Atrial fibrillation surgical ablation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] Anahita Deylamsalehi, M.D.[3] Vendhan Ramanujam M.B.B.S [4]

Synonyms and keywords: Cox-Maze, Cox Maze, Maze, Minimaze, Mini Maze, Mini-Maze, Cox maze procedure, Maze procedure, Minimaze procedure


The Maze procedure is a surgical treatment option for some patients with atrial fibrillation. In this procedure, a series of incisions in a cross-like pattern is made on the atria, which blocks the abnormal atria circuits, hence eliminating the atrial fibrillation. A number of improvements have been made to this surgical procedure since it was first invented. Recently, various methods of minimally invasive maze procedures have been developed; these procedures are collectively named minimaze, mini versions of the original maze surgery.

Indications for Catheter and Surgical Ablation

Class I Indications

In symptomatic paroxysmal atrial fibrillation patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, catheter ablation is recommended.[2]

Class IIa Indications

Class IIb Indications

Class III Indications

In symptomatic paroxysmal or persistent or longstanding persistent atrial fibrillation patients, prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic agent, stand alone surgical ablation is not recommended.[3]

Surgical Ablation

Cox Maze Procedure

  • James Cox, MD, and associates developed the "Maze" or "Cox Maze" procedure, an "open-heart" cardiac surgery procedure intended to eliminate atrial fibrillation, and performed the first one in 1987.[4]
  • Maze refers to the series of incisions arranged in a maze-like pattern in the atria.[5]
  • The intention was to eliminate atrial fibrillation by using incisional scars to block abnormal electrical circuits (atrial macroreentry) that atrial fibrillation requires.[5]
  • This required an extensive series of endocardial (from the inside of the heart) incisions through both atria, a median sternotomy (vertical incision through the sternum) and cardiopulmonary bypass (heart-lung machine; extracorporeal circulation).
  • A series of improvements were made, culminating in 1992 in the Cox Maze III procedure, which is now considered to be the "gold standard” for effective surgical cure of atrial fibrillation.[4]
  • It was quite successful in eliminating atrial fibrillation, but had drawbacks as well.[6]
  • The Cox Maze III is sometimes referred to as the “Traditional Maze”, the “cut and sew Maze”, or simply the "Maze".
  • Efforts have since been made to equal the success of the Cox Maze III while reducing surgical complexity and the likelihood of complications. During the late 1990s, operations similar to the Cox-Maze, but with fewer atrial incisions, led to the use of the terms "Minimaze", "Mini Maze" and “Mini-Maze”, although these were still major operations.[7]
  • A primary goal has been to perform a curative, "Maze-like" procedure, epicardially (from the outside of the heart), so that it could be performed on a normally beating heart, without cardiopulmonary bypass. Until recently this was not thought possible; as recently as 2004, Dr. Cox defined the Mini-Maze as requiring an endocardial approach:

“In summary, it would appear that placing the following lesions can cure most patients with atrial fibrillation of either type: pulmonary vein encircling incision, left atrial isthmus lesion with its attendant coronary sinus lesion, and the right atrial isthmus lesion. We call this pattern of atrial lesions the “Mini-Maze Procedure” … None of the present energy sources—including cryotherapy, unipolar radiofrequency, irrigated radiofrequency, bipolar radiofrequency, microwave, and laser energy—are capable of creating the left atrial isthmus lesion from the epicardial surface, because of the necessity of penetrating through the circumflex coronary artery to reach the left atrial wall near the posterior mitral annulus. Therefore, the Mini-Maze procedure cannot be performed epicardially by means of any presently available energy source.”[8]

Minimally Invasive Epicardial Surgical Procedures

1. No median sternotomy incision; instead, an endoscope and/or “mini-thoracotomyincisions between the ribs are used.
2. No cardiopulmonary bypass; instead, these procedures are performed on the normally beating heart.
3. Few or no actual [[incisions] into the heart itself. The "maze" lesions are made epicardially by using radiofrequency, microwave, or ultrasonic energy, or by cryosurgery.
4. The part of the left atrium in which most clots form (the “appendage”) is usually removed, in an effort to reduce the long-term likelihood of stroke.

Microwave Minimaze

Completely Endoscopic Microwave Ablation of Atrial Fibrillation on the Beating Heart Using Bilateral Thoracoscopy: [10][11]

Wolf Minimaze

Video-Assisted Bilateral Epicardial Bipolar Radiofrequency Pulmonary Vein Isolation and Left Atrial Appendage Excision: [13][12]

  • The Wolf Minimaze requires one 5cm and two 1cm incisions on each side of the chest. These incisions allow the surgeon to maneuver the tools, view areas through an endoscope, and see the heart directly.
  • The right side of the left atrium is exposed first. A clamp-like tool is positioned on the left atrium near the right pulmonary veins, and the atrial tissue is heated between the jaws of the clamp, cauterizing the area. Then the clamp is removed.
  • The autonomic nerves (ganglionated plexi) that may cause atrial fibrillation and may be eliminate it as well.
  • Subsequently the left side of the chest is entered.
  • The ligament of Marshall (a vestigial structure with marked autonomic activity) is removed. The clamp is subsequently positioned on the left atrium near the left pulmonary veins for ablation.
  • Direct testing to demonstrate complete electrical isolation of the pulmonary veins, and that the ganglionated plexi is no longer active, may be performed.

High Intensity Focused Ultrasound (HIFU) Minimaze

Surgical Ablation of Atrial Fibrillation with Off-Pump, Epicardial, High-Intensity Focused Ultrasound: [14]

Mechanism of Elimination of Atrial Fibrillation

Patient Selection

Surgical Results

  • Long-term success of the Minimaze procedures awaits a consensus. Attaining a consensus is hindered by several problems; perhaps the most important of these is incomplete or inconsistent post-procedure follow-up to determine if atrial fibrillation has recurred.[6]
  • It has been clearly demonstrated that longer or more intensive follow-up identifies much more recurrent atrial fibrillation, hence a procedure with more careful follow-up will appear to be less successful.[18]
  • In addition, procedures continue to evolve rapidly, so long follow-up data do not accurately reflect current procedural methods. For more recent Minimaze procedures, only relatively small and preliminary reports are available.
  • A new metric ("Single Procedure Risk Adjusted Success") has been proposed in an attempt to control for some of these inconsistencies, but it has not been widely accepted. With those caveats in mind, it can be said that reported short-term success rates range from 67% to 91%.[11][12][14]
  • Currently the limitation of ablation procedure deployed through a minimal access incision or port, constraints on the location and number of ablation lesions that can be performed.

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary (DO NOT EDIT)[19]

Rhythm Control

Surgery Maze Procedures

Class IIa
"1. An AF surgical ablation procedure is reasonable for selected patients with AF undergoing cardiac surgery for other indications. (Level of Evidence: C)"
Class IIb
"1. A stand-alone AF surgical ablation procedure may be reasonable for selected patients with highly symptomatic AF not well managed with other approaches. (Level of Evidence: B)"


External links


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  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee (2021). "Atrial fibrillation: diagnosis and management-summary of NICE guidance". BMJ. 373: n1150. doi:10.1136/bmj.n1150. PMID 34020968 Check |pmid= value (help).
  3. 3.0 3.1 3.2 Sarabanda, AV.; Bunch, TJ.; Johnson, SB.; Mahapatra, S.; Milton, MA.; Leite, LR.; Bruce, GK.; Packer, DL. (2005). "Efficacy and safety of circumferential pulmonary vein isolation using a novel cryothermal balloon ablation system". J Am Coll Cardiol. 46 (10): 1902–12. doi:10.1016/j.jacc.2005.07.046. PMID 16286179. Unknown parameter |month= ignored (help)
  4. 4.0 4.1 Cox J, Schuessler R, D'Agostino H, Stone C, Chang B, Cain M, Corr P, Boineau J (1991). "The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure". J Thorac Cardiovasc Surg. 101 (4): 569–83. PMID 2008095.
  5. 5.0 5.1 Cox JL, Churyla A, Malaisrie SC, Kruse J, Pham DT, Kislitsina ON; et al. (2018). "When Is a Maze Procedure a Maze Procedure?". Can J Cardiol. 34 (11): 1482–1491. doi:10.1016/j.cjca.2018.05.008. PMID 30121148.
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  9. 9.0 9.1 Khargi, K.; Hutten, BA.; Lemke, B.; Deneke, T. (2005). "Surgical treatment of atrial fibrillation; a systematic review". Eur J Cardiothorac Surg. 27 (2): 258–65. doi:10.1016/j.ejcts.2004.11.003. PMID 15691679. Unknown parameter |month= ignored (help)
  10. 10.0 10.1 Saltman A, Rosenthal L, Francalancia N, Lahey S (2003). "A completely endoscopic approach to microwave ablation for atrial fibrillation". Heart Surg Forum. 6 (3): E38–41. PMID 12821436.
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