The Maze procedure is a surgical intervention that cures atrial fibrillation (AF) by interrupting the circular electrical patterns that are responsible for this arrhythmia. Strategic placement of ablations 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 ablations 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.

The Maze procedure:

• ablates the arrhythmia
• restores synchrony between the atria and the ventricles
• preserves organized atrial contraction

  The name of this procedure is based on the concept of a puzzle. The ablations 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.

   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. The Thoracoscopic Maze is a minimally invasive procedure with just 3 small incisions on either side of the chest.

   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 ablations, 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.

   The actual Maze procedure itself takes about fifteen minutes to do. The classic Cox-Maze procedure involving incisions and suturing takes approximately 1 to 2 hours. The reduction in surgical time yields improved patient outcomes, reduced morbidity and mortality. The Thoracoscopic Maze procedure takes about 90 minutes total.

The total time in the operating room varies greatly depending on the complexity of the open heart surgery. The Maze procedure is generally performed in conjunction with common cardiac surgical procedures, which may include a heart valve repair, heart valve replacement, or coronary artery bypass graft.

   During the research and development phase of the Maze procedure, a sophisticated, computerized mapping system was devised and patients with AF were studied extensively. Once the characteristics of AF were better understood, it became clear that AF is less chaotic than was once believed. In fact, consistent areas in both atria where atrial fibrillation originates were identified in the patient population that was studied. This information lead to the idea of surrounding the electrical circuits with ablations.

   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.

   The Maze procedure has been performed since 1987. To date, over 350 cases have been performed by Dr. James L. Cox. Several thousand cases have also been done in Japan, and other European countries as well.
In the case of Dr. Cox' practice, the age range of the patients is 18-82 years of age, with an average age of 52. This group represents a typical demographic profile for other surgeons who perform the Maze procedure as well. The average length of time that patients are in AF before undergoing the Maze procedure is eight years. Virtually all patients have failed multiple drug therapies prior to surgery.

*At EMC, we are currently the largest Maze provider in the United States, with 200 cases performed.

   Among U.S surgeons reporting their data in the January 2000 issue of Seminars in Thoracic and Cardiovascular Surgery, the overall success of the Maze procedure is approximately 90%.

After recuperating from surgery, will I be able to resume normal activities?

   Yes, you will be able to return to all normal activities once the initial healing period is completed. At the end of 3 months, you should expect to be at about 80-90% of your normal energy level. You can still expect to feel more tired than usual and your level of stamina may not be completely normal. After six months, you should be back to normal.

Some patients find the structured workout of a cardiac rehabilitation program to be helpful in recovering from surgery. This type of program starts with a walking schedule for the first six to eight weeks and progresses into more vigorous supervised training following the initial recovery from surgery.

   That is incorrect. In fact, most patients do not need a pacemaker after the Maze procedure. If a patient has a normally functioning sinus (SA) node prior to surgery, then it is most unlikely that a pacemaker will be needed after surgery.

There may be other pre-existing conditions such as "sick sinus syndrome" or heart block, however, that have been masked by atrial fibrillation and once exposed, require pacemaker support. (Sometimes AF takes over as the primary heart rhythm when a condition such as sick sinus syndrome is present.)

Once the AF is eradicated with the Maze procedure, the underlying problem will surface and a pacemaker may be needed. Since electrophysiology (EP) studies are not obtained on all patients prior to surgery, there is no way to know the status of the sinus node and accurate predictions for pacemakers are therefore difficult to make.

   From the start of the procedure in 1987, follow-up information has been obtained on patients on a regular basis. To date, there have been no adverse or unexpected findings with the long-term patients.

   Atrial fibrillation 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 atrial fibrillation 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.

   Because the Maze procedure is open heart surgery, it is generally reserved for patients who have failed medical therapy with symptomatic and debilitating AF. I would advise you to find a good cardiologist to thoroughly investigate all the possible causes of your atrial fibrillation and to diagnose the type of AF that you may have. Once a full work-up is completed, then all of the available treatment options can be discussed before deciding upon a course of action. Each case is unique and must have an individualized approach based on the circumstances.

    If you do not feel differently in AF compared with a normal rhythm (unless there is another overriding problem such as frequent blood clots or strokes), then a Maze procedure probably would not be appropriate for you. The main reason patients undergo a Maze procedure is for relief of symptoms associated with the AF and improved quality of life. Many patients suffer severe side effects from the medications that they must take to control the AF and seek an alternative therapy that will allow them to discontinue the drugs.