Why so little talk about the Wolf Mini Maze here?

Why is there so little talk about the Wolf Mini Maze procedure here? I've done a search on this forum and there is very little discussion about it.

[wolfminimaze.com]

Dr. Wolf, who pioneered it, is in Houston and still doing them. I know the downside is it's more invasive, but his success rate seems very high, and another big advantage is the LAA problem seems to be permanently solved 100% of the time on the first procedure (you take the LAA home with you in a jar).

Thoughts on that?

There were some folks here that did mini mazes and posted about them 5-10 years ago. I recall one person who was a vocal advocate. Wouldn't be my first choice...

Brian, the success rates quoted for Mini-Maze surgery often ignore atypical left atrial flutter which is just as common an occurrence as a consequence of Mini-Maze AFIB ablation as it is after endocardial catheter ablation. Except then you will need to be referred out to an EP to finish off the CA for atypical left flitter too anyway so you very often really are not avoiding that second procedure. Surgeon very often downplay or ignore that little fact since they never deal with the flutter themselves and just refer out to an EP to fix ' the little nuisance" while often claiming a one and down deal with the Maze ... for AFIB only that is :-).

Plus dont kid yourself, recovery from a Mini-Maze is truly like getting run over by a Mack truck and takes several months to fully recover. You could under go 3 or 4 CA with a top level guy like Dr Natale and still not be subjected to the cumulative recovery burden of a single Mini Maze, And very rarely will even tough cases require more than 2 to 3 procedures who started their index procedure with Natale and followed through with him until completion of your 'expert ablation process' with him.That is the surest and quickest way to finish off the beast once and for all with the least amount of total work required and least overall procedure burden on your body and heart.

It does have a role especially for severely obese Afibbers over 400 plus pounds where its tougher to get good visualization with Fluoroscopy and then often a hybrid ablation is done in a hybrid lab with a surgical team first doing a mini-maze part of the procedure and then an EP comes in an burns the few endocardial lines and any isolation that cannot be easily reached by the surgeon epicardially.

They have a state of the art hybrid ablation lab at St Davids too, Burt Dr Natale said the rarely uses it any more as they have doing so good and doing the full endocardial ablation with very god success in even super obese people and thus the hybrid approach has just not been that n necessary any longer in elite level centers.

The mini-mize can deliver good results too for sure in the right hands but when you factor in it often does not spare that follow up ablation for flutter after all in many cases it’s a becomes a harder sell yet..

And most doctors, even many Maze surgeons, will recommend only coming for maze once you have failed at least 2 CA's due to the much rougher nature of surgical ablation.

Cheers!
Shannon



Edited 1 time(s). Last edit at 10/21/2017 08:22AM by Shannon.

This is a long post, but i thought some people may be interested in my personal experience of both the mini maze and RF ablation. More details about my diagnosis and the treatment can be seen on [afibandcycling.wordpress.com]

I live in the UK. This year I was part of a clinical trial for treatment of Persistent AF. CeaseAF, [www.hra.nhs.uk] This is an international study, and the Sheffield cardiology unit is the only centre involved in the UK

“The CEASE AF study will compare the results of a combined epicardial surgical plus endocardial catheter technique versus a standard endocardial catheter ablation technique for safety, efficacy and quality of life for patients with persistent or long-standing persistent Afib.”

This involved a mini maze procedure in April, using an Atri-clip to close the LAA followed by an RF catheter ablation a couple of weeks ago.

I was pleased to be selected for the trial; my waiting time was shortened and I believed that the mini maze was likely to have more of a chance of success than multiple catheter ablations. The follow up RF ablation was also pre-planned to be within six months of the mini maze, so I would not have to wait for the first ablation to fail and then return to the waiting list.

Under normal circumstances, I travel extensively for work, teaching technical courses to adults. However in 2017 my AF and particularly bisoprolol was affecting my concentration and ability to be on my feet for an entire day, so my duties were changed. I was then working mainly from home, developing course material, new products and meeting with industry figures on future developments. This is much less stressful than my usual job.

The mini maze took place in April; I had no complications, but the recovery was still difficult. Three entry wounds in each side and two collapsed and re-inflated lungs left me feel literally like I had been hit by a truck. I was dosed with morphine, followed by oxycodone, tramodol, codeine and finally paracetemol. I had to stay for two nights in the hospital. I think that this was the most miserable I had felt in my entire life.

At home, I was eventually able to walk around the block on day four and was able to walk up to up four miles by day fourteen. On day seventeen, I went back to work on light duties; marking and development. I felt much better than before the operation; I was generally in NSR and apart from a few small blips my heart was behaving. I did think later that I came back to work a little too soon and should have taken an extra week due to the level of fatigue I was feeling. Before the op I was extremely fit (an athletic life is what caused the AF in the first place); I hate to think of the impact n an elderly or infirm person.

After three months, the surgeon was very happy with his work; he saw nothing to worry about and scheduled the catheter ablation. He was expecting only minor work to be required.

In October, six months after the mini maze, I went for the catheter ablation. I had cleared my diary for the rest of that week and the two following weeks to ensure that I could be fully rested.

The procedure took 4½ hours; the EP discovered electrical reconnection on two of the pulmonary veins, so ablated these, performed a CTI line for Atrial Flutter and added a box lesion set on the posterior atrial wall. Atrial flutter had never been mentioned to me, but I understand it can be caused by the minimaze.

I had no recovery problems, except for a slight bleed at the catheter site in the groin, which meant a further couple of hours laying down flat. I was able to leave hospital the next day. I had no trouble walking and made the deliberate decision not to get back to exercise too quickly. Within a week, I was feeling better than I had for the previous year and a half; I cancelled my last week of sick leave and returned to work earlier than planned.

I can’t make a conclusion based on just myself, but the mini maze (it is only minimally invasive when compared to open chest surgery) was a terrible experience and the catheter ablation was easy. Hopefully in a few years the results from the CEASE-AF study will add to the data and help define the procedures that can give the best outcome, but unless the mini maze is shown to be streets ahead, I would not rush to recommend it to people.

Thanks JohnM,

Your experience is exactly why there isn’t a lot of interest in mini-mase procedures on our site ... It can certainly help reduce AFIB burden significantly in the right patient group when performed by a true expert, and can often do so with less repeat PVIs than is still all too common WITH LESS EXPERIENCED EP CA OPERATORS (underscore less experienced as those not in the upper 10 to 15% of elite level CA ablationist who regularly successfully treat persistent & LSPAF cases every day in their practices).

There very much is a role for the true Maze procedure which is certainly more invasive than even a mini-maze, but knowledgable EPs, Cardiologists AND even many CV Surgeons who perform a maze procedure and who all collectively understand the nuances of the AFIB ablation world, will almost invariably reserve their referrals for a maze (or even mini-maze) only to either super morbidly obese Afib patients for whom CA alone is more challenging due to more limited visibility using X-ray Fluoroscopy when it cannot penetrate large amounts of adipose and return a very clear imagine inside the left and right atria. Also, it takes extra expertise and experience level by a maestro CA EP to get consistently very good results with this class of patents.

Relatively normal body size afibbers are most often better served by carefully chosing only the most highly experienced CA ablationist whose case load is well over 50% persistent/LSPAF (granted there are not many these around so travel is most often required but the same is true for a truly experienced maze surgeon too) and making sure the CA EP has a renowned track record for success, while knowing that this class of patients odds are every bit as good, if not better, to rid themselves of the beast once and for all with a top volume CA ablationist over in average a 2 procedure process ... and more rarely occasionally a 2nd limited touch up can be needed (3rd procedure over all) can be needed even with the very best CA in these typically very challenging patients.

The statistical advantage in ‘success’ often quoted by the surgeon groups usually does not take much into account the not at all uncommon
atypical left atrial flutter issue which is every bit as prevalent in mini-maze patients as it is post CA ablation as well, and yet often comes as a bit of a surprise for the mini-maze patients. Most surgeons only focus on getting rid of AFIB since they themselves don’t know how to address atypical flutter and must then bring in an EP for another CA. I have heard some mini-maze surgeons say when asked about post maze left Aflutter that “it hardly ever happens to my patients” (typically not true with a number of well done studies underscoring that point) , and they usually almost brush it off as little more than a fleeting nuisance that they can bring in any ole EP to address ... that is being very optimistic :-)

Sometimes atypical left atrial flutter from an index mini-maze or CA can be relatively straight forward to address, but very often it can be a real challenge to get rid of by anyone other than a to- tier elite level CA operator who is intimately familiar with all the nuances and variable manifestations a left-sided flutter can take. And if your surgeon doesn’t send you to a top flight CA ablationist you very much can be in for a merry go round of repeat CAs chasing a pesky flutter than may well be beyond the comfort zone of a even a relatively decent Ablation EP who does not performs lots of these kind of atypical left flutter ablations every week.

The CV Surgeons I most respect, such as those who were trained by and with Dr James Cox who created the original maze procedure and that are usually expert at performing true maze procedures, most often limit recommending a maze (or mini-maze) to only the most challenging cases such as the morbidly obese with many co-morbidities ... or those who have failed multiple CAs ( though before using this class of patients as a reason for going surgical they should carefully consider the skill level and nature of the failed CAs the patient has undergone.)

Often the reason for multiple CA failures is not because the patient was inherently refractory and/or unsuitable for success with CA, but rather the reason is more often that they simply made an innocent yet poor choice(s) in which previous EPs to partner with to handle their case(s) that we’re very likely above the pay grade and comfort zone of a more traditional PVI-only kind of ablationist over his or her head with a patient having a more advanced case of AFIB!

In my view, unless the patient clearly meets the best criteria for referral to a surgical solution for AFIB, I would be far more comfortable strongly recommending they let a true expert very high volume operator who has been consistently and durably freeing legions of advanced AFB/aflutter patients from all forms of atrial arrhythmia in typically a 2 and occasionally a 3 procedure process, where the last one or two procedures, if needed at all, are truly of the ‘touch-up’ variety where the patients bounce back very quickly and is back in the saddle in sort order.

The surgical ablation approach can certainly work well in appropriate patients ... again it pays to use only highly experienced surgeons doing hundreds of maze procedure each year ... but the relative toll on the body and the similar frequecy of needing an atypical flutter ablation after either of those methods as the index ablation, makes it a slam dunk in my book to at least give a top volume persistent/LSPAF CA ablationist the first crack at it for the vast majority of ablation candidates.... with the one big caveat that the CA expert MUST be intimately familiar and experienced with performing LAA isolation when needed and who is also highly skilled at Non-PV trigger detection and ablation.

When making sure to check off those boxes in selecting an elite level CA ablation expert, most afibbers odds are excellen indeed, that they will achieve the holy grail of durable freedom from all atrial arryhthmia with a good deal less total physical pain plus a lot less mental stress as is so often part of very tough recovery process.

So if you choose a top flight operater like Dr Natale and after two ablations with him you find yourself going backwards (extremely unlikely in my long experience following hundreds of his cases in real time) then go for the most experienced true maze operator then, that you can partner with would be my strong recommecdation for anyone who isn’t an obvious well-vetted maze procedure candidate from the outset.

That is a far more sensible course in my view, but there are parts of the world where it’s very tough to find truly high volume LSPAF CA experts and in such a scenario I can certainly see the option for surgical ablation as a potentially better early choice too.

In any event, everyone has got to make their own best decision here after considering all factors and after honestly taking their own temperament and tolerance for risk into consideration.

Best wishes whatever decision you make Mac.

Shannon



Edited 2 time(s). Last edit at 10/21/2017 08:04AM by Shannon.