mini maze

Hi - I have been away from afibbers for a few years and have come back as the afib is now daily and almost constantly. Can anyone point me to a discussion of the mini maze procedure that may have appeared here? It sounds more promising than regular ablation, and it is time for me to consider one or the other. I'm in California and would like to do the mini maze in the San Francisco area. Any recommendations? Thanks. Phyllis

Phyllis,

Check this out this team. I am new to a-fib, but I know people who have used this group & were very pleased with the outcome. My father being one who had Vincent A. Gaudiani as his surgeon.

[www.pccvs.com]

Good Luck!

Phyllis:

Here are two places to start:

[www.stopafib.org]

<[af-ideas.com];

Your choice should depend on a number of factors, including your type of AF (paroxysmal vs persistent/permanent) and the availability of expert EPs and surgeons.

IMO the Wolf MiniMaze is *not appropriate* for those with persistent/permanent AF. Ask the surgeon what his success rates are.

MM variations, on the other hand, may be. Initial results are good, but the track record is short.

These variations include the Totally Thoracoscopic Mini Maze (TTM), which itself has variants (the five-box TTM), and the hybrid or convergent approach. (You can read more about these on the above sites.)

You might want to consult with Dr James Longoria at Sutter Health in Sacramento. Ask him how what he is doing compares to other TTM practitioners -- especially Dr John Sirak -- with regard to lesion set and success and complication rates.

You can find contact information via links here:

[af-ideas.com]

-- Dick

Thanks very much for the responses. The options of what to do next are another kind of maze that needs to be negotiated carefully!

Hi Phyllis,

Here is a link to my personal, non-scientific story about the minimaze:

[www.weststreetconsulting.com]

I am 4 years afib-free after a Wolf minimaze in August, 2006.

Russ

Phyllis,
I had the TTM procedure 7 weeks ago at Ohio State U Ross Heart Hospital by Dr John Sirak. I have been in NSR since and have had no issues at all. I am taking the recovery/healing process easy. My chest is still partially numb but that is part of the healing. I had paroxysmal AFIB for 5 years and chose this over cath ablation because of the success rate. Dr. Sirak I thinks sugar coats the process and recovery but the staff and hospital are more realistic. Having said that and knowing the recovery process I still would have went through with TTM because I was ready for a cure and be able to get back to excercise which I have started. When I started researching the process I looked at Dr Sirak, Dr Piggott (spell?) at Tulane and a Dr at Baylor. The Ross Heart staff were tremendous and treated me like a king, can't say enough about the staff. Good luck John

I evaluated the mini-maze versus the 5-box TTM that John talks about and finally ended up going in the direction of the 5-box procedure. I am scheduled for Dec. 15th. I already had 2 ablations for my paroxysmal AF and can't seem to stay in sinus. The mini maze guys weren't very confident and when I looked at the actual lines they were going to ablate, I wan't impressed and felt Dr. Sirak has the advantage since he closely follows Dr. Cox's lines. Moreover, the mini maze procedure can result in a 3 inch cut (along with others) versus the several smaller incisions from the 5-box. I'm looking to getting this part of my life behind me and I think this may be the procedure.

I also have been very interested in Sirak's procedure and reported sucess rate. I am very close to pulling the trigger on this and may be a room mate of Leika the week of 12-13.

Dennis

This is my first visit back to this forum in a long time. I am replying to this thread to update people, including all those who helped me in the initial decision process.

I had the TTM/Five-Box on 9/28/10, and was in NSR right on the table and ever since then. My operational report said that Dr Sirak was unsuccessful in inducing afib. I have had more energy, and I was taken off the low dose of sotalol at four weeks, and later was taken off of coumadin at eight weeks, with the concurrence of Dr Sirak and my local cardiologist. I took an ekg at 6 weeks and chest xray back at Ohio State (only a 90 min drive) and he pronounced my ekg as "perfect".

Others have mentioned the recovery issues as being numbness and some pain in various parts of the chest. I actually am still having trouble with my left side, while my right side is completely healed (no pain, no numbness). Left side not quite the same way. Intercostal nerve damage results from port insertions through the chest wall (a port is a plastic or metal small gadget through which the tools of the procedure are run). Nerve damage, which I understand to really be damage to the "myelin" sheath which surrounds the nerve, results in pain and numbness. Dr Sirak has told me that he has had zero incidences of long term intercostal pain over his entire patient population, which is some 450 patients. Note that he has had about 100 to 110 of the Five Box which he started in 2008, but had some 350 patients having a TTM prior to that.

The Five Box represents to me one of the best approaches because of the lesion set which Dr Sirak imparts on the heart surface. This lesion set approximates the Cox lesion set with several small and less important exceptions. The Five Box pattern stops any reentrant circuits which might try to form and also inhibits left side flutter, a somewhat rare but possible outcome from afib ablations in the left atrium. Dr Sirak has said that he has had zero left side flutter cases from his procedure.

Meanwhile, back to my pain: I am finding it somewhat bothersome, with swelling and some pain (mostly at late day and evening) but curiously, the swollen and painful part is some three or four inches away from the actual penetration site (yet along the same rib). I visited my Primary and had her look and she thought that the nerve sheath damage might have sparked some muscle reaction and that is what the swelling is for. I plan to discuss this further with Dr Sirak after the holiday, but my research on intercostal neuralgia and pain is not very optimistic. Based on Sirak's previous comments, I continue to think that things will get better.

For those considering the Five Box, I would recommend it. In spite of the discomfort I am still experiencing, the solid NSR is wonderful and worth the discomfort. I am optimistic that the discomfort will resolve as predicted. To me, the Five Box represents the best approximation of the Cox lesion set, has a high current success rate (>95% on a 100+ population set), and offers the highest chance for stopping afib in one operation or procedure.

I am happy to answer other more specific questions about this. Dr Sirak's website at www.ohioafib.com has plenty of details including a good illustration of where the ablation lines are placed in order to form the five box configuration.

Ken

Ken,

I am glad to hear you are doing so well. Hopefully the pain/numbness will disappear soon. It's always nice when people tell their stories. All the information one can get is always a good thing :-)

NSR forever,

Lisa

Hello Leika and Dennis,

My 5-box will be on December 13th in San Francisco. I'll look forward to your posts as we heal from our procedures.
Best,
Mike

Mike: who is doing a five-box on you? Which doctor? Is there a web site? I would be interested in comparing to the Five Box/TTM I had at Ohio State.

Ken

Hi Ken,
Kaiser San Francisco performed by Brian Cain. No website.
Mike

Ken--

I had the mini maze at Ohio State on November 17. I ran into some unexpected hurdles during what turned out to be two separate procedures over a two day period. My age (78), being 100 lbs overweight, and some previously undiagnosed lung disease were the major factors of my problems. Dr. Sirak worked his magic and I am in NSR. I won't go into the whole story at this point because this is my first time on a computer since the operation and I have a million emails to respond to--but I will write up the whole thing for you and your journal in the near future. The bottom line is that I am fine after a very technically difficult operation. I am taking longer to recover--but everything is working and I feel better every day. And best of all I am no longer in afib. If I were authorized to give them out---Sirak would have a medal of honor.

I share people's excitement over the development of variations of the TTM, especially the procedure performed by Dr. John Sirak:

[www.ohioafib.com]

I have found, however, some issues that lead to questions that one can ask of Dr Sirak and other TTM surgeons when trying to chose between one of them and top-tier EPs:

1) What factors might be important when choosing between a TTM and a CA done by an EP with a success rate as good as the TTM results.

What about the fact that the EP's results may be based on more cases and a longer follow-up?

What about the fact that a CA can ablate in the RA, if desired, reducing the possibility of post-op RA flutter?

But what if the patient has had one or more failed ablations?

And, the LAA can be removed during a TTM, purportedly removing/reducing the possibility of AF induced blood clots and the need for warfarin (This removal is controversial because the LAA may perform some unique functions (see LAA: Useless or Priceless by Hans Larsen on this site.)

What about the fact that continuous lines are difficult to make with the CA catheter and gaps can be proarrhythmic, but it is relatively easy to make continuous lesions surgically, especially with the advent of the Coolrail linear pen.

2) In a recent article, Dr James Cox lists three shortcomings of the Dallas Lesion set of Dr James Edgerton, which *could* apply to the "five box procedure". The absence of RA lesions has already been mentioned

[jtcs.ctsnetjournals.org]

[[Another has apparently been dealt with by Dr Sirak's technique, which is the possibility that in Dr Edgerton's Dallas lesions set (the critical lesion from the PV area to the trigone area divides Bachmann' bundle, possibly preventing syncronization of the RA and LA so that they contract at virtually the same time).

"The three lines constitute an enclosed triangle on the dome of the left atrium that is safely posterior to the interatrial septum and Bachmann’s bundle (Fig 1)." ]]

Another is that the Dallas lesion set leaves out is work on the left atrial isthmus near the coronary sinus. I do not know for sure whether Dr Sirak's technique takes care of this possibility.

Dr Cox also questions "the questionable ability of any current energy sources to create reliable permanent transmural lesions... from the epicardial surface of the beating heart." This seems to me to be a tall order for any procedure except the old cut-and-sew surgery to meet, especially the "permanent" criteria ... because it seems to me that many/most surgeons and EPs test for the block created by the lines they make.

Perhaps it is enough to know that Dr Cox's points represent *possible* reasons that the a TTM might fail, especially over the longer term...and that answers to questions based on these possibilities might help the prospective patient to decide what to do.

The other concern has been brought up by Chuck and Ken, that of unexpected problems with recovery. How rare these are and how their incidence might be reduced by improved technique will remain to be seen. Here is an article on intercostal neuralgia, including ways to prevent it ... leading the question of what the surgeon is doing in this regard.

[web.me.com]

Of course, each procedure has its possible complications, but this post is long enough!!

-- Dick

I had my 5-Box procedure by Dr. Sirak almost 4 weeks ago and am experiencing some of the post operative symptoms others are feeling. It's mainly due to the cryogenic intercostal block using liquid nitrogen to 'kill' the nerves during the recovery period. i discussed this with the Dr. in our pre-operative consultation and he said he would only consider not doing this if I were to beg. He really thought the longer term discomfort was superior to the intense pain from the procedure. The nerves regenerate over time until they function normally.

Like Ken, I will take this discomfort over being in AF. I'm able to control my pain fairly well with ibuprofen or naproxen. The numbness makes it feel like a have a roll of socks under each arm, which is a little bizarre. Being a side-sleeper, I am able now to sleep on either side without much discomfort so I appreciate that as well. If those nerves were firing, I think it would be more difficult. To me this is like having my mouth come back to life after a visit to the dentist -- one of the bad visits where you get a root canal or a bridge -- just slower.

Regarding Dr. Cox: It seems he poo-poos virtually all procedures but his own. Most of us are not going to undergo open heart surgery for AF unless there is another reason for opening our chests. To me the 5-Box procedure represented the closest thing to Dr. Cox's Maze procedure without opening me up and stopping my heart, which were an unacceptable risk. The thorascopic technique was clearly superior for my otherwise healthy heart. I believe the lesion set is the closest to the Cox set as one can get in a thorascopic procedure

I have been in NSR since the procedure and am just about off the very small amount of sotalol Dr. Sirak prescribed. I have anywhere from 1 to 5 'skipped beats' (PVC?) a day and that seems to be decreasing. I previously had two catheter ablations that failed pretty quickly. My heart never felt this good after those.

Hello Phyllis,
I had the mini maze done through Kaiser. I had 2 catheter ablations with minimal improvement with each one prior to the mini-maze. With the mini-maze they can get to more areas of your heart to ablate (they still use radio-frequency to burn the cells to block the signals causing the arrhytmyia). As you are aware there are always risks, during surgery a pulmanary vein broke spuing blood and they had to do an emergency sternotomy (cut opened my chest), but they did complete the maze procedure and what a difference, I am 90% better. The emergency was not common, I do not want to scare you but want to fully disclose the risks. I do not regret going through this. I still had some residual arrhytmia, but nothing like before the surgery. They did a third ablation to "touch up" some areas of my heart. After over a weak I have absolutey no arrhythmia, I am back to cycling and working out and hope to eventually get off the anti-arrythmia drugs and the coumadin. Although I had an emergency during the procedure, if all goes well the mini-maze is "minimally invasive" and the recovery time is much shorter than what I went through. I was only 1 out of about 90 that the doc had an emergency like this. This is only my experience, make sure you ask your doc a bunch of questinons. I am praying for you Phyllis.
God bless you, Randy.