The Hierarchy of Atrial Fibrillation Treatment
Although atrial fibrillation (AF) is typically first treated with anti-arrhythmia medications, long-term control of AF with medicines alone is successful only in about half of the treated patients.1, 2 In addition to the issue of long-term efficacy, drug therapy for AF is fraught with the problem of adverse reactions, ranging the relatively minor (fatigue, malaise, nausea, etc.) to causing life-threatening ventricular arrhythmias.
Procedures designed to cure atrial fibrillation fall into two categories: catheter-based (or percutaneous), and surgical (or epicardial). Both types of procedures vary widely in their practice throughout the United States and the world; no standardized protocol exists for the conduct of either protocol. However, the benchmark for all anti-arrhythmia procedures is the Cox-Maze III. Originally performed through a full sternotomy on an open, arrested heart, the operation successfully cured 96% of patients off anti-arrhythmia therapy.3 Subsequent studies by numerous clinicians have clarified the central reason for the high success rate of the original Cox-Maze: the isolation of the arrhythmogenic areas of the atria responsible for AF into electrically discrete compartments, particularly those connecting to the annulus of the mitral valve.
The original Cox-Maze operation created these compartments by making actual incisions in the atria which were subsequently sutured closed. Therefore, verification that any given compartment was in fact isolated was unnecessary, since the atrial muscle had been divided surgically, and non-conductive scar formed as the incisions healed. Later procedures modeled after the Cox-Maze were designed to spare the patient the trauma of an open-chest procedure. However, these later procedures – whether surgical or catheter-based – sacrificed the completeness of the Cox-Maze compartments, and did not thoroughly verify their true electrical isolation. The result has been a hodgepodge of procedures which offer an incomplete treatment of AF, and even worse, do not verify all of the procedural endpoints. Any unconfirmed ablation may represent an incomplete line left behind on the heart, which leaves the patient susceptible to even more malignant arrhythmias.
Only the five-box thoracoscopic maze procedure completely replicates all of the left atrial lesions of the Cox maze procedure. All ablations are contained with discrete compartments, enabling
real-time verification with the straightforward demonstration of electrical block. The result is a cure rate in excess of 95%, even in patients with persistent AF.4 No other procedure – whether surgical or catheter-based – offers the same comprehensive ablation pattern and rigorous intraoperative verification.
More Information
For more details about total thoracoscopic maze surgery to treat AF, request a phone consultation with Dr. John Sirak or call his appointment phone at (866) 486-9149 .
1. AFFIRM. New Engl J Med 2002;347(23):1825-1833.
2. Packer, et al. CABANA Pilot Study. Presentation at the American College of Cardiology Meeting, Atlanta, 15 March 2010.
3. Prasad, et al. The Cox-Maze III Procedure for Atrial Fibrillation. J Thorac Cardiovasc Surg 2003;126:1822-1827.
4. Sirak, J. The Five-Box Thoracoscopic Maze Procedure. Ann Thorac Surg (manuscript in press).
