Surgical Treatment of Atrial Fibrillation: A Comprehensive Guide to Performing the Cox Maze IV Procedure

Surgical Treatment of Atrial Fibrillation

A Comprehensive Guide to Performing the Cox Maze IV Procedure

Jonathan M. Philpott

Christian W. Zemlin

Ralph Damiano

Table of Contents

Cover

Title page

Copyright

Foreword

Preface

Acknowledgments

Uniform Abbreviation List

Chapter 1: Foundations and Fundamentals

Abstract

1. Triumph and tragedy of the Maze

2. Demystify the Maze—it’s all about circuit interruption

3. Understanding macroreentrant circuits (MRCs)

4. Interrupting MRCs

5. One MRC produces atrial flutter, two or more produce AF

6. Ventricular tachycardia: a brief aside

7. Understand that the Maze is a strategic option for AF

8. The six lines of scar in the Maze III/IV

9. The final Maze structure

10. Maze Underground—a method to understand how the Maze lines sometimes share segments and anchors

11. Lessons from the pioneers

12. Atlas nomenclature and illustration conventions

13. Antiarrhythmic drugs and MRCs

14. Making Maze lines using thermal ablation: the good, the bad, and the ugly

15. The Maze is a house of cards—a single break in just one line can result in a failure of the entire procedure

16. Triggers versus MRCs define the AF categories and treatment: the important difference between paroxysmal and nonparoxysmal AF

17. Understanding Maze evolution and nomenclature

18. Unintended benefits now commonly associated with the Maze

19. Fundamental principles needed for a successful Maze

Chapter 2: Outcome Tracking is Critical to Success—and a Mandatory Part of the Procedure

Abstract

1. To increase success rates you must know your outcomes

2. Why precise surgical ablation documentation is critically important

3. Surgeon-driven mandatory follow-up

4. Sample post-Maze management and outcome tracking

5. Failure: AF versus atrial flutter

6. Outcome tracking: homemade solutions, registry information, and database participation

7. Defining success

8. Dealing with failures

9. Concomitant intervention rate (CIR) tracking

10. Failure analysis

11. Surgical program performance improvement

12. Keys to program development and procedure acceptance

Chapter 3: Maze Indications, Perioperative Management, and Expected Success Rates

Abstract

1. Indications

2. Patient selection and pitfalls

3. Preoperative management

4. Anesthesia management

5. Postoperative considerations and management

6. General targets of success program guidelines at 5 years

Chapter 4: The Art and Science of Making Effective Maze Ablation Lines

Abstract

1. Introduction

2. RF ablation

3. Cryoablation

4. Which energy source for which purpose?

Chapter 5: Mastering the Initial Dissection and Cannulation: Making Ablation Easy and Safe

Abstract

1. Introduction

2. Sternotomy and exposure

3. Mobilize the SVC

4. Cannulation and bypass

5. Open the oblique sinus inferiorly

6. Open the oblique sinus superiorly over the LA dome and take down the superior pericardial reflections

7. Wide development of Sondergaard’s groove

8. Right PVI access

9. Left PVI access

10. Coronary sinus cannulation

Chapter 6: Overview of the Right Atrial Lesion Set of the Maze-IV

Abstract

1. Introduction

2. Importance of three right-sided lines

3. Maze Underground: line sharing

4. Preservation of the SA node and atrial pacemaker complex

5. Postoperative pacemaker insertion rates and the right side of the Maze

6. Goals

7. TEE and sequence adjustments

8. Complications and pitfalls

Chapter 7: The Vertical Atriotomy

Abstract

1. Electrical purpose

2. Specific goals

3. Complications and pitfalls

4. Step by step: how to create of the vertical atriotomy

Chapter 8: The Intercaval Line

Abstract

1. Electrical purpose

2. Maze Underground: shared line segments

3. Line components and assembly

4. Lessons from the pioneers

5. Specific goals

6. Complications and pitfalls

7. Step by step technical details

Chapter 9: The Modified and the Classic Right Atrial Appendage Line

Chapter 9A: The Classic RAA Interruption Line

Chapter 9B: The Classic Right Atrial Appendage Circuit Interruption Line (Classic RAA Line)

Chapter 10: Tricuspid Caval Isthmus Line

Abstract

1. Background

2. Electrical purpose

3. Maze Underground: shared line segments

4. Components and assembly: connecting three unique segments of the TCI line

5. Lessons from the pioneers

6. Specific goals

7. Complications and pitfalls

8. Step by step technical details

Chapter 11: Overview of the Left Side of the Maze-IV Lesion Set

Abstract

1. Introduction

2. Differences to the right side

3. Lessons from the pioneers

Chapter 12: Box Pulmonary Vein Isolation

Abstract

1. Background

2. Electrical purpose

3. Box PVI versus bilateral antral PVIs: a study of containment

4. Containment: comparison between the box PVI in the Maze-III versus Maze-IV

5. Maze Underground: shared line segments

6. Lessons from the pioneers

7. Box PVI line components and assembly

8. Complications and pitfalls

9. Maze-IV box PVI: step by step technical details

10. Alternative box PVI scenarios: step by step technical details

Chapter 13: LAA Line and Appendage Amputation/Exclusion

Abstract

1. Electrical purpose

2. Maze Underground: shared line segments

3. Components and assembly

4. Lessons from the pioneers

5. Stroke reduction purpose

6. LAA exclusion versus amputation

7. Specific goals

8. Complications and pitfalls

9. Step-by-step technical details

Chapter 14: The Mitral Valve Isthmus Line

Abstract

1. Electrical purpose

2. MVI line components and assembly

3. Lessons from the pioneers

4. MVI line pitfalls

5. Specific goals

6. Complications and pitfalls

7. Step-by-step technical instructions

8. Method A: the modified CS ablation line technique

9. Method B: the traditional CS ablation technique

Chapter 15: Intraoperative Testing

Abstract

1. Introduction

2. Testing nomenclature and basic principles

3. Limitations

4. Actionable intelligence: what do you do with the results of the test?

5. Intraoperative testing summary

Chapter 16: Sequencing Overview and Coronary Artery Bypass Implications

Abstract

1. Introduction

2. Events that mandate left side first sequences

3. Measuring CABG grafts and sequencing

4. General sequence overview

Chapter 17: Sequencing Examples Using the Modified MVI CS Ablation Line Technique

Abstract

1. Stand-alone open Maze-IV

2. CABG Maze (right Maze first/left Maze second)

3. CABG Maze (left Maze first/right Maze second)

4. Mitral Maze

5. AVR Maze (for as)

6. AVR Maze (for AI)

7. Tricuspid Maze

8. Mitral tricuspid Maze

9. AVR MVR Maze

10. AVR tricuspid Maze

11. CABG AVR Maze (right Maze first/left Maze second)

12. CABG AVR Maze: (left Maze first)

13. CABG mitral Maze (right Maze first)

14. CABG mitral Maze (left Maze first/right Maze second)

15. CABG tricuspid Maze

16. CABG mitral tricuspid Maze

17. CABG AVR mitral Maze

18. CABG AVR tricuspid Maze

19. AVR mitral tricuspid Maze

20. CABG AVR MVR TVR Maze

21. Aortic root replacement, Maze

22. Aortic root, ascending aorta/arch + Maze

Teaching Appendix: Thought Experiments to Understand Activation Waves, AF, Atrial Flutter, MRCs, and Complications of the Maze

1. Waves in a pool

2. Macroreentract circuits (MRCs)

3. Repolarization

4. Conduction velocity

5. LA size

6. Failure of medical management and PVI

7. Maze-III

8. Maze-IV

9. Poorly performed Maze-IV

10. Iatrogenic atrial flutter as a result of the Maze

Index

Copyright

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Foreword

Atrial fibrillation (AF) remains one of the central problems in cardiology. It continues to increase in prevalence and it is the most common arrhythmia problem clinicians see in practice. The most recent AHA Heart Disease and Stroke statistics estimate a prevalence of AF that is expected to rise to 12.1 million patients in the United States by 2030. Management of AF continues to be a challenge.

Jonathan M. Philpott is to be congratulated on what can only be considered a labor of love. He has continued a tradition started by our greatest anatomists and surgeons. This tradition was highlighted by Robert Anderson and Wallace McAlpine. Jon has produced what will be considered for a long time a classic work in the field of cardiac surgery. It should be read by cardiac surgeons, cardiac electrophysiologists, and anatomists. It is a beautifully illustrated and thought out approach to the surgical management of AF beginning with basic principles and taking us through the variations on the Cox-Maze surgical approach as well as its combination with valvular disease and coronary surgery. The writing and explanations are clear and drawings and figures are brilliant.

William Robertson Davies, a novelist, playwright, and professor said that a truly great book should be read in youth, again in maturity, and once more in old age. This book is a treasure and will be read and read again by anyone who cares for patients with AF.

Dr. Kenneth A. Ellenbogen

Kontos Professor, Chairman, Division of Cardiology

VCU School of Medicine, Richmond, VA, United States

February 16, 2017

The surgical treatment of atrial fibrillation (AF) has known an arduous path. Thirty years ago, Dr. James Cox gave us the key to restoring atrial rhythm. The Cox Maze was born of one of the first authentic multidisciplinary teams, with a group of curious and ingenious physicians exploring the most complex and poorly understood dysrhythmia. They had already conquered several vexing arrhythmias through mapping and dividing abnormal pathways. Now, they faced an unmappable and seemingly disorganized rhythm affecting the entirety of both atria. It was the most common arrhythmia in the world and one that would climb to the status of epidemic. The Cox Maze operation is a bench to bedside story in the most classic sense. Drs. Cox, Boineau, and Schuessler and their team crossed back and forth from laboratory to operating room, unearthing the truth about AF and designing its nemesis. The results of the cut-and-sew Cox Maze have been nothing short of spectacular and just as importantly, the science that eschewed from the work of the team at Washington University spawned an explosion of investigations and technology. Much of this growth in AF research and device design was wonderfully beneficial, but it also took surgery off the clear path forged at Washington University by Dr. Cox and his successor Dr. Damiano, into a period of lackadaisical implementation of incomplete and poorly created lesions attempting to mimic the Cox Maze, and only serving to send surgeons further from a valid therapy.

Fortunately, the undeniable success of the properly executed Cox Maze never faded and well understood energy sources took the place of the knife. Meanwhile, knowledge about myocardial substrate, metabolic stress, and the relation of AF to other cardiac and noncardiac disorders broadened. Surgeons and electrophysiologists have learned from the success of our predecessors that working together, we can design new methods to tailor durable elimination of AF. Add to this, the input of sleep specialists, endocrinologists, and specialized nurse practitioners and the new version of a multidisciplinary AF team takes shape. Still the most effective means of treating the most advance AF remains the Cox Maze, and our goal is always pursuit of that standard. While we recognize that we must strive to derail the progress and even the onset of AF through lifestyle and risk modification and even genetics, we will always be confronted with the consequences of established AF and need to treat it.

This text provides a deep dive into the Cox Maze and gives the reader the opportunity to become immersed in the logic and subtleties of the operation. Anyone seeking comprehensive understanding of the mechanics and methods of the Cox Maze and its dominance as AF’s most durable correction will want to read the authors’ insights and return to this book as a reference. The illustrations allow the reader to command the physical attributes of the operation in a comprehensive manner, previously never available.

If one is to practice arrhythmia surgery, one should become an arrhythmia surgeon. Here is a wonderful place to begin and a superb companion for the journey.

Dr. Marc Gerdish

Preface

Your journey has been my journey. This work has taken a decade to put together and the motivation stemmed from when I was in training and the Maze was this mysterious operation that nobody could explain to me in a way that made any sense.

I have long believed that if you can’t explain something you probably shouldn’t do it. With this in mind, I set out to design this atlas with the goal of explaining how to construct the Cox Maze IV procedure in as clear detail as possible to teach cardiac surgeons at all levels—those in current practice, cardiac surgical fellows, and interested residents and medical students—so that they can easily grasp the concepts necessary to understand why the Maze is designed the way it is and the necessary steps required to perform the procedure precisely and safely. The ultimate goal is to improve the quality of the Maze procedures being performed nationally and internationally, and to support the treatment of a greater number of patients with preoperative atrial fibrillation undergoing heart surgery.

Looking back now I wish that I could travel back in time and give this book to my younger self. It answers the questions I had then, and many of you have now. It details the reason why each of the lines were invented, and why they still work today. It details a decade’s worth of experience with complications and traps that had never been described, but are easy to avoid if you know about them. It will teach you how to safely make the dissection to create the lines, and it will guide you on how to sequence the Maze into just about any case you choose to take on.

To make it enjoyable to read, we tried to take on the tone of an experienced mentor having a conversation with a learning or inexperienced surgeon. Basically, we wanted to create a work that for the first time cracked the mystery of the Maze and broke it down into easy to understand concepts that everyone would quickly understand.

In many operating rooms across the nation, arrhythmia surgery is rarely considered and often scorned. The opposite should be true. The Maze procedure still is the definitive treatment of atrial fibrillation, and it has the potential to improve the lives of a vast number of patients. When you set out on your journey to master the Maze, keep this idea in mind. Your patients will be immensely grateful for your efforts.

Jonathan M. Philpott, MD

Norfolk, VA

Jonathan and I met at a conference in California, only to discover that we live and work within walking distance of each other in Norfolk, Virginia. We quickly realized that his interest in advancing surgical technique and mine in arrhythmia mechanisms, optical mapping, and new ablation technologies were a unique match, and we have been collaborating on animal studies and clinical studies ever since.

My laboratory is focused on the study of arrhythmia mechanisms, in animal and computer models, as well as on the development of new ablation technology. We use optical mapping with voltage-sensitive fluorescent probes to visualize and study cardiac electric activity in animal models ranging from mouse to pig. With optical mapping, you can actually see activation waves as they travel around the heart, crash into lesions, or find their way around them. This experience was crucial in producing many illustrations of wave propagation that you will find throughout the book. In computer models that use a variety of electrophysiological settings and geometries, we study the mechanism of arrhythmias, including the induction of atrial fibrillation. More recently, we began to use trains of ultrashort electric shocks, called nanosecond pulsed electric fields (nsPEFs), both for the defibrillation and ablation of cardiac tissue. This new technology development has especially profited from my collaboration with Jonathan, who is already an expert in the art of creating nsPEF ablations (in pigs)—a subject to be covered in future editions of this book.

Cardiac surgeons and biophysicists look at the heart from different angles, so much so that it may initially be hard to find common ground. Once we found it with the Maze procedure, our many discussions have broadened our understanding and opened doors for both of us, and they have ultimately allowed us to write a book that neither of us could have written by himself.

Christian W. Zemlin, PhD

Norfolk, VA

Acknowledgments

This work would not have been possible without spending considerable time with Dr. James Cox who helped us understand the purpose of the lines and how to begin performing the procedure correctly with my own hands. I am deeply grateful to his patience, guidance, and mentorship through my own journey to master this operation.

Second, the hundreds of new illustrations presented in this work could not have been created without financial assistance from AtriCure, Inc., and we greatly appreciate their support.

Adam Questell, our illustrator who created them, went to extraordinary length to understand the many, often complex aspects of wave propagation we wanted to explain and to find the most intuitive ways to present them. We look at him as the silent fourth author of the book.

Mary Chandler Philpott’s proofreading greatly helped us to bring the book into its final form.

Uniform Abbreviation List

Lesions

LAA line Left atrial appendage circuit interruption line

LPVI Left pulmonary vein isolation

MVI line Mitral valve isthmus circuit interruption line

PVI Pulmonary vein isolation

RAA line Right atrial appendage circuit interruption line

RPVI Right pulmonary vein isolation

TCI line Tricuspid caval isthmus circuit interruption line

VA Vertical atriotomy

Anatomy

AV Atrioventricular

CS Coronary sinus

DTA Descending thoracic aorta

IVC Inferior vena cava

LA Left atrium

LAA Left atrial appendage

LAD Left anterior descendent artery

LIMA Left internal mammary artery

LIPV Left Inferior pulmonary vein

LOM Ligament of Marshall

LPA Left pulmonary artery

LSPV Left superior pulmonary vein

MV Mitral valve

OM Obtuse-marginal artery

PA Pulmonary artery

PDA Posterior descending artery

PFO Patent foramen ovale

RA Right atrium

RAA Right atrial appendage

RIPV Right inferior pulmonary vein

RSPV Right superior pulmonary vein

SA Sinoatrial

SCA Subclavian artery

SVC Superior vena cava

SVG Saphenous vein graft

TV Tricuspid valve

Physiology

AF Atrial fibrillation

AI Aortic insufficiency

BPM Beats per minute

CHB Complete heart block

CVP Central venous pressure

MRC Macroreentrant circuit

NPAF Nonparoxysmal atrial fibrillation\

NSR Normal sinus rhythm

PAF Paroxysmal atrial fibrillation

Other

AAD Antiarrhythmic drugs

AVR Aortic valve repair

CABG Coronary artery bypass graft

CIR Concomitant intervention rate

CPB Cardiopulmonary bypass

DC Direct current

DCC Direct current cardioversion

ECG Electrocardiogram

EP Electrophysiology

HRS Heart Rhythm Society

ICD Implantable cardioverter defibrillator

MVR Mitral valve repair

PPM Permanent pacemaker

RF Radiofrequency

STS Society of Thoracic Surgeons

TEE Transesophageal echocardiogram

TIA Transient ischemic attack

Chapter 1

Foundations and Fundamentals

Abstract

Chapter 1 begins with the history of the Maze and reviews both its impressive initial successes and the subsequent confusion and divergence from its foundational principles that led to a mixed reputation today. To demystify the procedure, we begin with how the procedure aims to interrupt macroreentrant circuits (MRCs) around which excitation waves travel during atrial fibrillation (AF), and where these MRCs can occur in the atria. For each of the MRCs that commonly occur, the Maze creates a solid, unbroken, uniformly transmural line of scar to interrupt it: three lines for the right atrial side and three on the left, making up the six major lines of the Maze procedure. Fundamentals necessary to create a successful Maze are reviewed, including the critical importance of the ablation lines being uniformly transmural, that each line must have solid anchors on nonconductive tissue, the importance of preserving atrial activation and the conduction system of the heart, and how outcome tracking is so critical to the success that we consider it a part of the procedure. A final section reviews the evolution of paroxysmal into persistent forms of AF, the nomenclature of the Maze procedure through the years, and unintended benefits now commonly associated with the Maze.

Keywords

Cox Maze

Cox Maze-I

Cox Maze-II

Cox Maze-III

Cox Maze-IV

Maze

Maze-I

Maze-II

Maze-III

Maze-IV

atrial fibrillation

atrial flutter

paroxysmal atrial fibrillation

persistent atrial fibrillation

permanent atrial fibrillation

pulmonary vein triggers

PVI

iatrogenic atrial flutter

macro reentrant circuits

cryoablation

radiofrequency

RF

bipolar RF

thermal ablation tools

1. Triumph and tragedy of the Maze

When the first successful Maze procedure was performed by Dr. James Cox in 1987 at Washington University, it was a breakthrough in the treatment of atrial fibrillation (AF) [1]. By strategically placing cuts in the atrium, and then sewing them back together, he created nonconducting lines of scar (called lesions or simply lines) that interrupted macroreentrant circuits (MRC), vanquished AF, and made it difficult for the atrium to develop AF in the future. This resulted in durable freedom from AF without antiarrhythmic medications [2].

There were weaknesses in the original approach, but all of them were addressed in subsequent refinements [3]. The first lesion pattern, called the Maze-I, delayed the activation of the left atrium to the point that it contracted when the mitral valve was already closed, but by moving a lesion that was affecting Bachmann’s bundle, the delay could be avoided, yielding the Maze-II lesion pattern. The newly moved lesion was complicated by bleeding, and was thus almost immediately refined further to the Maze-III.

The resulting Maze-III procedure enjoyed remarkable success rates of durable freedom from AF, upward of 90%, even in the challenging cases of longstanding persistent atrial fibrillation [4]. It immediately eclipsed all existing methods to treat AF, and even now, 20 years later, the Maze procedure is by far the most effective approach. The greatest complaints about the Maze-III were the technical demands of making multiple cut-and-sew lesions, the time required to perform it, bleeding risks, and overall complexity. Although it had very good success rates, the Maze-III was hard to learn and master, and its adoption was very limited.

As a result, surgeons began to investigate ways to replace the cut-and-sew lines with ablation lines created with a variety of energy sources. Cryoablation relied on cooling tissue until it died, and it was pioneered by Dr. Cox himself [5,6]. Radiofrequency (RF) ablation relied on heating tissue until it died and was used along with cryoablation by Dr. Damiano at Washington University [7]. Both methods were shown to be able to reliably create long uniformly transmural lines of scar, and they dramatically reduced procedure times [8]. By keeping the pattern the same but replacing as many of the cut-and-sew lesions with RF, the Maze-IV was born. RF and cryoablation even complemented each other in their strengths, with RF providing the most precise lines in the shortest possible time, and cryoablation securing the lines onto nonconductive structures like a valve annulus. It appeared that the Maze procedure was on its way to become the universally accepted treatment of AF.

Unfortunately, the Maze has so far failed to live up to this promise. One problem was that a great variety of ablation devices became available on the market in rapid succession, using a host of energy sources including microwave, laser, high-frequency ultrasound, and a great variety of unipolar and bipolar RF devices. With the exception of cryoablation and bipolar RF, the new energy sources have so far failed to produce reliable lesions when tested in animals [9]. Many devices had significant limitations regarding where they could be placed and how they could be used, and Maze lesion pattern changes were made to accommodate the limitations of these devices, often at the expense of the procedure. The results were predictably dismal. Even though none of these ineffective devices are used anymore, their failures have done enduring damage to the reputation of the Maze.

Even the Mazes that were created with mature RF and cryoablation technology were often not as good as they should have been. Armed with new, faster methods to create lesions, many surgeons started to experiment and modify lesion patterns according to their perceived needs. As different surgeons strayed further and further away from the Maze’s careful design, lesion patterns became increasingly warped and incomplete. Many of the Mazes performed were not remotely close to the lesion pattern that made the Maze-III/IV successful. These operations should have been called extensive ablations for AF, but invariably surgeons continued to use the term Maze to describe what they were doing.

Besides these unwise deviations from the lesion pattern, the quality of the lines themselves became a significant problem. Tedious and time-consuming as the Maze-III had been, the certainty that cut tissue will develop a nonconducting scar was not (and is not) easy to match with RF and cryoablation. It is possible to create uniformly transmural lines with thermal energy sources, but it requires proper instruction and practice. Low success rates and complications from incomplete lines further tarnished the Maze’s reputation. In catheterization laboratories across the county where the failures and complications from these procedures ended up, the term Maze was used pejoratively, and cardiac surgeons were derided as dabbling in electrophysiology (EP). Many electrophysiologists concluded that cardiac surgeons were out of their depth trying to treat AF.

The challenge of making good lines with RF and cryoablation is aggravated by another powerful force that has been rarely described but that is a central theme of this text, and one that you must become aware of and confront directly. When performing a Maze-IV, you are operating without any immediate feedback about if the ablation line you make is complete or not. With the cut-and-sew Maze-III, the surgeon could be sure that all of the lines were completely transmural, because the tissue had been cut in half and sewn back together. The feedback was immediate and definitive. On the contrary, when we kill tissue by heating or cooling it, there is no way to accurately evaluate the quality of the maturing lesions to know if the line was complete or not immediately after its completion.

Just like when driving a car or piloting a plane—when performing open heart surgery continuous feedback is critical to success. Furthermore, longer term feedback is crucial not only in determining effectiveness but also central to performance improvement. Basically, immediate and long-term feedback about overall success are critical elements that are inherent in all other open heart procedures—except this one. In the case of the Maze using thermal energy sources, not only is immediate feedback about line integrity absent, longer term feedback to help guide quality has also been lost—and even worse, most surgeons were not conscious of it.

Without immediate feedback about line completeness and detailed follow-up, surgeons attempting to perform a Maze were in effect operating in the blind with no way to know if the lines they were making were solid, nor the ability to look at their failures. Bad habits and poor technique flourished in these blind conditions. It was a slippery slope, which with the passage of time became so powerful that there was confusion about which lines were necessary and if the procedure even worked at all. As a result, many surgeons continued to eliminate lesions or change the lesion set, getting further away from the fundamental principles of the Maze procedure. A lack of any formalized training on the principles of the procedure and its execution also contributed to significant confusion and contradictory information on the safety, efficacy, and reproducibility of the procedure.

Careless changes in lesion patterns, line breaks, and lack of immediate feedback all contributed to a loss of integrity in the procedure, culminating in a widespread perception that the Maze procedure was too complex and mysterious for surgeons to learn. This failure to understand the procedure correctly is, in our opinion, the central reason that it has not been universally adopted and has failed to achieve its true potential.

The procedure’s given name, Maze, is full of irony as the name also highlights the confusion and misunderstanding swirling around the procedure. A maze is a man-made structure designed to confuse people. To date, the Maze procedure remains one of the most misunderstood and underappreciated procedures in all of the surgical armamentarium. It remains commonplace for us to hear intelligent but misguided clinicians describe the Maze as an operation where a maze-like pattern is constructed on the surface of the atrium designed to prevent aberrant electrical signals from running around and getting trapped in dead ends. Nothing could be more untrue.

It does not make a maze-like structure on the heart to trap waves in blind alleys—it interrupts circuits by placing transmural complete lines of nonconductive scar across common paths of circuits and in doing so destroying them.

We believe that despite the frustrating recent history of the Maze, its potential is even greater now than it was two decades ago. The definitive treatment of AF is still a Maze procedure by an experienced surgeon, and modern devices—if applied correctly—allow the creation of reliable Mazes faster than ever. What is missing from our point of view is a way of teaching beginning Maze surgeons both the idea behind the Maze and the technical details that are crucial to its success, and to show them ways of outcome control that will over time ensure that they too can use the Maze to its full potential.

In this atlas, our goal is to demystify the Maze procedure by breaking it down into the objectives of each of the lines and the technical details of their execution. The lesions are grouped into right and left atrial lesion sets. Each line is then reviewed individually, along with its pitfalls and potential complications. We review sequencing of the lesions within different concomitant scenarios so that the procedure can be performed efficiently and safely in all structural heart procedures.

2. Demystify the Maze—it’s all about circuit interruption

The first step in teaching the Maze is to demystify the procedure. The Maze is designed to interrupt circuits. As noted earlier, it has nothing to do with trapping aberrant signals in blind alleys. Right here, at the beginning, take the image you have in your mind of the complex English garden maze with people getting lost in it and throw it out.

The Maze operation targets six common atrial regions where circuits driving AF are known to flourish, and for each region a line of scar tissue is placed which interrupts all potential MRCs that could potentially flourish within the region.

In active circuits, there is a wave of atrial activation which is going around and around a certain path, very much like a car on a race track following a loop. As the wave moves around this track, it activates all of the tissue to the right and left of its path as it moves, and in doing so it sends out a wake as it cycles around the circuit. With each cycle, these wakes spanning out from the left and right of the leading edge of the wave in the circuit will spread out and will travel across the entire atrium. If a single one of these potential circuits becomes active, it will literally bombard the entire atrium with a massive field of activation waves erupting from its path. The goal of the Maze is to destroy all of these tracks: the ones active at the time of the operation, and all of the ones that could potentially become active in the future. It is a procedure that uses six lines of transmural scar to interrupt potential circuits in the heart that can cause AF.

Accordingly, the Maze is a highly focused strategic procedure that works because of its completeness. The precise electrical purpose, goals, and pitfalls for each of the six lines must be clearly understood to master the procedure and achieve great clinical outcomes. There should be no confusion about any of the lines as the theory and goals of each are actually straightforward and simple to understand if taught properly.

It is also important at the beginning to understand what the Maze is capable of and what it cannot do. It is capable of circuit interruption—but little else. It does isolate the pulmonary veins and posterior left atrial wall, but otherwise, the heart is not compartmentalized. If a circuit becomes active outside the isolated back left atrium (LA) wall and pulmonary veins, the lines of the Maze will not block the incoming barrage of activation waves churning out of the circuit and flooding the entire atrium. The Maze works by stopping the circuits, but outside of the box pulmonary vein isolation (PVI), it does nothing to contain spreading activation waves.

It’s a misconception that the Maze makes it difficult to sustain AF. It does lower the probability of AF initiation, but if AF is initiated, the Maze pattern itself will not stop the fibrillation and somehow make the atrium fall back into normal sinus rhythm (NSR). It does not have this capability to contain or suppress active MRCs outside of the isolated LA. If one MRC outside a perfect Maze pattern activates, the patient will have atrial flutter. If two or more MRCs outside of the Maze pattern activate, the atrium will absolutely fibrillate—even with a perfectly constructed Maze pattern. The Maze is designed to prevent MRCs driving AF, but the pattern will do nothing to stop the waves coming from surviving MRCs that have become active.

We now turn to the intended target of the Maze, MRCs, to describe what they are and how they work to generate activation waves in the heart and cause both atrial flutter and AF.

3. Understanding macroreentrant circuits (MRCs)

MRCs are circular or oval tracks within the left and right atrium on which activation waves can revolve, and with each pass generate activation waves that stream out from the circuit and propagate through the atrium.

To understand this, imagine we are in a blimp observing a speedboat plowing through the water around a large spill way in the middle of a lake. From our position overhead, observe the wake spiraling out over the lake as the boat plows around and around the course and the pattern it creates on the surface of the lake (Fig. 1.1).

Figure 1.1   Waves emanating from a speed boat circling around large spillway.

The bow wave on the inside of the circle falls into the spillway, but the outer wave propagates outward in a spiral pattern.

Just like the path of a speedboat on the lake, an MRC is a loop in the atrium on which a wave of atrial activation circles around and around the track of the circuit. Each time it cycles, the wave comes back to where it started and reenters to go around again. This phenomenon is called macroreentry, and the wave is called a macroreentrant wave. We have illustrated this concept in Fig. 1.2, and have added a small boat to help make the transition from our water example to the heart, but as we progress through the chapter we will substitute the boat for the red arrow representing the MRC and its path.

Figure 1.2   Activation wave in cardiac tissue revolving around a nonconductive structure.

Red circular arrow shows the path of an excitation wave that revolves around the nonconducting structure (dark blue circle), a boat is shown to stress the analogy with Fig. 1.1. White lines show the excitation wavefronts, white arrows indicate the propagation of excitation waves. (A) Wave beginning to revolve a nonconducting structure. (B) The wake of the revolving activation wave eventually inundates the entire tissue.

Like the speedboat, the activation wave racing around the MRC track has a wake. As it passes along the loop, it activates the atrial tissue to the left and right as it moves and in doing so sends out its own wake—a wave of atrial activation—which fans out across the entire atrium. With each lap around the circuit, a new wavefront is generated and spreads out into the atrium.

Now, let us move back to the lake one last time, and find the speed boat again on its circular course plowing around and around—with each cycle a new wave is added, generating a field of waves spiraling from the track and across the lake. Let us go to a much higher altitude (Fig. 1.3) and again observe the boat and the lake. At this altitude we can barely see the speed boat, but the lake is bombarded by the waves emanating from the track. Notice that the waves will move throughout the lake as far as they can travel. They advance from end to end, and fill in all the small crooks and crannies of the lake.

Figure 1.3   Water waves emanating from a revolving speed boat reach every corner of the lake.

Macroreentrant waves in the atria do the same thing, but in a much more powerful way. Unlike the lake, inside the heart the waves do not lose energy as they travel across the lake. Inside the atria, one cell depolarizing activates the cells next to it, and they in turn activate the cells next to them. It is very much like a room full of dominos falling. In this manner, the waves of activation will advance until they strike a structure that does not conduct (like a valve annulus) or come across a patch of atrium that has already depolarized and cannot be stimulated. Second, unlike our boat on the lake example, they orbit much faster, completing approximately 5 rotations/second [10]. These waves continuously strike the atrioventricular (AV) node—bombarding it faster than it can respond, because of its repolarization time. Only if the AV node has repolarized, the arriving wavefront will propagate into the ventricles and result in a ventricular contraction.

With one active MRC, the AV node typically responds to about every second (or sometimes third) wave, producing a very rapid but regular tachycardia—this is atrial flutter. Atrial flutter is typically designated by how fast the AV node can react (e.g., atrial flutter with a 2:1 block, or atrial flutter with a 3:1 block).

4. Interrupting