unscientific survey at one center, when patients were asked whether or not they would undergo a Mini-Maze surgery again, 50% said no way, 30% said it was a lot harder than they thought it would be, but 1 out of 5 said it was worth it.

When patients were asked whether or not they would undergo a Mini-Maze surgery again, 50% said no way, 30% said it was a lot harder than they thought it would be, but 1 out of 5 said it was worth it.

Read our 5-star customer reviews. Get your copy Today

Read our 5-star customer reviews. Get your copy Today!

Extent of Scarring of the Left Atrium

Scarring in the heart permanently damages heart tissue and is usually avoided unless absolutely necessary. Circulation, nerve signal pathways, heart muscle fibers, transport function, the ability of the left atrium to contract, etc. may be affected. This is irreversible heart damage. Non-contracting scar tissue replaces normal heart muscle. This may weaken the heart and may later contribute to heart problems like congestive heart failure. Millions of patients today suffer from weak hearts due to heart muscle damage.

These ablation burns are normally not a problem in the Pulmonary Vein areas which function as pipes into the left atrium, but may be a problem in areas of the left atrium more involved in heart function and contraction.

Newer Mini-Maze surgeries, such as the Totally Thoracoscopic (TT) Maze, the Five-Box Thorascopic Maze Surgery and the Dallas Lesion Set are one-size-fits-all surgeries which create a specific pattern of ablation lines/burns on the left atrium. But we don’t know if this scarring is necessary or appropriate for all cases of A-Fib.

Questions for your surgeon: Patients should ask their surgeons if this scarring of the left atrium is necessary to fix their type of A-Fib. And ask, Would a Pulmonary Vein Ablation procedure, for example, fix their A-Fib without the added risks of heart surgery and permanent heart damage?

For more see Questions for Doctors (and What the Answers Mean) - Atrial Fibrillation, A-Fib, a fib, afib

Mini-Maze

For more about the Cox Maze and Mini-Maze surgeries, you may want to read Boston AFib 2006/Advances in Surgical Therapy for A-Fib by Dr. David C. Kress.

To help you select a cardiologist, electrophysiologist or surgeon:
• see Questions for Doctors (and What the Answers Mean)
• download our free ‘Questions for Doctors Worksheet’ (in PDF format).
• see our ‘Questions for Surgeons’ in our book, Beat Your A-Fib: The Essential Guide to Finding Your Cure by Steve S. Ryan, PhD.

 The Hybrid Surgery/Ablation

Relatively new is the Hybrid Surgery/Ablation in which a surgeon and a cardiac electrophysiologist (EP) team up to work together on the same patient.17 The genius of the Hybrid approach seems to be its complementary nature: the surgeon works on the outside the heart and the EP on the inside of the heart. (Similar multidisciplinary ablation techniques are called ‘hybrid ablation technique’, ‘convergence process’, ‘Convergent Maze Procedure’ and ‘Convergent Ablation”’.)

The surgeon working on the outside of the heart can produce visible linear lesions much easier on the smooth outside surface of the heart than the EP working on the inside of the heart with point-by-point catheter ablations. The EP working inside the heart, on the other hand, is better equipped to tell if a surgical lesion is effective or not. They can then detect any gaps and correct them with catheter ablation. For example, if the surgeon’s “entrance and exit block lesions” were incomplete, the EP can identify the conduction gaps and ablate them.

To eliminate all A-Fib signals, “the goal is to treat the full thickness of the tissue,” says Dr. Paul Wang of Stanford Hospital & Clinics.18 According to Dr. Laurent Pison of The Netherlands, “in almost a quarter of patients, catheter ablation [is] needed to finish incomplete epicardial [outside the heart] surgical lesions by endocardial [inside the heart] touch-up.”19 Endocardial catheter touch-up is often necessary to achieve bidirectional block of the pulmonary veins (in about a third of patients), but even more so in the box (roof and floor) surgical lesions (about two-thirds of patients).20

Also, the EP can ablate in areas surgeons currently can’t reach such as making a Caviotricuspid Isthmus line in the right atrium to stop Atrial Flutter. In addition, the EP utilizes diagnostic mapping techniques to confirm that all abnormal electrical signals have been interrupted. EPs have years of experience and training in mapping, tracking down and ablating A-Fib signals found in areas other than the pulmonary veins, while this is difficult for surgeons working from outside the heart.

VIDEO 2: Introduction to the Hybrid Surgery/Ablation Procedure. Dr. Robert Joy gives an overview of the hybrid procedure in which a cardiothoracic surgeon and an electrophysiologist work together in a single procedure; How it opens up a new opportunity for A-Fib patients who are not good candidates for catheter-based procedures alone. Posted on the Ellis Medicine website (includes a brief promotion of their services.) (1:46) 

Access Techniques

Most often surgeons access the heart using the same method as the Mini-Maze surgery. Three or more small incisions are made between the ribs for insertion of their scope and instruments. The EP usually accesses the heart by inserting a catheter through the femoral vein in the groin and threads the catheter up and into the heart.

Another minimally invasive surgical approach is to access the heart through the soft tissues of the abdomen and with a small hole made in the diaphragm. This “convergent” approach is intended to result in less discomfort and a more rapid recovery for the patient.

Three Variations of the “Hybrid” Approach

In this article we are describing a “sequential” Hybrid approach. First, the surgeon works on the patient, then the EP steps in and takes over to detect and correct any gaps, and ablates additional locations of A-Fib signals.
A second Hybrid variation is a “simultaneous” approach with both the surgeon and the EP working on the patient at the same time. As the surgeon makes a lesion on the outside of the heart, the EP monitors the inside of the heart. The EP can tell the surgeon immediately if a particular lesion is effective (complete) or not. The surgeon can adjust the lesion or the EP can ablate the area. According to Dr. Wilber Su of the Cavanaugh Heart Center at Good Samaritan Medical Center, “the simultaneous hybrid maze procedure combines the best of what surgeons have to offer…with the knowledge, testing and confirmation of ablation by the electrophysiologist.”
A third Hybrid variation is “non-synchronous” or two-staged; the surgeon and the EP work on the same patient but they do so at different times (and sometimes even different locations).
(For more, see 2011 Boston AF: Hybrid Ablation for Persistent A-Fib.)


Results of Hybrid Surgery

In a small study of 27 patients most of whom had long-standing persistent A-Fib (the most likely candidates for a Hybrid Surgery/Ablation), at six months 72.2% of patients were in sinus rhythm, and 66.5% were off of antiarrhythmic drugs. (Four patients were still in A-Fib and one developed right atrial flutter.) These results are comparable to the success rates of catheter ablation procedures.21

Risks of Hybrid Surgery

Patients should keep in mind that Hybrid surgery, though called “minimally invasive,” is still major heart surgery. It is invasive, traumatic, complicated, requires considerable surgical skills and experience, and is potentially risky. And added to this are the low but real risks of a catheter ablation. Combining these two levels of risk is probably more dangerous than the sum of the parts. Also, patients have to be on anticoagulants for at least 90 days after the surgery/ablation.

Who Should Consider Hybrid Surgery?

The Hybrid Surgery/Ablation can be an effective option for highly symptomatic patients with persistent atrial fibrillation and longstanding persistent atrial fibrillation who have failed one or two catheter ablations, for someone with a significantly enlarged left atrium, or for someone who is morbidly obese (making it difficult to create imaging maps necessary for catheter ablations). (For more, see 2011 Boston AF: Hybrid Ablation for Persistent A-Fib”.)

Final Thoughts about the “Hybrid”

Final thoughts about the Hybrid Procedures - Atrial Fibrillation, a fib, afib, A-Fib.

Final thoughts: Hybrids

Is the “Hybrid” Surgery/Ablation better and more effective than current advanced catheter ablation strategies?22Or the Mini-Maze?

Only time will tell. This is a relatively new operation with little long-term research or history of patient tracking.23  Dr. Hugh Calkins of Johns Hopkins Hospital writes, “It is clear that more research is needed…a much larger, multicenter trial of “hybrid AF ablation” that targets a population of patients with long-standing persistent AF… .”24Dr. Pison and colleagues note that the longer-term impact of this Hybrid Surgery/ablation strategy on atrial systolic function remains unknown.

Dr. Calkins also points out a logistical problem. It’s extremely rare to have tremendous expertise with catheter ablation and surgical A-Fib ablation at the same institution. Most centers are expert at one or the other. This will limit the number of facilities offering the Hybrid Surgery/Ablation approach, making it harder for patients to access this treatment choice. (See Steve’s Lists: Centers Performing the Hybrid Surgery/Ablation procedure.)

And finally, from a risk/reward perspective, if the Hybrid approach and advanced catheter ablation strategies have similar success rates, the advanced catheter ablation strategies might be preferable to Hybrid Surgery/Ablation.

A last thought, a prediction really, from Dr. M. Clive Robinson, a cardiothoracic surgeon with Bridgeport Hospital. Dr. Robinson, who performs the “hybrid”, has said “it is likely that the new hybrid ablation procedure will make Mini-Maze [surgery] obsolete,”25

Steve's List - Doctors by Specialty - Atrial Fibrillation - a fib, afib, A-Fib

Doctors by Specialties

 Steve’s Lists

 Doctors by Specialty

I’ve compiled several specialty lists from the A-Fib.com Directory of Doctors & Facilities called ‘Steve’s Lists‘.

For surgeons performing Maze/Mini-Maze operations, see Doctors & Facilities/Steve’s Lists Doctors by Specialties and more specifically, US Surgeons performing Maze and Mini-Maze operations.

For centers performing the Hybrid Surgery/Ablation, see Steve’s Lists: Centers Performing the Hybrid Surgery/Ablation procedure.

 Additional Readings

Advantages of the Convergent Procedure by Dr. James Edgerton
• FAST Trial: Surgical Versus Catheter Ablation―Flawed Study, But Important Results for Patients
• Advances in Surgical Therapy for A-Fib by Dr. David Kess
• Role of the LAA & Removal Issues

 Beware of Profit Incentives

 Mini-Maze Marketing

Beware: Mini-Maze Marketing & Profit Incentives

Beware!

Be advised that some hospitals, medical services, web sites, etc. may promote the Mini-Maze over catheter ablation, because current reimbursement rates are higher for surgery (currently around $15,000 in the US) than for catheter ablation. Mini-Maze-type surgeries represent a huge and growing market and an important income source for hospitals, surgeons, medical device companies, web sites, etc.

Some hospitals, medical services, web sites, etc. may promote the Mini-Maze over catheter ablation, because current reimbursement rates are higher for surgery (currently around $15,000 in the US) than for catheter ablation.

Some 25,000 patients underwent Mini-Maze-type surgeries in 2009. Surgical devices to treat A-Fib have sales of about $100 million a year.26

Profits may influence doctors to use medical devices for “off-label” treatments. (Companies are only allowed to market them for the uses for which they have been FDA-approved. The idea behind this restriction is to limit the number of U.S. patients exposed to experimental, relatively untested treatments.)

For example, AtriCure, of West Chester, Ohio, in 2010 agreed to pay $3.8 million to resolve allegations it marketed its surgical ablation devices for the unapproved purpose of treating irregular heartbeats (A-Fib). According to an article in Mass Device.

“The [U.S. Dept. of Justice, DOJ] lawsuit accused AtriCure of offering kickbacks to induce surgeons and hospitals to use its inpatient cardiac ablation procedure rather than less expensive, outpatient alternatives (such as catheter ablation). The company was accused of promoting the spread between Medicare reimbursement rates for its procedure and the cost to hospitals, and doling out kickbacks including free equipment, discounts, free advertising, marketing, and referral services and training for surgeons on its procedure.”27

According to Jacqueline Bell of Law360.com:

“The DOJ also alleged that AtriCure pushed heart surgery using the company’s medical devices when less-invasive alternatives were appropriate, and suggested to hospitals how to pump up Medicare reimbursement claims for surgical procedures using the company’s devices.”28

From Thomas S Burton, The Wall Street Journal:

AtriCure did not admit wrongdoing.29

And in another settlement:

Estech (Endoscopic Technologies), of San Ramon, California, agreed to pay $1.5 million to settle similar charges with the Justice Department, also without admitting wrongdoing30

Read how others have dealt with their A-Fib - see 'Personal Experiences' for stories of hope and inspiration.

Last updated: Monday, July 18, 2016

Back to the Top

Return to Treatments for Atrial Fibrillation

References    (↵ returns to text)
  1. MediFocus Guide “Atrial Fibrillation #CR004m July 10, 2009. p. 40.
  2. Damiano, Jr, Ralph J and Bailey, Marci. “The Cox-Maze IV procedure for lone atrial fibrillation.” Multimedia Manual of Cardiothoracic Surgery. MMCTS (July 23, 2007). doi:10.1510/mmcts.2007.002758 http://mmcts.ctsnetjournals.org/cgi/content/full/2007/0723/mmcts.2007.002758
  3. Burton, T. Surgical-Device Firms Walk Fine Line. The Wall St. Journal. March 2010.  Last accessed Nov 4, 2014. URL: http://tinyurl.com/BurtonSurgicalDevice
  4. Kiser, A C. Advantages of the Convergent Procedure UNC Cardiac Surgery and Electrophysiology Services, Last accessed Aug 27, 2015. URL: http://www.uncheartandvascular.org/index5289.html
  5. Wolf R, Schneeberger E, Osterday R, et al. (2005). “Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation”. J Thorac Cardiovasc Surg 130 (3): 797–802. doi:10.1016/j.jtcvs.2005.03.041. PMID16153931.
  6. Brugge, E. et al. “Comparison of bipolar and unipolar radiofrequency ablation in an in vivo experimental model”. Eur J Cardiothorac Surg. 28 2005:76-82.
  7. La Meir, M.  Surgical options for treatment of atrial fibrillation. Annals of Cardiothoracic Surgery. Vol 3, No 1 January 2014. doi: 10.3978/j.issn.2225-319X.2014.01.07
  8. Lockwood, D. et al. “Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: techniques for assessing conduction block across surgical lesions”. Heart Rhythm. 6 2009:S50-S63.
  9. Cui YQ et al. “Video-assisted minimally invasive surgery for lone atrial fibrillation: a clinical report of 81 cases.” Journal of Thoracic and Cardiovascular Surgery 1 February 2010 (volume 139, issue 2, Pages 326-332.
  10. Sirak, John H. http://www.ohioafib.com/maze-surgery/outcomes.cfm
  11. Kiser, A C. Advantages of the Convergent Procedure UNC Cardiac Surgery and Electrophysiology Services, Last accessed November 5, 2012 from http://acati.org/advantages.htm
  12. Feld, G. K., “Hot Topics: A Review of the 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation.” Atrial Fibrillation A CardioSource Clinical Community, April 09, 2012. Accessed Friday, January 11, 2013 URL: http://tinyurl.com/FeldGK
  13. Cohen, Todd J. “A Patient’s Guide to Heart Rhythm Problems.” A Johns Hopkins Press Health Book. Johns Hopkins University Press, Baltimore. 2010, p. 36. Mini-Maze surgeries “usually have significant risks compared with catheter-based electrophysiology procedures such as catheter ablation.”
  14. Borsama, L.V.A. et al. “Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST).” CIRCULATION. 111.074047 Published online before print November 14, 2011. http://tinyurl.com/Borsama
  15. Burton, T. Surgical-Device Firms Walk Fine Line. The Wall St. Journal. March 2010.  Last accessed Nov 4, 2014. URL: http://tinyurl.com/BurtonSurgicalDevice
  16. Schouchoff, Barbara. “Surgical Approaches for Atrial Fibrillation.” Critical Care Nursing Quarterly. July/September 2007, Volume 30, Number 3, pages 233-242. http://www.afibmaze.com/p4.html 
  17. In January, 2014, at the Boston A-Fib Symposium in Orlando I was privileged to attend a live demonstration via satellite from the Netherlands of a Hybrid Surgery/Ablation.
  18. Wang, Paul. Hospital Offers Innovative, Hybrid Procedure for Difficult Cases of Atrial Fibrillation. Stanford Hospital & Clinics Press Release, February 14, 2011. Last accessed February 24, 2014, URL: http://stanfordhospital.org/newsEvents/newsReleases/2011/dual-ablation.html
  19. Pison L, et al. Hybrid Thoracoscopic Surgical and
    Transvenous Catheter Ablation of Atrial Fibrillation. J Am Coll Cardiol.
    2012;60(1):54-61. doi:10.1016/j.jacc.2011.12.055.
  20. Kurfirst, V. et al. Two-staged hybrid treatment of persistent atrial fibrillation: short-term single-centre results. Interact Cardiovasc Thorac Surg. 2014 Jan. 12 [Epub ahead of print]
  21. Zembala M, et al. Minimally invasive hybrid ablation procedure for the treatment of persistent atrial fibrillation: one year results. Kardiol Pol. 2012;70(8):819-28. PubMed PMID: 22933215. Last accessed Feb 22, 2014, URL: http://www.ncbi.nlm.nih.gov/pubmed/22933215
  22. Such as the Bordeaux Five-Step Protocol or ECGI mapping/ablation system.
  23. There appears to be at least two research trials underway of epicardial-endocardial convergent procedures for the treatment of atrial fibrillation: a multicenter trial called the CONVERGE IDE (see http://tinyurl.com/CONVERGEIDE) and a trial by Inova Health Care Services (see http://clinicaltrials.gov/ct2/show/record/NCT01298986
  24. Calkins, H. Clinical Research: Heart Rhythm Disorders: Editorial. J Am Coll Cardiol. 2012;60(1):62-63. doi:10.1016/j.jacc.2012.01.068
  25. Bridgeport Hospital first in New England to perform hybrid ablation for atrial fibrillation. Bridgeport Hospital Press Release, July 6, 2011. Last accessed February 23, 2014, URL http://tinyurl.com/Bridgeportpressrelease
  26. Burton, T. Surgical-Device Firms Walk Fine Line. The Wall St. Journal. March 2010.  Last accessed Nov 4, 2014. URL: http://tinyurl.com/BurtonSurgicalDevice 
  27. Update: AtriCure finalizes settlement in federal whistleblower case. February 2, 2010. MassDevice.com Last accessed Jan 11, 2013 URL: http://www.massdevice.com/news/update-atricure-finalizes-settlement-federal-whistleblower-case; United States of America ex rel. Doe v. AtriCure Inc., case number 4:07-cv-02702, U.S. District Court/Southern District of Texas.
  28. Bell, J. AtriCure Settles Medicare Fraud Claims For $3.8M Law360.com. Last Accesse7 Jan 11, 2013, URL: http://tinyurl.com/BellFraudclaims
  29. Burton, T. Surgical-Device Firms Walk Fine Line. The Wall St. Journal. March 2010.  Last accessed Nov 4, 2014. URL: http://tinyurl.com/BurtonSurgicalDevice
  30. Ibid.

Role of the Left Atrial Appendage & Removal Issues

Left Atrial Appendage heart illustration; Source: Boston Scientific Inc. educational brochure

The Role of the Left Atrial Appendage (LAA) & Removal Issues

By Steve S. Ryan, PhD

In the first trimester or two of our time in the womb, The Left Atrial Appendage (LAA) was originally our left atrium (LA). When the final real Left Atrium (LA) formed gradually from the conjunction and evolutionary development of the four pulmonary veins, the actual LA chamber grew and ballooned out, pushing the smaller remnant LA up to the left top of the Left Atrium where it became became known as the Left Atrial Appendage (LAA) with its own functions and behaviors.

But as we age and as heart disease/A-Fib, etc. start to set in, the LAA can turn into “the most lethal, no longer essential appendage in the human anatomy.” (Thanks to Shannon Dickson for these insights about the LAA.)

One considered advantage of the Mini-Maze operations is that the Left Atrial Appendage (LAA) is closed or cut off. Most A-Fib blood clots which cause stroke come from the Left Atrial Appendage. By closing off the LAA, most but not all risk of stroke is eliminated even if you are still in A-Fib.

Failure to Completely Close Off the LAA is Common

However, in a study by Surgeon s, “both suture exclusion and stapler exclusion had extraordinarily low success rates. In fact, none of the patients with stapler exclusion had successful closure…This study presents clear evidence of the inadequacy of these techniques.”1

According to Dr. Marc Gillinov of the Cleveland Clinic, staplers “can be hard to apply to the appendage and tend to leave a little cul-de-sac and also cause bleeding and tearing, so they are not particularly safe or effective.”2

However, the AtriClip device (FDA approved June, 2010) makes it much easier for surgeons to close off the LAA during open heart surgery. The surgeon positions the rectangular-shaped device around the LAA and then closes it like a clamp. Blood no longer flows into and out of the Left Atrial Appendage.3 

AtriCure has developed a version of the AtriClip which can be used in Mini-Maze surgery.

Should the LAA be routinely cut out, stapled shut or closed off in all A-Fib patients?

Some question the need or benefit of removing the Left Atrial Appendage (LAA) if someone is no longer in A-Fib.

The rationale for closing off the LAA is that, in case the operation fails which happens occasionally, the patient is still protected from having an A-Fib stroke. 90%-95% of A-Fib strokes come from clots which originate in the LAA. In A-Fib, blood stagnates in the LAA and clots tend to form.

Another important consideration, even if a person is no longer in A-Fib, is that closing off the LAA may still prevent a stroke. The LAA is where most clots originate. If a surgeon is already working on the heart, why not close off the LAA and reduce the patient’s chance of having a future stroke? (If a surgeon didn’t close off the LAA, they could be sued if a patient later had a stroke, even if the patient was no longer in A-Fib.) Life (no stroke) is more important for most people than a possible reduced exercise intolerance.

In the future even people without A-Fib may have their Left Atrial Appendage closed off if it prevents or reduces the risk of a stroke. This may become a way to prevent stroke in older people, particularly women, who are more at risk of stroke as we age. There are currently a variety of devices, surgical and non-surgical, which can do this. LAA closure may become an important new way to reduce strokes, particularly in the elderly.

Functions of the Left Atrial Appendage

Some question the need or benefit of removing the Left Atrial Appendage (LAA) if someone is no longer in A-Fib. For a patient made A-Fib free, would their heart function better or more normally if they still had their LAA?

The LAA functions like a reservoir or decompression chamber or a surge tank on a hot water heater to prevent surges of blood in the left atrium when the mitral valve is closed.4Without it there is increased pressure on the pulmonary veins and left atrium which might possibly lead to heart problems later.

Conclusion

Cutting out or stapling shut the LAA also reduces the amount of blood pumped by the heart and may result in exercise intolerance for people with an active life style. (In dogs the LAA provides 17.2% volume of blood pumped.5) This is usually not a problem for patients with Persistent (Chronic) A-Fib, whose LAA has stopped contracting along with the fibrillating atrium. Cutting out or stapling shut the LAA won’t affect their cardiac output. But this may not be the case for patients with Paroxysmal A-Fib who still have large amounts of normal rhythm and whose LAA still functions normally.

But would a non-functioning LAA return to normal when someone with, for example, longstanding persistent (Chronic) A-Fib becomes A-Fib free?

The author isn’t aware of any surgeons (or EPs) who do pre- and post-LAA closure measurements of exercise ability, heart pumping function, etc. with and without the LAA.

(When doctors do a TEE [Transesophageal Echocardiogram] of the LAA of someone in A-Fib, the LAA doesn’t move at all and blood does not move. Doctors refer to this as “SMOKE” which is shorthand for Spontaneous Echo Contrast. The blood not moving looks like smoke inside the LAA.)

The LAA also has a high concentration of Atrial Natriuretic Factor (ANF) granules which help to reduce blood pressure.6Some preliminary research indicates that when the LAA is closed or cut off, the Right Atrial Appendage produces more ANF to compensate for the lost of the LAA.

Editor’s comment: If you are thinking of having a Cox Maze or Mini-Maze, discuss removing the LAA with the surgeon. Ask if they close off the Left Atrial Appendage and with what: sutures, stapler or the AtriClip.

Posted June 2013

Back to top

Return to Index of Articles: Maze, Mini-Maze, Convergent, LAA Closure Surgeries

Last updated: Sunday, February 15, 2015

References    (↵ returns to text)
  1. Damiano, Jr., RJ. “What Is the Best Way to Surgically Eliminate the Left Atrial Appendage?” Journal of the American College of Cardiology 2008, Sept. 9; Vol. 52, No. 11:930-1.
  2. AtriCure’s AtriClip system receives FDA 510(k) clearance (press release). June 14, 2010. 
  3. AtriCure’s AtriClip system receives FDA 510(k) clearance (press release). June 14, 2010.
  4. Al-Saady, N M, et al.  Left atrial appendage: structure, function, and role in thromboembolism
  5. Hondo T. et al. “The Role of the left atrial appendage. A volume loading study in open-chest dogs.” Jpn Heart J 1995 Mar;36(2):225-34.  http://www.ncbi.nlm.nih.gov/pubmed/7596042
  6. Atrial natriuretic peptide. Wikipedia.org. Last accessed April 13, 2014, URL: http://en.wikipedia.org/wiki/Atrial_natriuretic_peptide.

Advantages of the Convergent (Hybrid) Procedure

Convergent Procedure lesion pattern

Convergent Procedure lesion pattern

Advantages of the Convergent Procedure

UNC Cardiac Surgery and Electrophysiology Services

Andy C. Kiser, MD  Paul Mounsey, MD, Updated March 2014

(Reproduced with permission.)

Cardiac surgeons continually strive toward less invasive procedures which avoid approaches like full median sternotomies and thoracotomies. However, reports of minimally invasive cardiac surgical procedures may include hemi-sternotomies, mini-thoracotomies, or full median sternotomies without cardiopulmonary bypass.

True minimally invasive procedures must not only be defined by the size of the incision, but also by the invasiveness into the patient’s daily lifestyle and the impact on their quality of life.

There are a variety of techniques and devices in use for the surgical treatment of atrial fibrillation (AF). The current gold standard for the surgical treatment has been the Cox cut and sew maze procedure. There have been variations through the years leading to a host of other surgical AF procedures, such as the Wolf mini-maze1, practiced by many surgeons. Other techniques create myocardial lesions using some form of radiofrequency energy, laser, cryothermy or high-frequency ultrasound. All of these techniques require access to the heart through either a full sternotomy or less-invasive approaches with incisions on the left and/or right side of the chest. Some techniques require cardiopulmonary bypass and sometimes cardioplegia to stop the heart entirely.2,3 Until recently, no current technique or device provided access to the posterior left atrium directly.

Pericardioscopy is a totally endoscopic technique that provides direct visualization of, and access to, the epicardial surface of the beating heart without the need for cardiopulmonary bypass or prolonged postoperative recovery. Unlike a subxyphoid approach, pericardioscopy provides access to the heart via the central tendon of the diaphragm. This allows direct vision of the posterior cardiac structures with minimal hemodynamic compromise. Such access and visualization of the epicardial cardiac surface has enabled epicardial ablation techniques, like the Convergent Procedure, as a treatment for atrial fibrillation.4,5 Pericardioscopy eliminates the need for sternotomy or thoracotomy when access to the epicardial surface is necessary.

Convergent Procedure - Transdiaphragmatic Pericardioscipic Access

Transdiaphragmatic Pericardioscipic Access

 

SIMULTANEOUS ENDOCARDIAL AND EPICARDIAL ABLATION

The surgical treatment of atrial fibrillation (AF) is based upon the creation of an anatomical pattern of myocardial scar. The Corridor Procedure 6, the Radial Maze Procedure,6 and the Cox maze I-III7,8 are anatomical patterns designed to disrupt the re-entry circuits of AF by dividing the atria into non-conductive segments. Electrophysiologists, in comparison, use endocardial catheters and electrodes to identify the triggers causing AF and direct their treatments towards these foci of abnormal electrical activity in the atria. The individual success of these approaches, either surgical or endocardial, has been limited by technical complexity and/or less than desirable outcomes.

A truly successful and adoptable AF treatment has always seemed to be just out of reach. The acclaimed gold standard cut and sew maze procedure reports exceptional outcomes but remains a complex procedure that is rarely performed.9,10 The mini-maze11 and pulmonary vein isolation12reduce procedural complexity by decreasing the number of lesions and by eliminating cardiopulmonary bypass. However, both the surgeons and the cardiologists have demonstrated that when treatment is limited to the left atrium, outcomes suffer as a consequence.13,14 The endocardial, catheter-based AF ablations, not unlike the surgical procedures, remain long and technically difficult procedures performed by relatively few electrophysiologists. The high rate of repeat procedures and less than desirable long-term outcomes have been disappointing.15 Unfortunately, surgeons and cardiologists seldom collaborate in the development of new technologies and innovative approaches to overcome these individual procedural shortcomings.

The Convergent Procedure has been developed by a multidisciplinary team of cardiologist and cardiac surgeons to address the procedural and communication barriers. The Convergent Procedure is the simultaneous creation of a surgeon’s PEX epicardial ablation pattern and electrophysiologist’s endocardial ablation pattern (Figure 1).

Convergent Procedure - Convergent Procedure Lesion Pattern

Convergent Procedure Lesion Pattern

 

The surgeon’s ability to effectively create visible, and therefore contiguous, epicardial ablation lines has greatly reduced the amount of endocardial tissue which must be ablated to complete a successful trans-septal catheter procedure. The integration of a surgeon’s anatomical approach to AF with the physiological approach of the electrophysiologist’s has led to the development of the Convergent Procedure.

This convergence of technologies and expertise provides or allows for:

1. The creation of a complete, bi-atrial, endocardial and epicardial ablation pattern without a chest incision or cardiopulmonary bypass;

2. Intra-operative metrics to confirm procedural success;

3. Integrated patient care by cardiology and cardiac surgery; and

4. Decreased length of hospital stay and the number of repeat ablation procedures.

AN INTEGRATED APPROACH TO THE AF PATIENT

At the UNC Center for Heart & Vascular Care, we have created a multidisciplinary service that integrates the care of Arrhythmia patients. Evaluation of each case by the multidisciplinary team of arrhythmia experts ensures an individualized, yet consensus, treatment plan. Without this integrated approach, the best treatment option may not be available or may require much longer wait times, more travel and more inconvenience and delay for the patient.

The patient’s clinical presentation is vitally important to developing the multidisciplinary treatment plan. Left atrial size, AF type and AF duration are significant contributory factors. We advocate a 24-hour Holter monitor on all patients under evaluation to document the degree of AF burden. Additional evaluation includes a trans-thoracic echocardiogram and cardiac catheterization or stress test to exclude structural heart disease in the setting of AF.

The consensus opinion by the Heart Rhythm Society Task Force states that, “stand-alone AF surgery should be considered for symptomatic AF patients who prefer a surgical approach, have failed one or more attempts at catheter ablation, or are not candidates for catheter ablation.” Left atrial size and AF duration are important factors in this decision process. When the left atrium is larger than 6.0 cm or the duration of AF is greater than 5 years, the long term success for the Cut and Sew maze procedure are under 80% (Figure 2). It is difficult for the electrophysiologist to consistently and effectively complete pulmonary vein isolation when the left atrium is greater than 5.0 cm. Therefore, when a patient has paroxysmal AF and the left atrium is under 4.5-5.0 cm, we recommend percutaneous catheter ablation. In this population, simple pulmonary vein isolation may be effective in over 80% of patients.16

Patients with paroxysmal AF and a left atrium greater than 4.5 cm and those with persistent and long-standing persistent AF demonstrate the best outcomes when a bi-atrial lesion pattern is created. Surgeons who have experience with minimally invasive approaches choose the ablation technology best suited for their technique. Whichever approach and device is used, a comprehensive lesion pattern of contiguous and transmural lesions are essential. Persistence and intra-operative verification of lesion and pattern integrity is crucial. The Convergent Procedure has established new criteria for lesion integrity by the verification of procedural completion by endocardial electrophysiologic metrics. The Convergent Procedure is not complete until pulmonary vein isolation and posterior left atrial exclusion is confirmed, the coronary sinus is ablated, and a cavo-tricuspid isthmus lesion is created. These metrics provide confidence of procedural success and set new standards for the hybrid treatment of persistent and long-standing persistent AF.

Left: Success Decreases with Left Atrial Size>6.0cm; Right: AF Duration Predicts Sinus Rhythm Restoration Post Maze Procedure

Left: Success Decreases with Left Atrial Size>6.0cm; Right: AF Duration Predicts Sinus Rhythm Restoration Post Maze Procedure

 

Conclusion

There have been many minimally invasive approaches to treat AF, all based primarily upon the original work by Cox and his maze procedure. By integrating electrophysiology and cardiac surgery in a hybrid AF treatment, new procedural and perioperative standards have been established at our institution. The initial outcomes utilizing this multidisciplinary approach are excellent and patient satisfaction is overwhelmingly positive.

Reproduced with permission.17

Back to top

Return to Index of Articles: Maze, Mini-Maze, Convergent, LAA Closure Surgeries

Last updated: Sunday, February 15, 2015

References    (↵ returns to text)
  1. Wolf RK, Schneeberger EW, Osterday R, Miller D, Merrill W, Flege JB Jr, Gillinov AM. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg. 2005; 130:797-802
  2. Henry L, Ad N. The Maze procedure: a surgical intervention for ablation of atrial fibrillation. Heart Lung. 2008 Nov-Dec;37(6):432-9.
  3. Chitwood WR Jr, Wixon CL, Elbeery JR, Moran JF, Chapman WH, Lust RM., Video-assisted minimally invasive mitral valve surgery, J Thorac Cardiovasc Surg. 1997 Nov;114(5):773-80; discussion 780-2
  4. Kiser AC, Wimmer-Greinecker G, Chitwood WR. Totally extracardiac maze procedure performed on the beating heart. Ann Thorac Surg 2007;84:1783-85.
  5. Kiser AC, Wimmer-Greinecker G, Kapelak B, Bartus K, Sadowski J. Paracardioscopic ex-maze procedure for atrial fibrillation. Innovations 2008; 3:117
  6. Nitta T, Lee R, Schuessler RB, Boineau JP, Cox JL. Radial approach: a new concept in surgical treatment for atrial fibrillation I. Concept, anatomic and physiologic bases and development of a procedure. Ann Thorac Surg. 1999 Jan;67(1):27-35.2
  7. Cox JL, Schuessler RB, D’Agostino HJ Jr, et al.The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg. 1991 Apr;101(4):569-83,
  8.  Cox JL, Boineau JP, Schuessler RB, et al. Modification of the Maze procedure for atrial flutter and atrial fibrillation: I. Rationale and surgical results. J Thorac and Cardiovasc Surg 1995; 110:485-495
  9. Prasad SM, Maniar HS, Camillo CJ, et al. The Cox maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures. J Thorac Cardiovasc Surg. 2003; 126(6):1822-8
  10. Kosakai Y. Treatment of atrial fibrillation using the maze procedure: the Japanese experience. Sem Thor Cardiovasc Surg. 2000; 12:44-52.
  11. Wolf RK, Schneeberger EW, Osterday R, Miller D, Merrill W, Flege JB Jr, Gillinov AM. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg. 2005; 130:797-802
  12. Edgerton JR, Edgerton ZJ, Weaver T, et al. Minimally Invasive Pulmonary Vein Isolation and Partial Autonomic Denervation for Surgical Treatment of Atrial Fibrillation. Ann. Thorac. Surg. July 2008; 86:35-39
  13. Barnett SD, Ad N. Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis. J Thorac Cardiovasc Surg. 2006 May;131(5):1029-35.
  14. Calo I, Lamberti F, Loricchio ML, et al. Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a prospective and randomized study. J Am Coll Cardiol 2006;47:2504-2512.
  15. Cappato R, Calkins H, Chen SA, et al. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation. 2005;111:1100-1105
  16. Haissaguerre M, Jais P, Shah DC, Takahashi A, et al. Spontaneous initiation of atiral fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998; 339:659-666.
  17. Kiser, A., Mounse, P. Advantages of the Convergent Procedure.UNC Cardiac Surgery and Electrophysilogy Services. Accessed September 03, 2012. URL: http://acati.org/advantages.htm

Follow Us
facebook block 65 pix REVtwitter block 65 pixlinkedin block 65 pixpinterest.block 65 pix

A-Fib.com Mission Statement

Mug - Seek your cure - Beat Your A-Fib 200 pix wide at 300 resEncourage others
with A-Fib
click to order

A-Fib.com top rated by Healthline.com for the third year.
A-Fib.com top rated by Healthline.com for the third year. 2014  2015  2016




Support A-Fib.com. Every donation helps, even just $1.00

We Need You

Home | The A-Fib Coach | Help Support A-Fib.com | A-Fib News Archive | Tell Us What You think | Media Room | GuideStar Seal | HON certification | Disclosures | Terms of Use | Privacy Policy