Will LA reduce and should I get this Maze procedure

I have a mitral valve repair coming up in June. It's a minimally invasive robotic surgery At Cedars-Sinai with a thoracic surgeon who has done over 500 Mitral Repairs like mine,Robotically. They are at the top in the U.S. during the surgery they will also seal off The Left Atrial Appendage and perform A Maze procedure. I feel good about all of that but I'm getting a lot of conflicting info from different Cardiologists on the Maze. I was told by my Surgeon I would have a 65-70% of NOT reverting back to Afib with the Maze. Fast forward and a few days ago I went to the
ER for many issues which turned out to be Severe pnemonia. They admitted me and treated me With IV antibiotics. I am much better but during the time In the hospital a cardiologist who works out Of UCLA primarily came to visit me because of my heart. I told him my cardiologist is with Cedars Sinai and I have A mitral valve repair and maze procedure scheduled in June. Quite honestly he seemed very short and said
If it were him he wouldn't do the maze or procedure as i'd be on a lung bypass machine longer than without the Maze.

He proceeded to say because my left atria is Severely Enlarged, he expects I'll go back to Afib. He said it's not likely my left atria will reduce in size and that is also area I've been told otherwise. It's definitely confusing and I'm thinking this hospital cardiologist was hoping to get me as a patient? I have no idea but as soon as I said I have a doctor with Cedars Sinai and surgery scheduled he literally shot down everything
About the Maze procedure itself. I was also told by my surgeon I'd have a 65-70% chance to stay in sinus rhythm after the Maze and this doctor at the hospital said its closer to 30%,because of my severely enlarged left atria.

Obviously my surgeon knows my left atria is severely enlarged and they still gave the stats they did. At this point I'm a little confused. Does this hospital doctor have any point? Should I not do a Maze due to the severely enlarged left atria? His statistics also don't correlate with anything I've been told or read about the Maze but I'm asking what the thoughts are here on all of this. Thank you in advance.



Edited 2 time(s). Last edit at 03/07/2024 12:36AM by cornerbax.

I'm betting the cardiologist was a general cardiologist and not an EP or interventional cardiologist. A lot of general cardiologists are fairly ignorant of the state of the art in afib management and hold opinions formed decades ago. If I'm right about him being a GC, I wouldn't put a lot of stock in his predictions. I've never heard anyone quote a 30% chance of success for a Maze procedure, or even anything close to that. And he's wrong that the left atrium can't shrink. It can and does once the forces that enlarged it are gone for a long period of time (afib, other tachycardias, valve issues, heave weight lifting, endurance sports, hypertension). It's never going to return to its normal size, but at least some reduction is possible.

Time on the heart-lung machine is mainly going to be the valve and the LAA. I don't believe the Maze takes all that long once the chest is already opened.

I have run into the same confusing advice from different cardiologists. I was told early on before my pace maker that I would be a very good candidate for an ablation but while in the hospital the GC told me I was not a good candidate for ablation. When I finally saw the EP he said I was an excellent candidate. So confusing!

Carey,

Thank you as always. I just looked him up and he isn't an EP you are right, but it does say Interventional Cardiology. He has 2 star ratings on one site and 3 on another. Several people said he is rude and arrogant so not far off my Impression. With that said my left atria is 6.5cm and
listed as severely enlarged but I was pretty sure I've read people who have had larger left Atria and been cured of Afib. What's your thoughts on the 6.5cm size?

I did also ask my surgeon on total time I would be on a lung bypass machine and they said 70 mins or so. From what I've read that isn't bad at all. And like you, I've never heard anything nearly that low in terms of percentages from the Maze in restoring and staying in Sinus Rhythm. This doctor was very short, and was pretty venomous and very confident in telling me sinus isn't getting restored long term and my Left Atria
is at the point of no return. I wonder how it would of went if you were the patient, Carey and this guy was saying all of this to you.

@Calvin,

Yes very confusing is right. Did you get the ablation yet or no?



Edited 2 time(s). Last edit at 03/07/2024 12:38AM by cornerbax.

Quote
cornerbax
I wonder how it would of went if you
Were the patient, Carey and this guy
Was saying all of this to you.

I would ignore him and seek advice from an expert in Maze procedures. You've heard from one, but if you want to be sure a second opinion can never hurt, so find another surgeon who does a lot of Maze procedures, schedule a consult, and ask them.

Your left atrium is significantly enlarged, but I wouldn't take his advice on what that means for your prospects going forward. What does he actually even know about Maze procedures? I'm betting the answer is not much.

At this point Im going through with the Maze procedure. from everything I can digest, it would be almost idiotic not too. Most people can't even
get a maze done as doctors tend not to do a maze Unless they are operating on a different part of the heart already as such in my case with
The Mitral Valve.

This doctors only justification by what he said was the time on the lung bypass machine. From what I understand you don't want much over two
consecutive hours on lung bypass. I asked my thoracic surgeon and for all three procedures I would be on the bypass for about 70 mins. It makes no sense NOT to get The Maze. I searched further and he has lots of 1 star reviews to go with the 2 star reviews. I'm surprised he has a job at UCLA. Carey, assuming the mitral valve surgery is flawless and the maze keeps me in Sinus rhythm, even if the left atria were to not revert much in size, would there be anything to be concerned about if all other heart valves and muscles are fine?

What I'm saying is if everything is a success, and all other heart function is solid, would there still be issues or any kind due to the Left Atria size?



Edited 2 time(s). Last edit at 03/07/2024 12:40AM by cornerbax.

I know first hand what it's like having to deal with valve surgery and trying to decide on a multitude of things and getting conflicting opinions. I will try and address each one and hopefully it will help.
First, will the Maze procedure work and what are the chances? My surgeon was keen to do it as it adds no time and no additional risk. He gave it 90% which turned out to be far too generous. I got a second opinion from a top surgeon at Stanford who flat out said it would not work. I went ahead anyway and no - it did not work. My LA is also enlarged but I don't believe that was a factor. Also, I was told by many that it would not reduce in size but I am not sure about that either. 20 years ago I was told I was not a candidate for ablation because of my enlarged atrium. We know now that is not true.
Heart-lung machine - I needed open heart surgery to replace and fix 3 valves and was on the machine for much longer than 70 minutes. Entire surgery took 10+ hours. I trust the surgeon knew what he was doing. He did not think it was a huge problem. I did have complications post-surgery but that is another story and had nothing to do with the Maze
Back to the Maze - I think it is impossible to predict if it will work for you but for me since it is such a low-risk procedure I decided to give it a shot.
I am a little confused about the minimally invasive robotic surgeon part. I did not realize that the heart had to be stopped for that.
The doctor who was short and venomous sounds totally awful.
Will the enlarged LA cause other issues? Other than arrhythmia I have not heard that it would cause other major issues. I have had 3 ablations since my failed Maze in 2016 and may have several more. Such as it is. I am just grateful the most recent ablation lasted 4 years. I was told it would be 2 years.
Mary

Quote
cornerbax
What I'm saying is if everything is a success,
And all other heart function is solid, would
There still be issues or any kind due to the
Left Atria size?

No. LA size in and of itself does no harm. It only increases your risk of developing afib, but you're already there so that's not really an issue.

@no trigger,

It sounds like you had quite the surgery with 3 valves.....wow. 10 hours is a long surgery I'm glad all is well. I'm not sure of your situation or why the Maze didn't work as you didn't specify, other then to say it was not due to your enlarged left atria. Also,even though the Stanford doctor
ended up being right, as Carey said, I haven't ever heard of a 0% chance of a Maze Procedure working.

@Carey,

Thank you again for the helpful and great info. At this point I truly hope the Maze gets rid of the Afib, but right now my Left Atria is dealing with two major issues. Severe Mitral Regurgitation, and Afib. That's quite a bit of stress on the Atria and why it's severely dilated. Let's say that after the Maze procedure I have some kind of Afib or a flutter, would getting an ablation with someone like Dr. Natale be the next step? Also, let's say either afib or a flutter develop after The Maze, would that still be better on my Left Atria than with the Severe Mitral Regurgitation and the Afib combined?

What I'm asking is even if Afib or a flutter do develop after the mitral valve repair and Left Atrial appendage closure, would that still be less harsh and impactful on the Left Atria then when combined with Severe Mitral Regurgiation?



Edited 1 time(s). Last edit at 03/07/2024 12:45AM by cornerbax.

The regurgitation is your first priority. Everything will get better when that's fixed. If you do end up with afib/flutter after the Maze, and enough time has passed that you're sure it's not a transient thing, then yes, seeing someone like Natale would be the next step. You'll be a complex case, so someone of Natale's caliber is essential.

Thanks again, Carey. Yeah this 50% plus of Severe Mitral Regurgitation is wreaking havoc on my Left Atria. Fortunately, at this point my Left
Ventricle and Right Atria are only mildly dilated and my Right Ventricle is perfect. I'm really hoping the maze is a success as this has been quite the journey.



Edited 1 time(s). Last edit at 03/07/2024 12:46AM by cornerbax.

Yes, getting your mitral valve fixed is a priority and I hope that plus the Maze will prevent further Afib. In my experience, getting my severe mitral regurgitation fixed, wasn’t enough to stop my Afib and I did need to have an ablation with Natale, but then I didn't have a Maze with my mitral valve repair. Here’s hoping you come out Afib free.

If I remember correctly you had The Mitra Clip. I'm 48 and they said they wouldn't do a Mitra Clip as it hasn't been around long enough to determine long term results. They said I need a full surgery. They used a catheter for your Mitra Clip which is why they couldn't perform a Maze Procedure. From what I understand, just correcting the Valve that causes Afib will not stop Afib in and of itself as the heart has already learned the erratic electric impulses and will tend to revert back to those erratic impulses. This is why I hope The Maze actually works and prevents Afib from every coming back. As mentioned, my surgeon thinks that there's a 70% chance afib will be gone permanently. The surgery is beginning of June so we'll know soon enough.



Edited 1 time(s). Last edit at 03/07/2024 12:49AM by cornerbax.

Wait, they want to do open surgery solely because the MitraClip hasn't been around long enough?!

I think you need to evaluate the risks and benefits here. Open heart surgery is a very big deal with a long recovery period and major risks. Are you having this done at a major medical center?

They stated at my age and with no longevity of the Mitra Clip it isn't something they would do. There are other reasons such as closing the LAA and performing a Maze in the hopes to correct the Afib. It looks like there are 3 reasons. The surgery is a minimally invasive robotic surgery
which I am getting done at Cedars-Sinai, Los Angeles. I asked specific questions such as mortality rate. Mortality rate for this surgery is about 1% overall. However, at Cedars it's 1 in 3500 so a fraction of a percent. My Surgeon has done over 500 mitral valve repairs like mine at over 99% success rate. They are at the very top in the USA. I definitely did my homework.

Carey, with this said what are your thoughts?



Edited 1 time(s). Last edit at 03/07/2024 12:51AM by cornerbax.

It has been around for 20 years though it has usually been used on high risk patients. Here is a report on the MitraClip from Cedars Sinai, the hospital you will be treated at.

Quote

A minimally invasive procedure for leaky heart valves was found to be safe and effective in nearly 90% of patients, according to research by Raj Makkar, MD, and fellow Cedars-Sinai physician-scientists

. [www.cedars-sinai.org]

I think the reason that this is not the direction they are pointing you in is that most patients given the MitraClip have been “elderly,” not an adjective I am fond of! But if it works so well, why not spare younger patients the risks and longer recovery seen in open heart surgery. I don’t really get the logic.

@daisy,

That stat is on all leaky valves. I was told by my Thoracic Surgeon their success rate is over 99% as they actually specialize in Mitral Valve repair. Also, I'm copying a current article from Cedars-Sinai specifying that after 5 years over 95% of patients who had the robotic Mitral Valve repair there are Alive and well. I don't think it needs to be a secret, my Surgeon Is Dr. Joanna Chikwe and she also heads the Dept. I don't think I could be in better hands. Cedars-Sinai also feels the closing of the LAA via robotic surgery is far better then a Watchman, etc. With a fraction of a 1% mortality rate and myself with no Co-Morbidities I don't think I can do any better. An ablation I'm guessing has a similar mortality
Rate. Dr. Chikwe has also done more then 500 robotic Mitral repairs like mine which is the 2nd most in the USA.

Also, I am fortunate as I can keep my Mitral Valve, I don't need a pig skin or mechanical valve. Lastly, I was told a solid month for recovery, which is far less and much safer than a sternotomy. And have done over 500 Repair is the gold standard,” Chikwe said. “Patients who keep their own valves have faster recovery times as well as the best length and quality of life.”

Quote

More than 95% of patients who had robotic mitral valve repair at Cedars-Sinai were alive and well with intact repairs five years later, according to research Chikwe shared, published in The Journal of Thoracic and Cardiovascular Surgery. And although the surgery is complex, she said, it is remarkably safe (the risk of mortality is 0.3%, according to research published in the Annals of Thoracic Surgery) and an “everyday surgery” for the Smidt Heart Institute team.

Edited 4 time(s). Last edit at 03/07/2024 12:54AM by cornerbax.

Your Enlarged Left Atrium is 6.5cm diameter
What is the LA ESV Index?

LA Length 8.0cm
LA Area s MOD A4C 46.7cm squared
LA Vol s MOD A4C 202.0 ml
LA ESV MOD Index 4AC 80.1ml/m2

2 being squared so m squared.

In addition to the MitraClip not being around very long, the results are inferior compared to a surgical repair, especially at the higher stages of mitral valve regurgitation. That's why MitraClip is usually indicated only if you are not a good candidate for surgery because of older age, or other conditions.

Jim

Cedars-Sinai mentioned all of that as well as it being the best method of closure for the LAA. Again, I took this extremely serious and don't think there's a Surgeon for The Mitral Valve, Robotically, anywhere. Dr. Chikwe's Mortality rate is a fraction of a third of a percent. I would think is the same or even better than an ablation.



Edited 1 time(s). Last edit at 03/07/2024 12:56AM by cornerbax.

I agree you are in excellent hands. I have read very good things about Dr. Chikwe.
All the best.
Mary