Frequently Asked Questions About the Maze Procedure 

What is the Maze procedure? 

The Maze procedure is a surgical intervention that cures atrial fibrillation (AF) by interrupting the circular electrical patterns that are responsible for this arrhythmia. Strategic placement of incisions in both atria stops the formation and the conduction of errant electrical impulses and channels the normal electrical impulse in one direction from the top of the heart to the bottom. Scar tissue generated by the incisions permanently blocks the travel routes of the electrical impulses that cause AF, thus eradicating the arrhythmia. The major advantage the Maze procedure offers over other less-invasive forms of therapy is that it corrects all three problems associated with AF. The Maze procedure

The name of this procedure is based on the concept of a puzzle. The incisions create barriers and several blind alleys allowing for only one major route for an electrical impulse to travel from the top to the bottom of the heart. 

How is the Maze procedure ordinarily done? What kind of incision is made? 

The standard approach used for open heart surgical procedures (including the Maze) is to divide the breastbone (sternum) with an incision that is approximately 10-12 inches in length. This gives the heart surgeon direct access to the heart which lies angled to the left just under the sternum. Once the surgery is completed, the sternum is wired back together and the skin is closed with absorbable suture. The sternum will knit back together in 6-8 weeks and will be just as strong once the healing process is complete. 

I have heard that the Maze procedure can be done through a minimally invasive technique. 

Dr. James L. Cox, the inventor of the original Maze procedure and chairman of Cardiovascular Surgery at Georgetown University in Washington, DC, has developed a new minimally invasive approach for the Maze, using a small "keyhole" incision on the right side of the chest. Such an approach avoids the need for dividing the breastbone (sternum) that the standard approach for heart surgery requires. It is important to know that one's body size and the depth of the chest wall are key factors in determining whether one is a candidate for a minimally invasive Maze. One additional small incision is also made in the right groin (femoral area) to gain access to the femoral artery and vein for attaching to the "heart lung" machine. Patients with a known history of vascular disease, thrombophlebitis or previous vascular surgery may be excluded as candidates for minimally invasive surgery.

If other procedures such as valve replacement or coronary bypass are to be performed concurrently with the Maze procedure, then the standard open chest approach is likely to be used. The complexity of multiple procedures makes working through a small incision nearly impossible with the current technology. 

Does the heart have to be stopped to do a Maze procedure? 

The Maze procedure does require that the heart be stopped and necessitates the use of the "heart-lung machine" or cardiopulmonary bypass. In order to make the incisions and to close them with sutures, the surgeon needs to work on a non-beating heart. To protect the other organs while the heart is stopped, cardiopulmonary bypass supplies blood flow and oxygen to all of the body's organ systems. 

How long does the operation take? 

The answer varies greatly depending on the complexity of the surgical procedure and the approach that is used. The actual Maze procedure itself takes about an hour to do. The remainder of the time is spent safely engaging and disengaging from bypass, opening and closing the chest, and inserting the necessary pressure monitoring lines. The approximate total time in the operating room for a Maze procedure is about four hours. 

How is it determined where to make the atrial incisions? 

During the research and development phase of the Maze procedure, a sophisticated, computerized mapping system was devised and patients with AF were studied extensively. Once the characteristics of AF were better understood, it became clear that AF is less chaotic than was once believed. In fact, consistent areas in both atria where atrial fibrillation originates were identified in the patient population that was studied. This information lead to the idea of surrounding the electrical circuits with incisions. 

Additional research on canine models helped to establish the pattern of the incisions to eradicate the AF. The challenge was to discover just the right number of incisions to stop the AF while preserving the function of the atria. Additional revision of the Maze procedure over time has lead to its current form of practice. The Maze procedure is thus performed in the exact same manner with precise placement of incisions for each patient. 

How many people have had the Maze procedure to date? 

The Maze procedure has been performed since 1987. To date, over 300 cases have been performed by Dr. James L. Cox. Several thousand cases have also been done in Japan, as well.
In the case of Dr. Cox' practice, the age range of the patients is (22-78 years of age) with an average age of 54 for this group of patients. The average length of time that patients were in AF before undergoing the Maze procedure was eight years. 

What is the success rate of curing AF with the Maze procedure? 

The Maze procedure has resulted in 100% cure of atrial fibrillation, with 97% of patients on no medications and only 3% of patients taking medication to maintain normal sinus rhythm.

What is the operative mortality rate for the Maze procedure? 

The operative mortality is 1.8% for patients undergoing the Maze procedure. The deaths that have occurred with the Maze have been associated with complications that had arisen from other organ system failures and not from the surgery itself. 

What are the major complications associated with the Maze procedure? 

In the early postoperative period, fluid retention has historically been a complication. However, fluid management with two diuretics (fluid medications) Aldactone and Lasix for the first six weeks after surgery has been successful in overcoming this complication. The other complications are similar to those that occur with any open-heart surgery: bleeding, wound infection, stroke, and pneumonia. 

Are there any differences in the outcomes between a minimally invasive Maze and the standard Maze? 

No, both approaches have similar outcomes and the same rate of cure for AF. Patients who undergo the minimally invasive Maze tend to have a slightly faster rate of recovery in the first few weeks after surgery. However, the outcomes are the same for both surgical approaches. 

Can the Maze procedure be done in conjunction with other cardiac surgical procedures? 

Yes, the Maze can be performed with other procedures such as coronary artery bypass grafting or valve replacement.  

Is there a lot of pain after surgery? 

Pain is a very individualized experience for each patient. In general, the sternum is a relatively dull area of the body, having few nerve endings. Most patients who have had a standard open chest approach often complain of aching around the sternal incision and generalized discomfort that centers between the shoulder blades after surgery. Pain medication is readily available and patients are encouraged to take it as needed. Some patients find that a neck pillow is useful in reducing the shoulder aches and pains after surgery. 

The minimally invasive approach through the smaller keyhole incision may be associated with slightly more pain. Because the incision is located between the ribs (an area that is rich in nerve endings), it may be more uncomfortable. Methods such as nerve blocks are used to successfully to achieve adequate pain relief for patients. 

What is the average length of hospital stay with the Maze Procedure? 

Most patients are hospitalized an average of 10-12 days. Much of that time is spent waiting for the atrial tissue swelling to decrease postoperatively and the return of the sinus node function. Patients are usually in the intensive care unit for two days and the remainder of the time is spent on the step down unit. Typically, once patients reach the step-down phase, they are ambulatory (able to walk about) with a portable telemetry monitor (about the size of a Walkman) waiting for stabilization of the rhythm. 

What is the typical recovery time, and when do people generally return to work? 

In general, the recovery is complete about 6-8 weeks after surgery. Depending on the type of work that a patient performs and the surgical approach that was used (minimally invasive versus open chest), the decision to return to a full schedule is somewhat individualized. For those patients with physically demanding jobs, the recovery may be extended to three months for open chest procedures. 

After recuperating from surgery, will I be able to resume normal activities? 

Yes, you will be able to return to all normal activities once the initial healing period is completed. At the end of 3 months, you should expect to be at about 80-90% of your normal energy level. You can still expect to feel more tired than usual and your level of stamina may not be completely normal. After six months, you should be back to normal. 

Some patients find the structured workout of a cardiac rehabilitation program to be helpful in recovering from surgery. This type of program starts with a walking schedule for the first six to eight weeks and progresses into more vigorous supervised training following the initial recovery from surgery. 

How do I best prepare for surgery? 

There really isn't any one special formula that I can give you to get ready for surgery. The best advice I can think is to be mentally and emotionally comfortable with your decision to have the Maze procedure and try to stay well prior to surgery. We can always reschedule the surgery should an unexpected illness arise. 

What kinds of tests are typically performed prior to surgery? 

An echocardiogram is essential for all patients prior to a Maze procedure. The echocardiogram is an ultrasound study of the heart that helps physicians to evaluate the structure and the function of the heart and the valves. In addition, all patients over the age of 40 will need to have a cardiac catheterization to assess the coronary arteries for evidence of blockage. 

Other patients with clinical evidence of heart abnormalities or suspected heart conditions may also need a catheterization to further assess cardiac function. This is an important and necessary study because, should significant heart disease be present, only then can a heart surgeon determine what course of action should be taken prior to the time of surgery, thus preventing serious complications (such as a heart attack). A cardiac catheterization can be performed on an outpatient visit by an interventional cardiologist of your choice. The catheterization film will need to be forwarded to a heart surgeon for review prior to surgery. 

Other basic diagnostic tests including labwork, an electrocardiogram and a chest x-ray will be required prior to surgery. The need for more specialized tests such as an electrophysiology study (EP) is determined on an individual basis. 

Will I need a blood transfusion? 

It is possible that you may need a blood transfusion with any open heart procedure and the Maze is no exception. The US blood supply is quite reliable and all blood components are carefully screened for AIDS, syphilis, Hepatitis B and C and other viruses. 

Can I donate my own blood before surgery?

Yes, there are several mechanisms available for donating your own blood before surgery. It is possible to donate at a local blood bank and have it shipped to the hospital, but specific guidelines must be followed. Also, be aware that there are usually fees associated with the collection, processing, and testing of "autologous" blood for which the patient will be responsible. Please contact our office for additional information on how to arrange for autologous donation.

I have a pacemaker. Can I still have a Maze procedure done?

Yes, having a pacemaker is not a contraindication for the Maze procedure. Pacemakers do not affect the surgical procedure and may even reduce the time spent in the hospital postoperatively.

I have heard that everyone who has a Maze procedure needs a pacemaker after surgery. 

That is incorrect. In fact, most patients do not need a pacemaker after the Maze procedure. If a patient has a normally functioning sinus (SA) node prior to surgery, then it is most unlikely that a pacemaker will be needed after surgery. In the case of Dr. Cox' practice, to date, no one with a normal sinus node has required a pacemaker after the Maze procedure.

There may be other pre-existing conditions such as "sick sinus syndrome" or heart block, however, that have been masked by atrial fibrillation and once exposed, require pacemaker support. (Sometimes AF takes over as the primary heart rhythm when a condition such as sick sinus syndrome is present). 

Once the AF is eradicated with the Maze procedure, the underlying problem will surface and a pacemaker may be needed. Since electrophysiology (EP) studies are not obtained on all patients prior to surgery, there is no way to know the status of the sinus node and accurate predictions for pacemakers are therefore difficult to make. 

What should I expect long term (5-10 years) following the Maze procedure? 

From the start of the procedure in 1987, follow-up information has been obtained on patients on a regular basis. To date, there have been no adverse or unexpected findings with the long-term patients.

Will having the Maze procedure limit cardiac surgical procedures (bypass, valve replacement) in the future?

No. The Maze procedure will not hamper further cardiac surgical interventions, however, there is usually scar tissue formation following any open-heart procedure. Generally speaking, the second procedure is usually more difficult because of this presence of scar tissue.

Will I need to take an anticoagulant such as WARFARIN (Coumadin) after surgery? 

Usually, patients are given aspirin during the first six weeks after surgery. Coumadin may be necessary for other conditions, but it is not routinely prescribed following the Maze procedure. 

Will I have AF after surgery? How long will it last? When can I expect it to stop completely? 

Atrial fibrillation occurs in 44% of patients within the first three months after surgery. The reason that it occurs is that, following the surgery, the atrial tissue swells and the refractory periods (rest periods) of the atrial cells become shorter, making it easier for an irregular beat to trigger AF. However, postoperative atrial fibrillation is usually more responsive to medical therapy. Once the AF is converted with medications, it is important to remain on the medication to prevent future occurrences of AF. 

At three months, the healing process is usually complete and all medications are withdrawn. The current data indicates that there is a 3% recurrence of AF after the initial three month postoperative period. These patients are successfully treated with medications and remain in normal sinus rhythm.

I have just been diagnosed with AF. Should I have the Maze procedure? 

Because the Maze procedure is open-heart surgery, it is generally reserved for patients who have failed medical therapy with symptomatic and debilitating AF. I would advise you to find a good cardiologist to thoroughly investigate all the possible causes of your atrial fibrillation and to diagnose the type of AF that you may have. Once a full work-up is completed, then all of the available treatment options can be discussed before deciding upon a course of action. Each case is unique and must have an individualized approach based on the circumstances. 

I have AF,  but I really don't know when I am in it and it doesn't seem to bother me too much. Should I consider a Maze procedure? 

If you do not feel differently in AF compared with a normal rhythm (unless there is another overriding problem such as frequent blood clots or strokes), then a Maze procedure probably would not be appropriate for you. The main reason patients undergo a Maze procedure is for relief of symptoms associated with the AF and improved quality of life. Many patients suffer severe side effects from the medications that they must take to control the AF and seek an alternative therapy that will allow them to discontinue the drugs.