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"Jill and I put you and your work in our prayers every night. What you do to help people through this [A-Fib] process is really incredible."

Jill and Steve Douglas, East Troy, WI 

“I really appreciate all the information on your website as it allows me to be a better informed patient and to know what questions to ask my EP. 

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Baltimore, MD

Doctors & patients are saying about 'Beat Your A-Fib'...

"If I had [your book] 10 years ago, it would have saved me 8 years of hell.”

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"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."

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Cavanaugh Heart Center, 
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"Within the pages of Beat Your A-Fib, Dr. Steve Ryan, PhD, provides a comprehensive guide for persons seeking to find a cure for their Atrial Fibrillation."

Walter Kerwin, MD, Cedars-Sinai Medical Center, Los Angeles, CA

Maze & Mini-Maze Surgeries

My Top 5 Articles: Surgical Treatment Options for Atrial Fibrillation

When drug therapies fail or if not a candidate for catheter ablation, patients look to surgical treatments to reduce the risk of stroke, to ease symptoms or to cure their Atrial Fibrillation.

Here are my top 5 articles about the Maze & Mini-maze surgeries and role of the left atrial appendage:

  1. The Cox-Maze & Mini-Maze Surgeries and the Hybrid Surgery/Ablation
  2. Advantages of the Convergent (Hybrid) Procedure
  3. Considering a Mini-Maze? Don’t Destroy the Ganglionic Plexus
  4. The Role of the Left Atrial Appendage (LAA) & Removal Issues
  5. The Watchman™ Device: The Alternative to Blood Thinners

Mini-Maze Surgery with Cardiac Surgeon Dr. Dipin Gupta

See our library of videos about Atrial Fibrillation

Cardiothoracic surgeon Dipin Gupta, MD, discusses this surgical treatment for persistent atrial fibrillation. The Mini-Maze is done without open-heart surgery and using a small incision on the side of the chest. Published by MedStar and Cleveland Clinic. March, 2015 (4:35) Go to video->

FAQs Understanding A-Fib: Options for Asymptomatic Longstanding Persistent A-Fib

 FAQs Understanding A-Fib: Asymptomatic Longstanding Persistent A-Fib

FAQs Understanding Your A-Fib“My EP won’t even try a catheter ablation. My left atrium is over 55mm, and several cardioversions have failed.  I am 69 years old, in permanent A-Fib for 15 years, but non-symptomatic. I exercise regularly and have met some self-imposed extreme goals. What more can I do?

As you already know, being in permanent (long-standing persistent) Atrial Fibrillation can cause other long term problems like fibrosis, increased risks of heart failure and dementia. So you are wise to be concerned.

I’m not surprised your electrophysiologist (EP) is reluctant about a catheter ablation. Being asymptomatic with 15 years of long-standing persistent A-Fib and a Left Atrium diameter of 55mm, most EPs wouldn’t recommend or perform a catheter ablation on you.

Drug Therapy Option: Tikosyn

Tikosyn (dofetilide) for long-standing persistent atrial fibrillation at

Tikosyn (dofetilide)

Have you tried the newer antiarrhythmic drug Tikosyn (generic name dofetilide)?

Tikosyn was designed for cases like yours. It’s a Class 1A drug that works by blocking the activity of certain electrical signals in the heart that can cause an irregular heartbeat.

The only inconvenience of Tikosyn drug therapy is you have to be in a hospital for 3 days for observation and to get the dosage right.

Benefits of Activity and Exercise on Your A-Fib

You are truly blessed to be so active and without noticeable symptoms in spite of being in A-Fib. While exercise will not reduce the size of your LA, your activity level may compensate for the lack of pumping of your left atrium. In fact, your ventricles may be acting kind of like a turkey baster sucking blood down from your non-functioning LA before pushing blood out to the rest of your body.

Catheter Ablation and Surgical Options

Catheter ablation: Studies of non-paroxysmal A-Fib have shown that a successful catheter ablation can significantly reduce atrial dilation and improve ejection fraction. But, with your A-Fib being persistent long-standing, this may not apply.

Surgery: A Cox Maze IV surgery may reduce the volume and size of your left atrium while hopefully making you A-Fib free, but surgeons may be reluctant to tackle your case since the success rate is under 80%. A Cox Radial Maze is open heart surgery which is very traumatic and risky. It may be hard to justify open heart surgery if you’re asymptomatic.

My Recommendations

1. If you haven’t tried it yet, ask your EP about taking the newer antiarrhythmic drug Tikosyn.

2. If you’ve tried Tikosyn and it doesn’t help you, I recommend you consult an EP who specializes in longstanding persistent A-Fib. See Steve’s Lists. You may need to travel, but it may be worth it to you for your peace of mind. Also, ask the EP if surgery may be a helpful option.

3. Based on the results of the EP consult, I’d seek the opinion of a cardiac surgeon who performs the Cox Maze IV surgery. (See Steve’s Lists of surgeons who treat A-Fib patients.)

Making an Informed Choice

Armed with the above information you will be able to determine how you want to proceed. This is a decision only you can make.

With no A-Fib symptoms and a fulfilled life with plenty of body and soul enriching exercise, you may decide you are content with your present A-Fib status.

Resources for this article
Pump A. et al. Efficacy of catheter ablation in nonparoxysmal atrial fibrillation patients with severe enlarged left atrium and its impact on left atrial structural remodeling. J Cardiovasc. Electrophysiol. 2013 Nov;24(11):1224-31. doi: 10.1111/jce.12253

Go back to FAQ Understanding A-Fib
Last updated: June 18, 2018

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


Areas outside of the heart with clusters of nerve cells.

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.

Resources for this article
Routine ganglionic plexus ablation “should not be performed” in advanced atrial fibrillation patients. Cardiac Rhythm News, Issue 33, June 2016, p. 2.

Driessen AH, et al. Ganglion Plexus Ablation in Advanced Atrial Fibrillation: The AFACT Study. J Am Coll Cardiol. 2016;68(11):1155-1165. doi:10.1016/j.jacc.2016.06.036

Ganglionated Plexus Illustration: Heng, C. Atrial Fibrillation Mechanism and autonomic nervous ganglion ablation.

FAQs Understanding A-Fib: Which Procedure Has the Best Cure Rates

 FAQs Understanding A-Fib: Best Cure Rate

FAQs Understanding Your A-Fib“I have paroxysmal A-Fib and would like to know your opinion on which procedure has the best cure rate.”

The best cure rate isn’t the only criteria you should consider when seeking your Atrial Fibrillation cure.

Let me first review your top three procedure options: cardioversion, catheter ablation, and surgical Maze/Mini-Maze.

Electrocardioversion: When first diagnosed with Atrial Fibrillation, doctors often recommend an Electrocardioversion to get you back into normal sinus rhythm. But for most patients, their A-Fib returns within a week to a month. (However, you might be lucky like the A-Fib patient who wrote us that he was A-Fib free for 7 years after a successful cardioversion.)

Catheter Ablations: Radio-frequency and CryoBalloon catheter ablations have similar success rates 70%-85% for the first ablation, around 90% is you need a second ablation. Currently, CryoBalloon ablation has a slightly better cure rate with the least recurrence.

It’s crucial you choose the right electrophysiologist (EP), one with a high success rate and the best you can afford.

How to achieve these high success rates? It’s crucial you choose the right electrophysiologist (EP), one with a high success rate and the best you can afford (considering cost and travel expense). What counts is the EP’s skill and experience.

You want an EP who not only ablates your pulmonary veins, but will also look for, map and ablate non-pulmonary vein (PV) triggers. That may require advanced techniques like withdrawing the CryoBalloon catheter and replacing it with an RF catheter to ablate the non-PV triggers. (See our Choosing the Right Doctor: 7 Questions You’ve Got to Ask [And What the Answers Mean].) 

Cox Maze and Mini-Maze surgeries: Success rates are similar to catheter ablation, 75%–90%. But surgery isn’t recommended as a first choice or option by current A-Fib treatment guidelines. Compared to catheter ablations, the maze surgeries are more invasive, traumatic, risky and with longer (in hospital) recovery times

When should you consider the Maze/Mini-Maze? The primary reasons to consider a Maze surgery is because you can’t have a catheter ablation (ex: can’t take blood thinners), you’ve had several failed ablations, or if you are morbidly obese.

Atrial Fibrillation is not a one-size fits all type of disease.

You should also consider that Mini-Maze surgeries have built in limitations. For example, unlike catheter ablations, mini-maze surgery currently can’t reach the right atrium, or other areas of the heart where A-Fib signals may originate (non-PV locations). The more extensive surgeries create a great deal of lesions burns on the heart which may impact heart function.

So How Do You Choose the Best Treatment For You?

Atrial Fibrillation is not a one-size fits all type of disease.

Your first step is to see a heart rhythm specialist, a cardiac electrophysiologist (EP), who specializes in the electrical function of the heart.

An EP will work with you to consider the best treatment options for you. If your best treatment option is surgical, your EP will refer you to a surgeon and continue to manage your care after your surgery.

To help you find the right EP for you, see Finding the Right Doctor for You and Your A-Fib.

Thanks to Thomas Scheben for this question.

Go back to FAQ Understanding A-Fib
Last updated: June 18, 2018

Choosing the Right Doctor: 10 Questions You’ve Got to Ask (And What the Answers Mean)

By Steve S. Ryan, PhD, Last updated: January 6, 2019

10 Questions You’ve Got to Ask at

10 Questions for Doctors

When you set up a consultation appointment with a doctor, think of it as an interview. Don’t worry, doctors are also ‘interviewing’ you to determine if they can help you.

To scrutinize prospective doctors, this list of 10 questions will solicit the information you need to select the best doctor (cardiac electrophysiologist) for your type of A-Fib and your treatment goals.

Our coordinated worksheet lists the 10 questions with space for a doctor’s answers. Just download the PDF file “Questions for Doctor’s” Worksheet (and save to your hard drive). Then, print a worksheet for each doctor you interview.

Interview Questions and a Doctor’s Possible Answers (and What They Mean)

Familiarize yourself with these questions before your interviews. Afterwards, use this page to compare the doctor’s answers to typical responses and what each response may mean to you.

(File your worksheets and other notes in your A-Fib binder or folder for future reference—later you might want a second opinion).

1. What treatments do you recommend for dealing with or curing my type of A-Fib?

If the doctor only talks about different medications, you should probably talk to other doctors on your list. Overall, Drug Therapies have poor success rates, and don’t address the progressive nature of Atrial Fibrillation.

Think of a consultation as an interview. Don’t worry, doctors are also ‘interviewing’ you to determine if they can help you.

Today, the best and least invasive A-Fib treatments are RF Catheter Ablation and CyroBalloon Catheter Ablation.

2. Do you perform Catheter Ablation procedures for my type of A-Fib? What methods or techniques do you use or prefer?

Response #1:    “I only work or prefer to work in the right atrium.” Or, “I will eliminate the Atrial Flutter in your right atrium first.” 

Translation: These responses indicate a doctor may not have the experience or be comfortable working in the left atrium. Though it’s more difficult to work in the left atrium, most A-Fib comes from the left atrium pulmonary veins. You may have Atrial Flutter in your right atrium along with your A-Fib, but it may well be triggered by the A-Fib coming from your left atrium. You should probably talk to other doctors on your list.

Response #2:    “We recommend catheter ablation of the AV node and implanting a permanent pacemaker.”

Translation: Though this used to be one of the most common treatments for A-Fib, you don’t want to be burdened with a permanent pacemaker for the rest of your life when there are better options available.

Also, this procedure leaves you in A-Fib and dependent on medication for the rest of your life. Unless you have a Sinus Node problem and need a pacemaker, you should probably talk to other doctors on your list.

Response #3:    “We use Circumferential Ablation to eliminate A-Fib.” Or “Segmental Ablation…” Or “Anatomically-Based Circumferential Ablation…” Or “Pulmonary Vein Antrum Isolation…”

Translation: All good answers. Circumferential, Segmental, Anatomically-Based Circumferential (also referred to as Left Atrial Ablation) and Pulmonary Vein Antrum Isolation (PVAI) are refinements or different Pulmonary Vein Ablation procedure strategies. All offer you a good chance of being cured of your A-Fib. Circumferential is the most used technique.

Response #4:    “We use a special catheter sensor to pinpoint ectopic beats coming from areas of the heart, mostly from the Pulmonary Veins in the left atrium. We then ablate these areas.”

Translation: Good answer. (Ectopic beats come from any region of the heart that ordinarily should not produce heart beat signals, such as the pulmonary veins.)

This response indicates the doctor and/or medical center is targeting specific spots generating the A-Fib signals. This technique, first called Focal Catheter Ablation, was the first technique developed to ablate A-Fib. Today you may hear the terms Pulmonary Vein Isolation/Ablation, PVI/A or Pulmonary Vein Antrum Isolation (PVAI).

However, most centers today use either Circumferential or Segmental techniques to first ablate or isolate the entire area around the openings of all four Pulmonary Veins. If the A-Fib signals persist, then they’ll proceed to target and abate the specific source of the ectopic beats.

Response #5: “Besides RF Catheter Ablation, we also can use CryoBalloon Catheter Ablation to isolate the Pulmonary Veins.”

Translation: This response indicates the doctor and/or medical center are versatile and can use either or both techniques to find and ablate your A-Fib signals.

The safety and effectiveness of RF catheter ablation and Cryoballoon catheter ablation are similar. EPs have been doing RF ablations for decades. It works. The CryoBalloon Ablation (FDA-approved in 2010) is a relatively new method of ablation without a long-term track record. Both are low risk procedures.

Warning: stay away from EPs who only do CryoBalloon ablation. Some EPs, with no expertise with RF catheter ablations, are now doing CryoBalloon ablations because they’re easier (i.e. less demanding) and faster to perform (more lucrative).

What’s important: Not the type of ablation you choose, but rather the skill, expertise and experience of your EP.

3. What is your success rate for my type of A-Fib? How do you define ‘success’? (Is the patient free of A-Fib and free from drug therapy? Or free of A-Fib but still on medications?)”

Major centers with a lot of experience have a success rate of around 70%–85% for Paroxysmal A-Fib (and a higher success rate of 90%–95% if a second ablation is necessary). If their success rate is 50% or less, you should probably look elsewhere.

If you have Persistent or Long-standing Persistent A-Fib, you have to be prepared to have at least two ablation procedures.

4. How long have you been performing catheter ablations for my type of A-Fib and how many procedures do you perform a year? 

There are many electrophysiologists (EP) and several medical centers that have been doing Pulmonary Vein Ablations for years and have done hundreds (or thousands) of Pulmonary Vein Ablations.

At a minimum, you want an EP who performs around a 100 procedures a year. A doctor who only does a few ablations a month, may not be doing enough to maintain or develop ablation skills. (Less than 20 Pulmonary Vein Ablations a year means they are probably still in their “training” stage.)

5.“What do you do if I’m still in A-Fib at the end of the ablation procedure? 

Response #1:    “I’ll use electrocardoversion to shock your heart back into normal sinus rhythm.”

Our “Questions for Doctor’s” Worksheet is FREE. Download
(and save to your hard drive). Print a worksheet for each interview

Translation: This is NOT the answer you want to hear. A doctor who leaves a patient in A-Fib and shocks them back into sinus rhythm may be remiss and just wants an easy way to wrap up the procedure. Run, don’t walk, to another EP.

Response #2:    “I’ll look for non-PV triggers using computer mapping technology and then ablate those areas.

Translation: This is the type of answer you want to hear. Not all A-Fib signals originate from the Pulmonary Veins, but most do. That’s why doctors ablate the openings to the PVs first.  

Response #3:    “I’ll use a drug to stimulate the areas of your heart that are capable of producing A-Fib signals, then ablate those area.

Translation: Again, this is a perfectly acceptable answer. The EP is on the hunt to ablate your non-PV A-Fib signals.

Response #4:   “If I’m doing a CryoBalloon ablation, I’ll remove the Cryo catheter and switch to an RF catheter. Then using mapping technology, I’ll look for non-PV triggers and ablate those areas.”

Translation: When having a CryoBalloon ablation, this is the preferred answer. (Ideally, in this situation you’ve selected an EP with a dual skill-set, i.e., RF ablation expertise in addition to their CryoBalloon skills.)

6. What kind of complications have you had after ablations?

Every A-Fib doctor has had some complications when doing Pulmonary Vein Ablation procedures. A catheter ablation is a low risk procedure, but it is not risk free.

Possible complications include blood clots and stroke, PV Stenosis (post-op swelling of pulmonary vein openings which can restrict blood flow and lead to fatigue, flu-like symptoms, and pneumonia), Cardiac Tamponade (pooling of fluid around the heart that can cause a drop in blood pressure) and Phrenic Nerve Paralysis (related to the diaphragm, and usually temporary).

Doctors and their office staff are usually very open about the complications they have had and can usually give you statistics. If they are not, you may want to look elsewhere for your doctor.

7. “What techniques or technologies do you use to increase the safety and effectiveness of your procedures? For example, how do you protect the esophagus?”

A doctor’s use of technology may improve their effectiveness compared to other doctors or medical centers.

Examples: Using an imaging system that gives 3-D images of the inside of the heart, of the position of the esophagus, and of catheter placement and pressure; Using an energy source like the CryoBalloon catheter system to produce circular lesions around the pulmonary veins; Using magnetic or robotic arms that aid in more precise placements of lesions or ablations.

Damage to the esophagus during an ablation (called Atrial Esophageal Fistula) is a very rare complication (less than 1 in 1000+), but is often fatal. Heat from the RF catheter damages the esophagus which lies just behind the heart; then over the next 2–3 weeks, gastric acids can eat through the weakened area. Doctors and medical centers take precautions to avoid this damage including prescribing Proton Pump Inhibitors to prevent gastric acid damage.

When you ask how the doctor protects the esophagus, you should hear answers like:

Response 1:     “We use low power at the back of the heart.”

Response 2:      “We use a temperature probe in the esophagus to make sure it doesn’t get too hot.”

Response 3:      “We use barium paste in the esophagus so that we can see where it is when we make ablations and don’t make ablations near the esophagus.”

Response 4:      “We give Proton Pump Inhibitors like Nexium for 2–3 weeks after an ablation to protect the esophagus.”

If you don’t get answers like these, especially about taking Proton Pump Inhibitors after an ablation, it might be wise to talk with other doctors.

Order your copy Today!

8. Do you ever refer your A-Fib patients for Maze or Mini-Maze surgery?

Some A-Fib patients might be better served by a Maze or Mini-Maze surgery. For example, someone who needs open heart surgery for another problem might well combine that surgery with a Maze operation.

Someone who can’t tolerate warfarin (brand names Coumadin and Jantoven) or other blood thinners might turn to a Mini-Maze surgery. Most Mini-Maze surgeries are the result of referrals by electrophysiologists.

(If a doctor doesn’t normally refer patients for Maze or Mini-maze surgeries, this isn’t necessarily a reason for their rejection. They may be concerned about a loss of quality control if they send patients to a surgeon, someone who’s not a specialist in heart rhythm problems.)

9. (For female patients) What is the extent of your training specifically related to women’s heart health?

Women tend to have different symptoms of heart disease than men, in part because their bodies respond differently to risk factors such as high blood pressure.

Cardiologists who specialize in women are more common than ever. Medical centers now have clinics devoted to women’s heart health. Women with A-Fib may want to seek out a specialist who is up-to-date in this field of research.

10. Observations of the doctor’s demeanor, approachability and listening skills. Is this someone you want to work with? Who understands how A-Fib makes you feel? Who inspires your trust?

Download and save the FREE companion worksheet to “Choosing the Right Doctor: 10 Questions You’ve Got to Ask”.

Print a worksheet for each doctor you interview.

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Back to Finding the Right Doctor For You and Your A-Fib

If you find any errors on this page, email us. Y Last updated: Sunday, January 6, 2019

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.)

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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

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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 nearly 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.

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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.

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

Last updated: Tuesday, June 12, 2018

Resources for this article
• 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.

• US Food and Drug Administration. “AtriCure Synergy Ablation System – P100046” December 15, 2011.

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.


Why a cardiac electrophysiologist (EP)? graphic at

Click for graphic: Why you need a cardiac electrophysiologist (EP).

To seek treatments beyond medications, you may need to change doctors.

You should see a cardiac Electrophysiologist (EP)a cardiologist who specializes in the electrical activity of the heart and in the diagnosis and treatment of heart rhythm disorders.

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 cardiac 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 Directory

This 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.

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 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

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.; 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.)

 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.

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 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

Learn what to include in your packet of medical records. Read Why You Need an A-Fib Notebook and 3-Ring Binder and Your Personal A-Fib Medical Summary.

10 questions-to ask when inteviewing doctors for your A-Fib at

Click to download the free PDF

Before your appointment, send each doctor a packet with your A-Fib-related 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 originals from your three-ring A-Fib binder.

Questions to Ask: Use Our Free Worksheet

To help you scrutinize prospective doctors, we’ve written a set of 10 interview questions to help you find the right doctor for your treatment goals. Use our free PDF download, ‘Questions for Doctors Worksheet‘, to 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. 

During Your “Interview”

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

Audio recording: In addition, consider using an audio recorder to help you remember things. (Most doctors don’t mind, but always ask permission beforehand.) Many cell phones can make a recording for you.

Take Along a Trusted Friend: 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.

Afterwards: How to Interpret the Answers You Received

Back home, compare answers and your notes about each doctor. To ‘interpret’ the doctors’ answers, see our article, “Choosing the Right Doctor: 10 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.

Your relationship with your doctor is important. Read our post: Do You ‘Like’ Your Doctor, Do You ‘Connect’?…How it Affects Your Health

Also Assess the Doctor’s Manner and Personality

Warning - cautionYou’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?

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.

Gender bias: 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. To read more about gender bias by doctors, read The Facts About Women with A-Fib: Mother Nature and Gender Bias—Or—Get Thee to an EP ASAP/

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.

Overview of All of Treatment Options

 Treatmant Option: Catheter Ablation

Illustration: Radio frequency (RF) catheter ablation at

Illustration: Radio frequency (RF) catheter ablation

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. Learn about FHRS designations.

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 Lists: 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.

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 Treatment Option: Maze or Mini-Maze

Video still of Dr William Harris - Mini-Maze Surgery 150 x 96

Mini-maze surgery

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 (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 Lists: 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: Surgeons vs. EPs

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 (

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 Return to Where to Start

Last updated: Tuesday, December 6, 2016

Footnote Citations    (↵ 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:
  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.

US Doctors performing Maze and Mini-Maze Surgeries – a List by

Steves List logo 200 pix at 96 resUS Centers and Surgeons Performing Maze and Mini-Maze Operations

If you aren’t a candidate for a catheter ablation, another option is the Maze/Mini-Maze surgery. We’ve compiled a list of Medical Centers and doctors performing the Maze surgeries organized by US state (when applicable).

Alabama · Arizona · Arkansas · California · Connecticut · Florida · Georgia · Illinois · Indiana · Louisiana · Maryland · Massachusetts · Michigan · Minnesota · Missouri · New Jersey · New York · North Carolina · Ohio · Oklahoma · Oregon · Pennsylvania · South Carolina · Tennessee · Texas · Utah · Virginia · Wisconsin


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


University of Alabama at Birmingham, Division of Cardiovascular Disease


Cavanaugh Heart Center


Samuel T. Rayburn MD PA


USC Healthcare Consultation Center II 

Hoag Memorial Hospital Presbyterian 

University of California San Francisco, East Bay Surgery 

University of California, Irvine Medical Center, Division of Cardiothoracic Surgery 

Pacific Coast Cardiac & Vascular Surgeons

Sequoia Heart Surgeons

Sacramento Cardiovascular Surgeons 

Sutter Medical Group Cardiology 

Kaiser Permanente San Francisco Medical Center 

Stanford School of Medicine


Yale Cardiac Surgery


Shands Hospital at the Un. of Florida 

Mayo Clinic Jacksonville 

Atrial Fibrillation Institute/St. Vincent’s Heart and Vascular Center 

St. Joseph’s Hospital, Tampa/Advanced Center for Atrial Fibrillation

Sarasota Memorial Hospital (Dr. Paul Vesco)


Emory University Heart Center 

Piedmont Heart Institute

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Northwestern Memorial Hospital, Division of Cardiac Surgery 

University of Chicago Medical Center, Department of Surgery 

Illinois Cardiac Surgery Associates, SC 

OSF St. Francis Medical Center Illinois Cardiac Surgery Associates 


Community Heart and Vascular Hospital

Clarian Health Group/Methodist Hospital 


New Orleans Heart


Capital Cardiovascular & Thoracic Surgery 

Johns Hopkins Un. 

University of Maryland Cardiac Surgery


Massachusetts General Hospital

Beth Israel Deaconess Medical Center 

North Shore Medical Center

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Borgess Heart Center, Kalamazoo

Great Lakes Cardiothoracic/Northern Michigan Hospital


Mayo Clinic Rochester 


Wheeler Heart/Vascular Center 

Washington Univ. School of Medicine 

St. John’s Cardiovascular Specialists



St. Joseph’s Hospital and Medical Center 

Robert Wood Johnson University Hospital


Montefiore Medical Center CAR,  Division of Cardiology-Montefiore-Einstein

Maimonides Medical Center, Atrial Fibrillation Center

New York Columbia Presbyterian Hospital

Lenox Hill Interventional Cardiac & Vascular Svcs


Asheville Cardiovascular Surgery 

University of North Carolina at Chapel Hill

Wake Forest University/Baptist Medical Center

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Deaconess Hospital Atrial Fibrillation Center, Cincinattti

Cleveland Clinic Foundation

The Ohio State Un. Medical Center, Columbus

St. Rita’s Medical Center, Lima


University of Oklahoma Health Sciences Center


Swanson Gatley Cardiothoracic Surgeons/St. Vincent’s Medical Center


Allegheny General Hospital, The Gerald McGinnis Cardiovascular Institute


Greenville Hospital System,  University Medical Group Cardiothorasic Surgery


Methodist University Hospital 

Vanderbilt Heart Center for Atrial Fibrillation


Methodist DeBakey Heart & Vascular Center

Texas Heart Institute/Cardiovascular Care Providers, Inc. 

University of Texas Houston/Memorial Hermann Hospital 

Cardiothoracic Surgery Associates of North Texas 


Intermountain Medical Group


Inova Heart and Vascular Institute, Inova Fairfax Hospital


Aspirus Heart & Vascular Institute, A-Fib Clinic

Froedtert & Medical College Clinics

Midwestern Heart Surgery Institute, St. Luke’s Medical Center

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

NOTICE: We offer no preferential listings. We accept no fee, benefit or value of any kind for listing a specific doctor or medical center. 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.—your independent source of unbiased information about Atrial Fibrillation, research and treatment options.


Steve’s Lists of 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, 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. 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 is your independent source of unbiased information about Atrial Fibrillation, resources and treatments.

Last updated: Saturday, March 17, 2018

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

Developed by Dr. James Cox in 1987, the Cox Maze operation was the first treatment that made patients A-Fib free. In the Cox-Maze open heart “cut and sew” operation, the surgeon made numerous incisions in your atria. This “maze” of incisions divided your atria into electrically isolated segments, thereby blocking the electrical impulses that cause A-Fib from spreading throughout the heart. The atria continued 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-Maz 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 or go through the diaphragm 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). See 

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.

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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, the Dallas Lesion Set, and the Biatrial Maze 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


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. While 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 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


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

“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 16, 2018

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Footnote Citations    (↵ 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
  3. Burton, T. Surgical-Device Firms Walk Fine Line. The Wall St. Journal. March 2010.  Last accessed Nov 4, 2014. URL:
  4. Kiser, A C. Advantages of the Convergent Procedure UNC Cardiac Surgery and Electrophysiology Services, Last accessed Aug 27, 2015. URL:
  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.
  11. Kiser, A C. Advantages of the Convergent Procedure UNC Cardiac Surgery and Electrophysiology Services, Last accessed November 5, 2012 from
  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:
  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.
  15. Burton, T. Surgical-Device Firms Walk Fine Line. The Wall St. Journal. March 2010.  Last accessed Nov 4, 2014. URL:
  16. Schouchoff, Barbara. “Surgical Approaches for Atrial Fibrillation.” Critical Care Nursing Quarterly. July/September 2007, Volume 30, Number 3, pages 233-242. 
  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:
  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:
  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 and a trial by Inova Health Care Services (see
  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
  26. Burton, T. Surgical-Device Firms Walk Fine Line. The Wall St. Journal. March 2010.  Last accessed Nov 4, 2014. URL: 
  27. Update: AtriCure finalizes settlement in federal whistleblower case. February 2, 2010. Last accessed Jan 11, 2013 URL:; 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 Last Accesse7 Jan 11, 2013, URL:
  29. Burton, T. Surgical-Device Firms Walk Fine Line. The Wall St. Journal. March 2010.  Last accessed Nov 4, 2014. URL:
  30. Ibid.

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