The Five-Box Thoracoscopic Maze Procedure

Hey evervyone,

I know that there have been some discussions on the The Five-Box Thoracoscopic Maze Procedure and I am puzzled why it is not being embraced more. I am really curious what the very intelligent people on this board think on this matter. I am considering this option, as opposed to going with Natale.

Just going through posts on this board, I see that many people have had repeated ablations without success (even with the awesome Dr. Natale).

Dr. Sirak does not have the huge number of procedures under his belt, however
isn't this modality superior than that of ablations? It just seems from the data that the chance of being cured with the five box is higher. What can be done surgically seems to be greater than that of a catheter ablation. Dr. Sirak seems to quantify his data and publish with specifics more than some others. He was very open with me about everything...even compications that have occured, such as a bleed requiring a sternotomy. He told me that stenosis and esophageal fistulas were not risks using the five box.

Looking forward to anyone who has thoughts pro or con on this. Why would someone not go for this over an ablation?

Hi Mike,

I am also curious why more haven't gone this route. I really like the fact that the procedure does not require any radiation exposure. I have asked Dr. Sirak about his procedure and he said that with Mike's history of two failed ablations a third is unlikely to help him but that with Mike's profile he is almost guaranteed a positive outcome with the five box.

Debbie

Ken opted for this procedure by Dr. Sirak a year ago - he last posted in May: <[www.afibbers.org];

See all posts: [www.afibbers.org]

Hi Mike,
I also am inpressed with Dr Sirak's record. I was going to take the plunge with him this year but decided to give lifestyle and supplements more time. I have had some success and will ride this success for as long as it lasts. If and when things get worse for me surgery is the way I will go and Sirak is on the top of my list. His reported success rate is outstanding and no radiation exposure during the procedure. The recovery is harder than an ablation but he reports an almost 100% success rate so you might have to do it only once.
As I write this my friend is being cardioverted for Atach. He has had 4 ablations and about 4 hrs of radiation exposure. I guess he might need a fifth. He got two af free years from his last ablation. I don't think Sirak has long term results yet.
Although you didn't solicit my opinion I feel strongly about this so I had to comment.
Dennis

Mike,

I think the only reservations are the low number of total procedures and the lack of long term evaluation due to the fact that it's a new procedure.

I have had one failed ablation and like Dennis I am trying the lifestyle and supplement route; but as of now if I had another procedure it would be the 5 Box.

EB

" I am puzzled why it is not being embraced more"

It is a highly skilled procedure like the full Cox maze so the learning curve is steep and long. It is also a lot more invasive than catheter ablation so I think it will remain a 3rd line procedure for the most difficult cases much like Cox maze.

Is it more invasive than a Wolf Mini-Maze?

I am no expert on the matter, however I do not think it appears to be more invasive than the Wolf Min Maze.

Maybe others here have more knowlege on the matter.
Best regards, Mike

I am comparing the invasiveness to catheter ablation, not Wolf mini maze. The thoracoscopic access is probably very similar to Wolf. Sirak's procedure major improvement is that he does more to access the floor of the left atrium allowing him to connect lesion lines to the mitral annulus so that his lesion sets mimic those achievable in Cox Maze. Given your failed ablations, it may be a reasonable way to go and I think Sirak is the one that can do it competently.

Thanks for the clarification-

At the risk of overwhelming people with technical detail (including myself), I am offering some comments made by James Cox on Dr James Edgerton's Dallas Lesion Set, which my readings of descriptions of his and Dr Sirak's 5-box procedure lead me to conclude that they share certain features in common -- in particular the routing of the LIPV to mitral valve line ---- which i Dr Cox's version ran to the mitral valve annulus, while in Dr Edgerton's version it terminates in the trigone region -- thereby I assume missing damaging the the circumflex artery with RF energy, a problem that had kept other epicardial surgery from truly replicating the Cox maze. You will see that Dr Cox questions whether the Edgerton route is truly without problems ....

(Dr Cox also disagrees with Dr Sirak on the importance of work in the R atrium -- it is my impression, that, as Dr Sirak says, the usual RA flutter is easily dealt with with a short CA.)

I am not going to try to comment on the validity of Dr Cox's concerns or to judge whether it can be exactly and equally applied to Dr Sirak's lesion set. I will say that I would be interested in what Dr Sirak's response would be to Dr Cox's concerns....

Of course, one form of answer will come from success rates from a larger number of patients, including those with persistent/permanent AF.

A quick comment on why the TTM/5-box is on the short list of treatments:

First of all, in many people's minds and images, CA is a (relative) walk in the park (you just lie down and zone out for while), while surgery, is, well !surgery! with serious cutting and bleeding, with (short) time spent in intensive care and possibly battling with pain, which may last for while, as it did for Ken (?)

The other factor is that it is new --- meaning that in principle it is impossible to pass permanent judgement not only on success rates, but also on bad effects that might show up after considerable time. Even though the same could be said of CA and other surgeries (except for the original cut-and-sew Cox Maze?), those who do not like taking outcome risks in spite of powerful process arguments will be especially hesitant.

The last point is that isn't it true that some/many who might refer patients to Dr Sirak *may* will be reluctant to admit that he might do a better ****than he or his colleagues?

-- Dick

From: J Thorac Cardiovasc Surg 2010;139:1374-1386
© 2010 The American Association for Thoracic Surgery

Expert Commentary
The longstanding, persistent confusion surrounding surgery for atrial fibrillation
James L. Cox, MD
Emeritus Evarts A. Graham Professor of Surgery, Division o


_________________________

(I have cut out a lot that is relevant so as not to violate copyright rules...

Hopefully this will be enough to give you a sense of the import of the questions/concerns...

 
Having enumerated these many differences between the Dallas procedure and the maze procedure, it should be mentioned that the potential intra-atrial conduction block with the Dallas procedure may not be as severe as it was with the maze I procedure, because conduction across the left atrial isthmus was complete in the maze I procedure because of the "mitral line" and coronary sinus lesions. Deletion of those lesions in the Dallas procedure allows the impulse to travel from the right atrium to the left atrium across this isthmus. The impulse will not travel as quickly across the isthmus as it normally would across Bachmann's bundle, however, because the myocardial fibers in Bachmann's bundle are oriented parallel to (in the direction of) impulse propagation and therefore promote extremely rapid conduction. After the creation of conduction block through Bachmann's bundle with the Dallas procedure, the sinus impulse must traverse the crista terminalis posteriorly to enter the left atrium, and those fibers are oriented perpendicular to the direction of impulse conduction, which greatly slows conduction of the sinus impulse from the right atrium to the left atrium (Figure 9).62 Although this example of "anisotropy of conduction" will not likely result in complete conduction block between the right and left atria posteriorly, it may well delay conduction from the right atrium to the left atrium enough to cause the left atrium and the left ventricle to beat simultaneously as they too often did after the original maze I procedure. If this intra-atrial conduction delay proves to be insignificant, if recurrent AF from residual macro-reentrant drivers in the left atrial isthmus does not prove to be a problem, and if surgeons add the right-sided maze III lesions, the left atrial lesion set of the Dallas procedure holds promise as a viable alternative to the left atrial lesion set of the maze procedure. A separate critical concern with Dallas approach, however, relates to the questionable ability of any currently available energy source to create reliable permanent transmural lesions in the atrium from the epicardial surface in a beating heart. Thus the unpredictability of an epicardial energy source coupled with a new unproven lesion pattern portends a significant failure rate in the future, again with no ability to tell whether the failures are due to the energy source or to the lesion pattern.

Dr. Cox has always maintained that mini-maze type procedures including Wolf and 5-box cannot duplicate what is achievable with open heart maze. The 90%+ single procedure success rate with Cox maze has not been bettered with either CA or mini-maze (and it's variations) so his point has proven true. However, only a few hundred procedures are done nation wide annually so it is critical to find an experienced surgeon. That would be the first criteria. The other criteria is that one is having open heart surgery for other repairs anyway, such as CABG. I don't know how cases a year are done specifically for AF and nothing else and I would guess it would be a handful.

Hi researcher,

I would be interested in reading or learning more about Dr Cox's comments on the 5-box.

In his recent article here:

[jtcs.ctsnetjournals.org]

he comments on the Edgerton Extended Dallas Lesion Set (some of which might apply to Dr Sirak's version) but not on the 5-box.

Also, re his success rate: I remember others noting that the way of measuring success of the original cut-and-sew Cox maze was based on patients' report when contacted by phone (correct?).

Dr Edgerton (as it happens) has reported on how rates differ depending on how AF is monitored:

[jtcs.ctsnetjournals.org]

-- Dick

Apparently Dr Sirak left Ohio for MACTS in VA and now left VA.
Anyone know where he went?

Thanks,

BD

Greetings: I am the "Ken" referred to above. I had the original 5-Box procedure on 9/28/2010 after two+ years of paroxymal afib which was progressing to a greater afib "burden". I had zero afib coming off the table and today, 7 years almost to the day, I have had no afib. I came upon this thread through a search as I am trying to track down a live link to Dr Serak's paper on the details of his procedure and the results. He had emailed me a copy of his paper, but I am trying to provide a link to another forum, hence my search.

First, Dr Serak has moved from Virginia and is resetting his practice at St Rita's Hospital in Lima OH. I believe he was operational on 9/1/2017.

Second, Dr Serak improved his procedure several years ago by increasing the process for ensuring transmural ablation lines by making a first pass with RF energy, a second pass with cryogenic (cold) energy, and a third pass with RF energy. Three passes makes certain the lesion is transmural even through scar tissue, fibrotic tissue, and extra fat deposits, all of which lead to failures with standard CA. When I had my procedure in 2010, he was only doing single pass RF. He success statistics on over 200 patients was in the low 90s (90-92%). Each patient wore holter monitors at 3, 6, 12, and 24 months and failure was any 30 sec sustained burst of afib. The success rate was thus based on actual objective data, from every patient.

After he converted to the 3-pass model, his measured success rate on another 400 (I am guessing here) patients was in the 94-96% range, measured by the same process as I described above. He has stated that because of his approach, he is almost always successful with afib patients who have failed 1, 2, even 3 previous CA attempts.

I would be happy to try and answer any questions that any of you might have, but I have not been a regular reader of these forums here, as I have been well past needing attention on afib.

As a post script, and with full disclosure, I am slated for bypass surgery in the coming months, as my LAD is 100% blocked and another secondary vessel is 75% blocked. I am not in the morgue because of an extensive system of collateral circulation. In fact, I exercise (with a little help from nitro) regularly, but am tired and slowly getting worse. I still correspond with Dr Serak, and have described my case to him and sent him cath scans. He has given me advice on his thoughts on approach. However, he pointed out that the "adhesions" from the 5-box procedure I had 7 years ago are extensive and will limit some of the choices I have for revascularizing my blocked arteries. For example, closed chest bypass is probably out as well as robotic assisted bypass. (Sidebar: If you think researching afib solutions is complicated, I hope you never have to look into the bypass options which are out there now.). So that has been a "negative", but I never regretted the day I had the 5Box. Further, it can be assumed that my 5 decade long battle with CAD, which has led to the need for bypass, also resulted in the appearance of the afib which the 5Box cured.

I hope these details proved helpful to someone and again, I would not mind responding to further questions or comments.

Regards,
Ken