Atrial fibrillation (AF or AFib) is the most common irregular heart rhythm in the United States. Atrial fibrillation is an abnormal heart rhythm originating in the atria (top chambers of the heart). Instead of the impulse traveling in an orderly fashion through the heart, many impulses begin simultaneously and spread through the atria, causing a rapid and disorganized heartbeat.

At one time, atrial fibrillation was thought to be a harmless annoyance. However, atrial fibrillation is now recognized as a dangerous condition. Atrial fibrillation doubles the risk of death. It also increases the risk of stroke five to seven times compared to a person without atrial fibrillation. In addition, atrial fibrillation may cause congestive heart failure and uncomfortable symptoms related to a rapid heart rate. Click here to learn more about atrial fibrillation (afib).

Medical Management of Atrial Fibrillation
Initially, medications are used to treat atrial fibrillation. The atrial fibrillation medications may include:

• Rhythm control medications (antiarrhythmic drugs)
• Rate control medications (to slow the heart rate)
• Rhythm or rate control medications combined with Coumadin (warfarin - an anticoagulant or blood thinner) to prevent blood clots and stroke

Surgical Treatment for Atrial Fibrillation
Surgical treatment for atrial fibrillation is considered when:

• Medical therapy does not effectively control or correct atrial fibrillation
• Medications for atrial fibrillation are not tolerated
• Anticoagulants can not be taken
• Symptoms of atrial fibrillation continue, despite medical therapy
• Blood clots, including strokes, occur

Surgical treatment for atrial fibrillation also may be considered when surgery is needed to treat a coexisting heart condition, such as valve or coronary artery disease.

Evaluation
To determine if surgical treatment for atrial fibrillation is appropriate, a thorough evaluation will be performed, which includes:

• A review of your medical history
• Echocardiogram (echo)
• Complete physical examination
• Holter monitor test
• Electrocardiogram (ECG)
• Other tests as needed

After the evaluation, the surgeon will discuss your treatment options and together, you will determine if you are a candidate for surgery.

Who is a candidate for atrial fibrillation surgery?
Cleveland Clinic surgeons have vast experience in the ablation (cure) of atrial fibrillation. Using the very latest technology, Cleveland Clinic heart surgeons can now extend treatment to virtually all patients with atrial fibrillation. Patients considered for surgical ablation fall into two groups:

1. Patients with isolated atrial fibrillation - may be candidates for minimally invasive (endoscopic or “keyhole”) treatment approaches, or the Maze procedure.
2. Patients with atrial fibrillation who require heart surgery for other reasons, most commonly to treat coronary artery disease or valvular heart disease.

Are there any risks?
Surgical treatments for atrial fibrillation involve anesthesia and are generally very safe. However, as with any surgical procedure, there are risks. Special precautions are taken to decrease these risks. Your doctor will discuss the risks of the procedure with you.

SURGERY FOR PATIENTS WITH ISOLATED ATRIAL FIBRILLATION
Minimally Invasive Approach

Currently, most patients with paroxysmal (intermittent) atrial fibrillation are candidates for minimally invasive surgical ablation. Approaches include keyhole surgery or a completely endoscopic approach. In both techniques, the procedure includes isolation of the pulmonary veins and excision (removal) of the left atrial appendage.

Lines of conduction block (scar tissue) are created on the heart using microwave, ultrasound or radiofrequency energy. The conduction block interrupts the abnormal circuits that cause atrial fibrillation, enabling restoration of normal sinus rhythm. Recent advances are expected to enable these approaches to be extended to patients with continuous atrial fibrillation. Click here for a closer look at the keyhole approach.

The Maze Procedure
Certain patients with isolated atrial fibrillation, especially after failed percutaneous ablation or with continuous atrial fibrillation and/or enlarged atria, are candidates for the Maze procedure. This procedure, developed by Dr. Jim Cox, can treat the atrial fibrillation and restore the atria to a more normal size.

During the Maze procedure, a series of precise incisions are made in the right and left atria to interrupt the conduction of abnormal impulses. This allows sinus impulses to travel to the atrioventricular node (AV node) as they normally should.

The Maze procedure has been very successful with a 98% success rate in "lone atrial fibrillation" patients and a 90% success rate overall. Post -procedure freedom from stroke has been over 99%.

PATIENTS WITH ATRIAL FIBRILLATION WHO REQUIRE OTHER HEART SURGERY

Atrial fibrillation is very common in patients who require heart surgery for other reasons (such as mitral valve surgery, aortic valve surgery, coronary artery bypass grafting, and other surgical procedures). Recent data from The Cleveland Clinic demonstrate that untreated atrial fibrillation in such patients increases mortality (see graphs below). Therefore, in patients with a history of atrial fibrillation, Cleveland Clinic surgeons treat the atrial fibrillation during other types of cardiac surgery.

Survival After Heart Surgery
Atrial fibrillation surgery combined with mitral valve repair	Atrial fibrillation surgery combined with bypass graft surgery
Patients with untreated preoperative AF (blue lines) have reduced survival. Now, all AF is ablated at the time of heart surgery.

Surgeons may perform either a classic Maze procedure or a modified Maze procedure. The classic Maze procedure cures atrial fibrillation in more than 90 percent of patients, but requires about one hour to complete. In most patients who are having additional heart surgery, the surgeon chooses to perform a modified Maze procedure.

Modified Maze Procedure

Bipolar radiofrequency device used in surgery for atrial fibrillation. The curve of the jaws helps ensure that the electrodes are placed on atrial rather than pulmonary vein tissue. As a result, no incidents of pulmonary vein stenosis have occurred. (Photo courtesy of Atricure)

During the modified Maze procedure (also called surgical pulmonary vein isolation), the surgeon uses alternate energy sources instead of incisions to create the key lines of conduction block.

The modified Maze procedure requires only 15 to 20 minutes of operative time and restores sinus rhythm in 75 to 85 percent of patients.

Selected patients with valvular heart disease and atrial fibrillation may be candidates for a minimally invasive approach that enables treatment of both conditions.

Bipolar radiofrequency device used during modified maze procedure.

Four alternative energy sources - including radiofrequency, cryothermy, microwave and laser - have been used during the modified Maze procedure. The goals of all four energy sources are to:

1. Produce lesions and ultimately scar tissue to block the abnormal electrical impulses from being conducted through the heart; and
2. Promote the normal conduction of impulses through the proper pathway.

Radiofrequency: A radiofrequency energy catheter is used to heat the tissue and produce the lesions. There are a variety of surgical techniques related to the type of catheter used, the dose of energy and the types of lesions created.

Cryothermy device used to create lesions during modified maze procedure. (Photo courtesy of Cryocath)

Cryothermy (also called cryoablation): Very cold temperatures are transmitted through a probe (cryoprobe) to create the lesions. Cryothermy is used commonly during arrhythmia surgery to replace the incisions made during the Maze procedure.

Microwave: A wand-like catheter directs microwave energy to create the lesions.

Laser: Lasers rapidly create the lesions or lines of conduction block. Laser technology offers promise for the development of additional minimally invasive approaches.

	Video - Microwave Thoracoscopic - Minimally Invasive Ablation (Animation) - click on the small arrow on the bottom left of the player to start & stop tape
Keyhole approach- outside view of Pulmonary Vein Isolation with radiofrequency energy
Note: Video Requires QuickTime to view videos. Click here to download QuickTime Free. (a new browser window will open with this link. The inclusion of links to other web sites does not imply any endorsement of the material on the web sites or any association with their operators.) Requires a High Speed 56k modem or T1/DSL/Cable modem connection to view

What happens during the surgery?

Surgical treatment for atrial fibrillation may require 2 to 4 hours.

During minimally invasive surgery, the surgeon views the epicardial (outer) surface of the heart using an endoscope. Specialized instruments are used to isolate the pulmonary veins and create the lines of conduction block. Unlike traditional heart surgery, there is no large chest wall incision, and the heart is not stopped.

Because the surgeon can view the outside of the heart using special endoscopes, the risk of pulmonary vein stenosis is nearly eliminated. In addition, no catheters are introduced into the left side of the heart, reducing the risk of blood clots and strokes.

The Maze procedure requires an incision along the sternum (breast bone). The incision may be traditional (about 6 to 8 inches long), or in some cases, minimally-invasive (about 3 to 5 inches long). The heart-lung machine oxygenates the blood and circulates it throughout the body during surgery.

During the Maze procedure, the surgeon makes incisions in both atria to isolate and stop the abnormal electrical impulses from forming. The impulses are directed down a normal pathway. When the heart heals, scar tissue forms and the electrical impulses that caused the atrial fibrillation are blocked from traveling through the heart.

Photo of pulmonary vein isolation in modified maze procedure.

The modified Maze procedure involves a single incision in the left atrium. The energy probe of choice is inserted, and under direct vision, used to create the lesion lines. As in the classic Maze procedure, these lesions create lines of conduction block that interrupt the abnormal impulses of atrial fibrillation and restore the normal sinus rhythm.

Excision of the left atrial appendage
The left atrial appendage is a small, ear-shaped tissue flap located in the left atrium. This tissue is a common source of blood clots in patients who have atrial fibrillation.

During surgical procedures to treat atrial fibrillation, the left atrial appendage is removed and the tissue is closed with a special stapling device.

• Receive specific instructions to help you prepare for surgery. Information about eating, drinking and taking medications prior to surgery will be discussed.
• Meet with your anesthesiologist, nurse clinician, cardiologist and surgeon.
• Discuss your surgery and have an opportunity to ask questions.

Patients admitted to the hospital prior to surgery will receive details of pre-surgical procedures and preparation from their cardiologist and surgeon.

See Heart Surgery at the Cleveland Clinic for more information

After Surgery
The patient is transferred to an intensive care unit (ICU) for close monitoring for about one to two days after the surgery. When the patient’s condition is stable, he or she is transferred to a regular nursing unit (called a telemetry unit).

The monitoring during recovery includes heart, blood pressure and blood oxygen monitoring and frequent checks of vital signs and other parameters, such as heart sounds.

Most patients stay in the hospital about 5 to 7 days after the procedure, depending on their rate of recovery. Patients who had minimally invasive surgery may be able to go home 2 to 3 days after surgery. Your health care team will follow your progress and help you recover as quickly as possible.

Recovery
Full recovery from surgery takes about 6 to 8 weeks. Most patients are able to drive in about 3 to 8 weeks after surgery. Your health care team will provide specific guidelines for your recovery and return to work, including specific instructions on activity, incision care, and general health after the surgery.

Thirty to fifty percent of patients experience skipped heartbeats or short episodes of atrial fibrillation during the first three months after the procedure. This is common due to inflammation (swelling) of the atrial tissue and is treated with medications. After the heart has healed, these abnormal heartbeats should subside.

A small number of patients (about six percent) require a pacemaker after surgery due to an underlying rhythm, such as sick sinus syndrome or heart block, which previously was undetected.

Medications after surgery may include:
Anticoagulant (blood thinner), such as Coumadin, to prevent blood clots

Antiarrhythmic medication to control abnormal heartbeats

Diuretic to reduce fluid retention

Other medications as needed

Your doctor will monitor your recovery and determine when or if these medications can be discontinued.

Will you need to follow-up with a cardiologist?
You will return to your local doctor within one week of being discharged from the hospital to ensure you are healing properly. You will then follow-up with your cardiologist within 4-5 weeks of being discharged to check on your heart rhythm and again to ensure you are healing properly. We recommend that you have an EKG at 3 months, 6 months, and 12 months after surgery and then annually thereafter. We would appreciate it if you would ask your doctor to send a copy of the EKG to The Cleveland Clinic to add to your medical records. If you notice atrial fibrillation starting after you are discharged, you will need to see your cardiologist immediately. Cleveland Clinic staff is happy to work with you, your local doctor and your local cardiologist on helping you recover fully after your surgery. Your post-surgery nurse clinician will give you a phone number to contact for any post-discharge questions.

Successful Results

Surgeons began performing the Maze procedure at the Cleveland Clinic Foundation in 1991. Improvements in surgical techniques over the years have produced successful results in most patients:

• Long-term freedom from atrial fibrillation
• Decreased symptoms
• Greatly reduced embolic events (such as blood clots or stroke)
• Decreased atrial (top chamber of the heart) size in those with enlarged atria pre-surgery, particularly those who undergo Maze procedure with mitral valve repair procedure.

Click here to see our surgical outcomes

To be evaluated for surgical treatment of atrial fibrillation:

• Click here or you may also call the Heart Center Resource and Information Center Nurse at 216/445-9288 or toll-free 866/289-6911.
• You may also use our eClevelandClinic second opinion consultation using the internet.

For questions or more information, you may contact us by email, using the Contact Us Form. Please state "Center for Atrial Fibrillation" in the Question or Comment Section. You may also call the Heart Center Resource and Information Center Nurse at 216/445-9288 or toll-free 866/289-6911. Webmail and phone calls are answered between 8:30 am to 4:00 pm on regular business days.

If you are already treated at the Cleveland Clinic Foundation for atrial fibrillation, talk to your cardiologist about whether surgery is an option for you.

Click on the links below to find Heart Center physicians who:

• treat atrial fibrillation
• perform surgery to treat atrial fibrillation

• For a transcript of the WebMD chat with Dr. Gillinov, click here.*
• A Closer Look at Heart Treatments” Webcast Archive: Cleveland Clinic Surgeons discuss Surgical Treatment of Atrial Fib, Coronary Artery Disease, and Valve Disease
• For many articles on the surgical treatment of atrial fibrillation, click here
• Click here to find related publications written by Heart Center physicians

Center for Atrial Fibrillation home page

*a new browser window will open with this link. The inclusion of links to other web sites does not imply any endorsement of the material on the web sites or any association with their operators