Current PV ablation techniques are achieving partial success rates in curing paroxysmal AF. Curing" Those not "cured" of AF, may be significantly improved after an ablation. They may have fewer or less intense attacks of AF. Medications that didn't work before may now control the AF. But for some there may not be any noticeable improvement at all.

During PV ablation a soft, thin, flexible tube with an electrode at the tip is inserted through a large vein or artery in your groin and moved into your heart. This catheter is directed to the precise location(s) in your heart that are producing your AF. These points are burned off or isolated from your heart.

If you are in AF during the catheter ablation procedure, it's relatively easy for the doctors to determine where the A-Fib signals are coming from and to ablate (destroy) them.

However, if you have intermittent AF (Paroxysmal AF), it's harder to pinpoint exactly the source(s) of the A-Fib signals. The challenge for doctors is how to locate and eliminate AF signals when the patient is not in AF. Since research has shown that almost all A-Fib signals come from the openings (ostia) of the four pulmonary veins in the left atrium, one technique is to make circular radiofrequency (RF) Ablation lines around each pulmonary vein opening (called "Circumferential" or "Empirical Ablation"). This isolates the pulmonary veins from the rest of the heart and prevents any pulses from these veins from getting into the heart. However, it's difficult to make circular RF lesions and they aren't always successful. This technique can achieve good success rates with for people with paroxysmal AF. For people with chronic AF, success rates may not be as good.

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What is the Maze procedure?
The Maze procedure is a surgical intervention that treats AF by interrupting the circular electrical patterns that are responsible for this arrhythmia. Strategic placement of incisions in both atria stops the formation and the conduction of errant 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 incisions permanently blocks the travel routes of the electrical impulses that cause AF, thus eradicating the arrhythmia. The major advantage the Maze procedure offers over other less-invasive forms of therapy is that it corrects all three problems associated with AF.

What does the name “Maze” stand for, or mean?
The name of this procedure is based on the concept of a puzzle. The incisions create barriers and several blind alleys allowing for only one major route for an electrical impulse to travel from the top to the bottom of the heart.

How is the Maze procedure ordinarily done? What kind of incision is made?
The standard approach used for open heart surgical procedures (including the Maze) is to divide the breastbone (sternum) with an incision that is approximately 10-12 inches in length. This gives the heart surgeon direct access to the heart which lies angled to the left just under the sternum. Once the surgery is completed, the sternum is wired back together and the skin is closed with absorbable suture. The sternum will knit back together in 6-8 weeks and will be just as strong once the healing process is complete.

Does the heart have to be stopped to do a Maze procedure?
The Maze procedure does require that the heart be stopped and necessitates the use of the "heart-lung machine" or cardiopulmonary bypass. In order to make the incisions and to close them with sutures, the surgeon needs to work on a non-beating heart. To protect the other organs while the heart is stopped, cardiopulmonary bypass supplies blood flow and oxygen to all of the body's organ systems.

How long does the operation take?
The answer varies greatly depending on the complexity of the surgical procedure and the approach that is used. The actual Maze procedure itself takes about an hour to do. 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 four hours.

What does this procedure usually cost, and does insurance cover it?
Most insurance plans do cover the cost of the Maze procedure. It is not classified as an experimental procedure. Coverage and reimbursement are based according to the patient's specific benefit package and contract. A predetermination of coverage from the insurance company will be obtained prior to the procedure. However, the actual reimbursement amount cannot be determined until all the hospital and physician charges have been submitted. The approximate cost is $60,000.

What is the operative mortality rate for the Maze procedure?
The overall operative mortality for patients undergoing the Maze procedure is 3%. There is a significant increase in mortality and morbidity associated with patients aged greater than 65 years of age.

What are the major complications associated with the Maze procedure?
In the early postoperative period, fluid retention has historically been a complication. However, fluid management with two diuretics (fluid medications) Aldactone and Lasix for the first six weeks after surgery has been successful in overcoming this complication. The other complications are similar to those that occur with any open-heart surgery: bleeding, wound infection, stroke, and pneumonia. The Maze procedure is frequently performed with other cardiac surgical procedures such as coronary artery bypass grafting, mitral valve repair and/or valve replacement.

What is the average length of hospital stay with the Maze Procedure?
Most patients are hospitalized an average of 10-12 days. Much of that time is spent waiting for the atrial tissue swelling to decrease postoperatively and the return of the sinus node function. Patients are usually in the intensive care unit for two days and the remainder of the time is spent on the step down unit. Typically, once patients reach the step-down phase, they are ambulatory (able to walk about) with a portable telemetry monitor (about the size of a Walkman) waiting for stabilization of the rhythm.

What is the typical recovery time, and when do people generally return to work?
In general, the recovery is complete about 6-8 weeks after surgery. The decision as to when one should return to a full schedule is somewhat individualized. For those patients with physically demanding jobs, the recovery may be extended to three months for open chest procedures. It is possible that you may need a blood transfusion with any open heart procedure and the Maze is no exception.

AF occurs in 38% of patients within the first three months after surgery. The reason that it occurs is that, following the surgery, the atrial tissue swells and the refractory periods (rest periods) of the atrial cells become shorter, making it easier for an irregular beat to trigger AF. However, postoperative AF is usually more responsive to medical therapy. Once the AF is converted with medications, it is important to remain on the medication to prevent future occurrences of AF.

At three months, the healing process is usually complete and all medications are withdrawn. The current data indicates that there is a 3% recurrence of AF after the initial three month postoperative period. Typically, these patients are successfully treated with medications and remain in normal sinus rhythm.

The risks of the maze procedure are similar to the risks of any heart surgery and include:

Bleeding
Infection
Stroke
Pneumonia
Heart attack (myocardial infarction, or MI)
Death

Other arrhythmias - Approximately 30% of people need to have a pacemaker implanted after a maze procedure for new arrhythmias.

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The Wolf MiniMaze

The Wolf Mini Maze procedure combines the best of both the catheter ablation and the Cox Maze operation, with minimal invasion, which to an AF/atrial flutter patient really doesn't mean anything, it's still surgery.

To a Lone AF/Atrial flutter, (referred to as LAF) patient, meaning someone who doesn't have any other heart problems, other than, the AF, surgery is surgery and no one wants to have surgery, it is always the "last resort.

Patients with AF are the only ones, who know the horror of the disease, it can be devastating to their lives. They live in constant fear that the next heart beat will be AF, so there isn't really any need to explain what AF means to some one with it, THEY KNOW.

The catheter ablation procedure doesn't offer a very high success rate and the Cox Maze procedure involves open heart surgery, where the patient is connected to a heart lung machine and their heart is actually stopped from beating, while the surgeon actually cuts through the sternum, spreads the ribs and then cuts into the heart, where they make "Maze" incisions that will leave scar tissue, which will block the erroneous electrical signals that cause the AF/Atrial flutter.

The Cox Maze procedure is usually performed when open heart surgery is required for another heart problem, such as replacing a heart valve. Dr. Wolf's procedure is performed through two small incisions, approximately 3 inches long, between the ribs. The instruments that he uses are so small that he doesn't even have to spread the ribs to reach the heart. He performs the ablation on one side of the heart, with a special tool that can achieve in 8 seconds what the normal ablation instrument would take 3 minutes to do.

He then performs the Maze incisions on the other side of the heart and while doing this, also removes the "atrial appendage. "The atrial appendage is a actually a useless part of the heart, (sort of like the appendix), and isn't needed for the heart to work properly.

The reason that the atrial appendage is removed is that it sticks out into the flow of blood through the atrial chamber in a manner that it can capture parts of the blood and cause blood clots which can break loose and cause a stroke or embolism.

The patients stay in the hospital is only 2 to 3 days and and the complete recovery time is much less than that with the open heart surgery.

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xxxxxxxDr. Wolf in surgery xxxxxxxxxxxMinimally invasive wolf Mini Maze xxxxxxxxxxxxxxincisions

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