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Treating Persistent Afib With Minimally Invasive TT-Maze Procedure

For patients with long-standing persistent atrial fibrillation, common treatments such as endocardial ablations may not provide a solution.

The Totally Thoracoscopic (TT)-Maze procedure offers a minimally invasive approach to treating these patients and allowing them to avoid complications such as stroke, heart attack or heart failure.

Jonathan Praeger, MD, a cardiac surgeon with the USC Cardiac and Vascular Institute at Keck Medicine of USC, spoke about the procedure and its benefits.

When and why do you recommend the TT-maze procedure?

The TT-maze is an extremely effective treatment for a certain subset of AFib patients — those with longstanding persistent atrial fibrillation. This type can be extremely difficult to treat, especially with endocardial ablations alone.

Long-standing persistent atrial fibrillation is a very different disease than paroxysmal AFib. Instead of individual localized triggers setting off an arrhythmia, you have total remodeling and fibrosis of the atrial muscle itself. An endocardial approach is significantly less effective for this subset of patients due to procedure complexity and electrical connections on the epicardial surface of the heart.

I most often see TT-maze patients who have been in AFib for extended periods of time. Often, they have had a failed endocardial ablation. That said, it doesn’t have to be that way. For example, if we know the patient has had AFib for over a year, it’s worth thinking about a TT-maze early on.

How is a TT-maze different from a standard maze procedure?

The standard maze is typically done for concomitant atrial fibrillation. That is, for atrial fibrillation in association with other cardiac issues such as coronary artery disease or valvular disease.

In this case, the maze is done at the time of cardiac surgery. In contrast, the TT-maze is done for stand-alone atrial fibrillation and it is completely thoracoscopic. It’s a minimally invasive procedure — I work through incisions that are less than a centimeter. You get the benefits of a maze procedure without having to open the chest.

Is this a situation where you would take the place of an electrophysiologist?

No — very much the opposite. I believe the best chance for success is to work in partnership with an electrophysiologist. Again, this is a certain subset of AFib patients that are symptomatic and extremely difficult to treat with standard methods.

Although it varies, an electrophysiologist can perform endocardial ablations on the right side quite easily. On the epicardial surface, I perform the left-sided lesion sets, plus clipping the left atrial appendage for stroke reduction and I also take down the Ligament of Marshall. While transecting this ligament is very simple for a surgeon working on the outside of the heart, from a positional standpoint, it is difficult for an electrophysiologist to do.

This truly is a combined effort. The results are very good — and better than endocardial ablations alone. A team approach will allow for the best chances of success.

What kind of results are typical?

I have seen patients with very long-standing conditions and multiple previous ablations get back into sinus rhythm. It has changed their lives, and that success is what drives me to continue. This is not just sinus rhythm; many patients get out of atrial fibrillation, off of medications and even off of blood thinners. That’s a great success.

The quality-of-life improvement can be remarkable. I had a patient who was afraid to exercise. Just the thought of exercise gave her extreme anxiety. Now she’s out there being active and doing what she loves. It’s great to see.