Surgery Options for AFib: Maze, Mini-Maze, and More.

Treatment for atrial fibrillation (AFib) is a complex topic. While many patients can control their symptoms with medications or simple procedures, some patients require more extensive surgical interventions.

In this article, I will explore the Maze, Mini Maze, and Convergent surgical options for treating AFib. Understanding the benefits and risks between these procedures is essential in determining which one would be the best option for your needs. Finally, I will then also compare surgical options for AFib with traditional catheter based ablation procedure.

So, let’s compare the three most common surgical procedures done to treat AFib.

The Maze Procedure

Created by Dr. James Cox in 1987, the Maze procedure quickly became the gold standard surgical treatment to eliminate atrial fibrillation. It is also commonly called the “traditional maze,” or the “cut and sew maze” procedure.

The Maze procedure is an open-heart surgery. During the operation, the surgeon opens the patient’s breastbone and places them on a heart-lung bypass machine. The machine pumps oxygenated blood around the body while the heart is stopped to perform the procedure. Scar tissue is created throughout the heart to act as electricity conduction barriers to prevent heart arrhythmias. Surgeons can perform additional procedures like heart valve replacements and bypass surgery at the same time as a Maze procedure.

Success Rates of Maze Procedure

The largest study of Maze procedures was conducted on 282 patients who underwent the traditional Maze procedure. In the study, 78% of the patients were in normal sinus rhythm without any anti-arrhythmic medications at 12 months after surgery.

Complications and Recovery for a Maze Surgery

Like all surgeries, the Maze procedure comes with the expected risks. Anesthesia complications, surgical site infections, and post-operative blood clots are all possible complications of this procedure. The incidence of major postoperative complications is 11%, including an operative mortality rate of 2%.

Because of the open nature of the procedure, the recovery period requires a post-operative hospital stay of 5-7 days. You may stay in an intensive care unit (ICU) for close monitoring if needed.

Once discharged, strict precautions for lifting, driving, and other activities will be in place to help you heal. Most patients report having fully recovered 6 months after the procedure.

The Mini Maze Procedure

An alternative to the traditional Maze procedure, the Mini Maze procedure was created to reduce recovery times. The Mini Maze is an effective and less invasive option for treating atrial fibrillation, when compared to a traditional Maze surgery.

The Mini Maze is a minimally invasive or laparoscopic procedure. Instead of opening the chest, three or four small incisions are created in the chest. Long surgical tools are inserted, and the surgery is done via a live video recording.

Unfortunately, not everyone is a good candidate for this procedure. The Mini Maze works best for patients with paroxysmal (occasional) AFib or those with an otherwise healthy heart.

watch a detailed video of the wolf mini maze here.

Success Rate of Mini Maze Surgery

In a recent study of 465 patients who underwent the Mini Maze procedure, 74% of people no longer experienced symptoms of AFib within a year of surgery.

Complications and Recovery for a Mini Maze Surgery

All normal surgical complications are still possible in those who undergo a Mini Maze procedure. Additionally, there is a low risk for switching to an open-heart surgery during the procedure should complications arise. A recent study found the reported complication rate to be 25%, with the most common complication being pneumothorax (injury to the lungs during surgery).

Because of the minimally invasive nature of the procedure, recovery from a Mini Maze is much less extensive. The average hospital stay after the procedure is 3-4 days, and most patients can return to regular activities with 2-4 weeks.

It can take multiple months for a person to see results from the procedure, as a result, many patients are put on a short-term course of anti-arrhythmic medications.

The Convergent (Hybrid) Procedure

The newest surgical option of the three, a convergent or hybrid procedure can treat tissue both inside and outside of the heart. It is usually done as one procedure, but it can also be divided into two sections done a few days apart.

Similar to a Mini Maze, the convergent procedure is minimally invasive. Small incisions in the chest are used to insert instruments to create scar tissue in specific patterns on the outside of the heart. An electrophysiologist in a catheter lab then performs the second portion of the procedure. It is performed through a needle puncture in the groin, where a catheter is threaded through the large vein to the heart.

When done together, scar tissue is created inside and outside of the heart, which may better block electrical conduction within the heart to prevent irregular heart rhythms. The separate steps of the convergent procedure can be done in the same procedure or on different days.

watch a detailed video about the convergent procedure here.

Success Rate of a Convergent Procedure

In a recent article, it was found that of 340 patients who underwent a convergent procedure, at 12 months, 81.9% of patients were in sinus rhythm, while 54.1% of patients were in sinus rhythm while not taking AADs.

Complications and Recovery of a Convergent Procedure

In addition to the normal risks of surgery, some patients experience chest pain, trouble breathing, or fluid retention after this procedure. A recent study reports the complication rate of a convergent procedure is 10%.

Like the Mini Maze, the expected hospital stay after the procedure is 3-4 days. On the first day after the procedure, you may be admitted to the ICU for additional monitoring.

During the first 2-4 weeks while at home, strenuous activity should be avoided. Once healed, normal activities can be resumed.

AFib Surgery vs. Catheter Ablation

So, if these surgical options have a high level of success, why would anyone get a catheter ablation instead?

While the surgical procedures have been proven to be more effective at treating the symptoms of atrial fibrillation in some studies, they also come with additional risks. In addition, the results of various studies are inconsistent on whether surgical or catheter ablation is more effective in treating AFib.

At the same time, there have also been studies that have shown that a catheter ablation procedure can be as equally as effective as a surgical ablation in patients with paroxysmal or early stage atrial fibrillation. Meanwhile, another study demonstrated the results in long-standing persistent atrial fibrillation were similar between catheter and surgical ablation procedure.

As reported above, the complication rates from surgical ablation procedures can be anywhere from 10-25%. Meanwhile, a recent systemic review of over 80,000 catheter ablation procedures found a complication rate of 2.9%.

For those who do not require surgical intervention, a catheter ablation is a safer and still effective option for treating AFib.

Also keep in mind, many patients with atrial fibrillation have additional medical conditions that may increase the associated risks of a surgical ablation procedure; such as, coronary artery disease, congestive heart failure, or chronic obstructive pulmonary disease.

Putting It All Together

If medications have not successfully treated your AFib, you should discuss your treatment options, including surgical ablation procedure with your physician.

Your doctor can help you decide which procedure is best for you, weighing in the risks and benefits of each option. Getting educated about your options is the best way to advocate for your own health – and I hope this article sheds some helpful light on the different procedures.