Considering a Mini-Maze? Don’t Destroy the Ganglionic Plexus
Many surgeons performing Mini-Maze or other Maze operations for A-Fib routinely ablate/destroy the Ganglionic Plexus (GP) areas on the outside of the heart which contain clusters of nerve cells.
But recent studies show this strategy is not only ineffective but causes a lot of complications.
AFACT stands for Atrial Fibrillation and Autonomic modulation via Thoracoscopic surgery
The AFACT Trial: Mini-Maze Surgeries for Paroxysmal or Persistent A-Fib
The 2016 randomized clinical trial from Amsterdam in The Netherlands included 240 participants who underwent mini-maze surgeries: totally thoracoscopic pulmonary vein isolation for paroxysmal A-Fib or isolation plus Dallas lesion set for persistent A-Fib.
Approximately half also received ganglionic plexus ablation in which four major ganglionic plexus were ablated as well as the ligament of Marshall in the ganglionic plexus group. Patients were followed for one year.
Results: Ablating GPs—No Clinical Benefit, More Complications
The researchers found no clinical benefits associated with ganglion plexus ablation added to a thoracoscopic ablation strategy, and significantly more complications.
There were significantly more recurrences in the ganglionated plexus group (78.1%) than in the control group (51.4%). And what is worse, more than double the number of major adverse events occurred in the ganglionic plexus group such as major bleeding and sinus node dysfunction which required pacemaker implantation.
Presenting at 2016 Heart Rhythm Society scientific session, researcher Dr. Joris R de Groot stated that “ganglionic plexus ablation is associated with significantly more periprocedural major bleeding, sinus node dysfunction and pacemaker outcome, but not with improved rhythm outcome.”
He concluded that routine ganglionated plexus ablation offers “no clinical benefit” in this patient category, and “should not be performed.”
The 2016 AFACT trial may finally have determined that ablating GPs doesn’t work.
What Patients Need to Know
Surgery Not Recommended as First Choice Treatment for A-Fib: Current guidelines do not recommend surgery as a first choice or option for A-Fib. Surgery is generally more invasive, traumatic and risky than a simple catheter ablation procedure.
Routine ganglionated plexus ablation offers “no clinical benefit” and causes major permanent complications.
Most current surgical strategies have built in limitations. For example, if you have A-Flutter coming from the right atrium, current surgical techniques don’t access the right atrium or some other non-PV trigger sites. See Cox-Maze, Mini-Maze and Hybrid Surgeries. In such cases, one often needs a catheter ablation after the surgery.
Make Sure Your Surgeon Doesn’t Ablate Ganglionic Plexus Areas: If you have to have surgery for A-Fib, make sure your surgeon does not ablate the ganglionic plexus areas as part of his A-Fib surgery. Ablating the ganglionic plexus areas doesn’t improve ablation results and causes more major permanent complications. As Dr. de Groot unequivocally states, ganglionic plexus ablation “should not be performed.”
The Bottom Line if Having Mini-Maze Surgery
If you have to have surgery for A-Fib (versus a catheter ablation by an EP), make sure you ask the surgeon if they ablate the ganglionic plexus areas as part of your A-Fib surgery. (Don’t expect a surgeon to volunteer this info. You have to ask!)
If they say yes, hand them a copy of this post. Then find another surgeon.