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Surgical Maze

What are the surgical options to treat atrial fibrillation?
New concepts for the surgical treatment of atrial fibrillation were introduced in recent years, when the surgical device industry introduced different ablation technologies to support various platforms for surgical ablation. As a result, cut-and-sew maze procedures are no longer performed on a regular basis and device-based procedures are widely performed. All procedures include control of the left atrial appendage. The surgical procedures in use include:

1. The full Maze procedure is performed in two ways:
   • Median sternotomy, which involves a midline incision and splitting of the breastbone, and is offered to candidates as part of a combined procedure, such as coronary artery bypass grafting or valve surgery with indications for surgical ablation of atrial fibrillation. It is also offered to patients who are not eligible for the minimally invasive approach as a stand-alone procedure.
   • A minimally invasive approach, which is performed through a small right-anterior throracotomy and has the same high success rate as the Full Maze procedure.
2. Pulmonary vein isolation
   • This procedure is offered to patients who have intermittent atrial fibrillation. The procedure is performed through bi-lateral (left and right) incisions in the chest wall and includes left atrial appendage disarticulation.

What is the surgical Maze procedure?
The Maze procedure is a surgical intervention that cures atrial fibrillation (AF) by interrupting the circular electrical patterns that are responsible for this arrhythmia. Creating surgical ablation lines in both atria stops the conduction of erratic electrical impulses, and channels the normal electrical impulse in one direction, from the top of the heart to the bottom. Scar tissue generated by the the ablation permanently blocks the travel routes of the electrical impulses that cause AF, eradicating the arrhythmia. The major advantage that the Maze procedure offers over other less-invasive forms of therapy is that it corrects all three problems associated with AF, restoring sinus rhythm, facilitating the synchrony between the atria and the ventricles, and preserving organized atrial contraction.

Does the heart have to be stopped to do a Maze procedure?
In some cases the procedure does require that the heart be stopped and a heart-lung bypass machine to be used. This is because surgeons need to work on a non-beating heart to create the ablation lines. A heart-lung bypass machine supplies blood flow and oxygen to all of the body's organ systems to protect them while the heart is stopped. In modern AF surgery, the use of the heart-lung machine have been reduced to minimum in most cases. For example, pulmonary vein isolation only is performed through bi-lateral incisions in the chest wall and without the use of heart-lung machine.

How long does the operation take?
The length of the operation varies depending on the complexity of the surgical procedure and the approach that is used. The actual Maze procedure itself takes about an hour. The remainder of the time is spent safely engaging and disengaging from bypass, opening and closing the chest, and inserting the necessary pressure-monitoring lines. The approximate total time in the operating room for a Maze procedure is about two to three hours.

How does a doctor determine where to make the atrial incisions?
The Maze procedure is performed in the exact same manner with precise placement of incisions for each patient. During the research and development phase of the Maze procedure, it became clear that AF is less chaotic than was once believed. There are consistent areas in both atria where AF originates; this was the information that led to the idea of surrounding these areas with incisions.

What is the success rate of curing AF with the Maze procedure?
The Maze procedure cures atrial fibrillation about 95% of the time.

What are the major complications associated with the Maze procedure?
Fluid retention is sometimes a complication. However, patients who take diuretics for the first six weeks after the surgery usually overcome the problem. Other complications include bleeding, wound infection, stroke and pneumonia. These are possible complications with any open-heart surgery procedure.

Can the Maze procedure be done in conjunction with other cardiac surgical procedures?
Yes, the Maze procedure is frequently performed with other cardiac surgical procedures, such as coronary artery bypass grafting, mitral valve repair or valve replacement.

Can someone who has already had heart surgery have a Maze procedure?
Though it is possible to have a Maze procedure if you have had other cardiac surgery, your physician will need to review your medical records and evaluate your case.

Is there a lot of pain after surgery?
Each patient experiences pain differently. In general, the sternum has relatively few nerve endings. Most patients who have had chest surgery complain of aching around the incision and general discomfort between the shoulder blades. Patients are encouraged to take pain medication as needed. Some patients find that a neck pillow is useful in reducing the shoulder aches and pains after surgery.

What is the average length of hospital stay with the Maze Procedure?
Most patients are hospitalized an average of three to five days, while the atrial tissue swelling decreases after surgery and the sinus- node function returns. Usually, patients stay in Intensive Care for one to two days and then move to a step-down unit for the remainder of their hospital stay. Typically, once patients reach the step-down unit they are able to walk around with a portable telemetry monitor.

What is the typical recovery time, and when do people generally return to work?
The typical post-operative recovery time is about four weeks after surgery. Though the decision about when to return to a full schedule depends on each patient, those with physically demanding jobs may have a recovery as long as three months.

After recuperating from surgery, when will patients resume normal activities?
By the end of six to eight weeks, patients should expect to be back to their normal energy. Patients may feel more tired than usual and may not have the stamina they once had until about six months after the surgery.

Cardiac rehabilitation, a structured and monitored work-out program, helps many people recover from surgery. To learn more about cardiac rehabilitation at Inova, click here.

What kinds of tests are typically performed before surgery?
An echocardiogram is essential for all patients before a Maze procedure. The echocardiogram is an ultrasound study of the heart that helps physicians evaluate the structure and the function of the heart and the valves. In addition, diagnostic tests, including labwork, an electrocardiogram and a chest X-ray, will be required prior to surgery.

Patients over the age of 40, as well as those with clinical evidence of heart abnormalities or suspected heart conditions, will undergo cardiac catheterization to assess cardiac function. A cardiac catheterization can be performed as an outpatient visit by an interventional cardiologist. The catheterization film will be forwarded to your heart surgeon for review before surgery.

Can someone with a pacemaker have a Maze procedure done?
If you have a pacemaker, you may still be able to have the Maze procedure. Pacemakers do not affect the surgical procedure and may even reduce the time spent in the hospital after the surgery.

Does everyone who has a Maze procedure need a pacemaker after surgery?
Most patients do not need a pacemaker after the Maze procedure.

There may be other pre-existing conditions, such as "sick sinus syndrome" or heart block, that were masked by atrial fibrillation and become obvious after the surgery. If that happens, a patient might need a pacemaker.

For those who had AV node ablation in the past, but are still symptomatic with AF, is the Maze procedure an option?
Yes. Patients who have had an ablation procedure can still undergo the Maze surgery.

What should patients expect over the long term (five to 10 years) following the Maze procedure?
Since the procedure began in 1987, follow-up information has indicated no adverse or unexpected findings with patients over the long term.

Will having the Maze procedure limit cardiac surgical procedures (bypass, valve replacement) in the future?
The Maze procedure does not prevent further cardiac surgical interventions. However, scar tissue usually forms following any open-heart procedure, making a second procedure more difficult.

Will anticoagulant medication, such as Coumadin, be required after surgery?
Usually, patients are given Coumadin during the first 12 weeks after surgery. Coumadin may be necessary for other conditions, such as mechanical valve implantation, that are dealt with during the same surgical procedure, but it is not directly related to the Maze procedure.

Will patients have AF after surgery? How long does it last? When will it stop completely?
AF occurs in 40 to 45% of patients within the first three months after surgery, because the atrial tissue swells and rest periods become shorter, making it easier for an irregular beat to trigger AF. However, AF after surgery usually responds well to medication.

Should someone just diagnosed with AF have the Maze procedure?
Because the Maze procedure is open-heart surgery, it is generally reserved for patients for whom medication has not been successful. The average length of time that patients experience AF before undergoing the Maze procedure is eight years. To determine if a patient should have the Maze procedure, a full work-up is completed and all of the available treatment options are discussed. Each case is unique and must have an individualized approach, based on the circumstances.

Should patients with AF who don't know they are experiencing it and are not bothered by it consider the Maze procedure?
Patients who are unaware if they are experiencing AF or a normal rhythm are probably not appropriate candidates for the Maze procedure. Generally, patients undergo surgery to relieve symptoms associated with AF and improve quality of life.