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Ken_Close 150 x150 pix

Ken Close, A-Fib Support Volunteer

Editorial: Bias in Coverage of Mini-Maze?

by Ken Close, A-Fib Support Volunteer, December 2014

Editor’s comments; Recently Ken Close, a treasured colleague and A-Fib Support Volunteer, wrote me to present his thoughts on surgical approaches to curing A-Fib. (Ken had Dr. John Sirak’s Five-Box Thoracoscopic Maze Operation and is A-Fib free.)
Ken and I have exchanged emails over the years and may disagree sometimes, but we are united in our desire to help A-Fib patients and to provide the best info available. We welcome Ken’s comments and point of view.

Dear Steve,

“We have had a long standing series of exchanges, so I hope you take these comments with that in mind. I am surprised and disappointed with the general tone of the page on the Cox-Maze, Mini-Maze, and Hybrid Surgical Operations. I know you have been skeptical of surgical approaches for a long time, yet it seems in your writing that some bias has crept in.  As credibility is important, this is what I find disappointing. Also, many visitors, coming to your site for information and being generally less informed, will be unable to detect any bias in your comments.

Several examples:  you talk of the negative effects of the surgical approaches, yet you nowhere that I could see compare that to the lower (often miserably lower) success statistics for catheter ablation. In some cases, CA success rates have been reported in the low 30s. Would someone who has had several or more failed CAs be interested in the surgical approach if it offered a higher chance of success?  Most likely yes. In Dr. Sirak’s words, “Catheter ablation (CA) is a common alternative treatment; however, it is an inferior alternative to the current totally thoracoscopic maze procedure (surgery), especially for people with advanced forms of atrial fibrillation.” “as I will indicate in an upcoming paper, even pulmonary veins are isolated in less than 10% of post-catheter ablation patients…even with multiple CAs.”

I know I have previously described to you the sources of variability that lead to lack of transmural lesions in CAs. (Uniploar vs bipolar RF energy and less ability to control temperature, variable contact pressure at the end of the probe – 2-3 feet away from the operators hands, variable thickness of heart surface and its movement, and difficulty of making a straight and continuous lesion line with a series of dots). True, many operations are successful. True, various technical innovations try to speak to these inherent limitations. But not to mention the tradeoff that inevitably exists hurts the objective nature of your providing information to people seeking to understand how to deal with their A-Fib.

You cite one study and give a low (very low) percentage success for mini maze. There are other studies showing much higher success rates, so they could at least be combined or shown as a range. Dr Sirak’s several published, peer reviewed papers reveal objective success measures in the 90s and should be included for completeness.

I am not sure if there is a paper published on Dr Sirak’s modification of his 5Box TTM (Total Thoracoscopic Maze) procedure, wherein he creates the pattern of lesions with three applications, first RF, then Cryo, then RF, to better insure transmurality, especially in fibrotic hearts (which would have no chance of success with catheter ablation and are probably patients with multiple failed CAs). His success rates reported in our on-line 5Box group of which I continue as Moderator, moved his success rates (over 500+ total patients) from the low 90s to the mid-90s. (If memory serves, it is some 400 patients with single burns and 120+ with triple burns.)

Yes, we have talked loss of transport function before with burns over the surface of the atria. Transmural CA lesions will have this same issue, if it is to be an issue. Questions about this with Dr Sirak suggest the data (beyond my detailed understanding) do not show any transport function loss.

It has always been hard for me to completely understand the lesion lines needed to isolate all parts of the atria from A-Fib source signals. In the past Dr Sirak has described to our group that there is one place a lesion MUST be placed to isolate A-Fib circuits and it is a place IMPOSSIBLE to ablate with catheter ablation. I would have to do a lot of digging through past message archives to find the exact reference. But I doubt your statement “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.”  In fact, just the opposite may be true. And if your statement is incorrect, then new A-Fib information searchers are misled big time, counter to the spirit of your site.

You seem to have interviewed several surgeons and quote them in several places on this page.  It would be great to see some comments (and perhaps quotes) from an interview you might do with Dr Sirak. (I can supply his cell phone number if you are interested, or it is available on his web site.)

You state some of the risks to surgical approaches accurately, but do a disservice by publishing the Unscientific survey about how many would not want to have a surgical approach again. How about an UNscientific survey of the many people I know about who had multiple failed catheter ablations yet are now in NSR because of the 5Box TTM and who would never want still another catheter ablation. That could at least balance the scales a bit. Removal of the comment would be the best, in my opinion.

I hope you do not take offense in this message. I am one of your fans and have appreciated all that you do, especially the more prolific FB postings which give me new data most of the time. Thus I was surprised and disappointed to read the incomplete and in my opinion misleading information on PART of your mini-maze page.”

Ken Close
E-mail: closeks(at)

Sunny Mills asked to add her comment to Ken’s message.

“Steve, I would like to add a comment to Ken’s article about surgical interventions ; my maze was a disappointing failure and left me so much worse off for the procedure. So I’d like to add my 2 cents worth and my experience.” Sunny Mills, Email:

Sunny just had an ablation by Dr. Andrea Natale which seems to have worked. He had to ablate multiple sites in the right atrium which surgical approaches normally don’t access.

Editor’s comments:
Be advised that, according to current guidelines, surgical approaches are not recommended as first-line or first choice options for A-Fib.
If you are interested in Dr. Sirak’s operation, Ken Close can connect you with a website for patients who have experienced Dr. Sirak’s operation. But it is closed to the general public.
References for this Editorial
Sirak, John H.
Sirak, John H.

Last updated: Friday, September 30, 2016

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