Minimally Invasive Procedure May Cure Atrial Fibrillation

Los Angeles - June 1, 2007 - Cardiothoracic surgeons at Cedars-Sinai Medical Center specialize in a minimally invasive surgical procedure that restores normal heart rhythm and peace of mind for patients who suffer from atrial fibrillation.

“Just in the past few years, we’ve made real progress in actually curing patients,” said cardiothoracic surgeon Gregory P. Fontana, a specialist in minimally invasive procedures who serves as vice chairman of Surgery for Pediatric Surgical Services at Cedars-Sinai. Fontana and his colleagues specialize in the Wolf Mini-Maze procedure, which was developed by Randall K. Wolf, M.D.

“There are other minimally invasive maze procedures being attempted, but they appear to have lower success rates. We have been using the Wolf procedure for more than two years and have had very good success with it, and so have other hospitals around the country,” said Fontana, adding that Cedars-Sinai cardiothoracic surgeons are part of a national working group that is evaluating the technique. According to Fontana, who has performed about 30 of the procedures in the past year, the Mini-Maze has been available in the United States for about three years and has very good outcomes.

Atrial fibrillation affects more than 2 million Americans, according to the American Heart Association. Overactive and irregular nerve impulses cause the two upper chambers of the heart, the atria, to quiver instead of beating effectively. This leads to a variety of potential complications, including a 25 percent reduction in the heart’s pumping function and a high risk of stroke.

Although symptoms tend to vary by severity of the disorder, extreme fatigue and a low tolerance for exercise are common complaints. Even patients who have no recognized symptoms – and may not be aware they have atrial fibrillation (AF) – can have a five- to eight-year reduction in life expectancy because of the stress placed on the heart. But until recently, patients had few therapeutic options other than long-term medication management – taking a variety of drugs to attempt to correct an abnormal rhythm, control a racing heart rate, and thin the blood to reduce the risk of blood clots and strokes.

Fontana and his colleagues at Cedars-Sinai are believed to have the largest experience with surgical AF treatment in the western United States. In addition to the Mini-Maze, they perform in certain cases the Cox-Maze procedure, which is done during open-heart surgery with the heart stopped and the patient connected to a cardiopulmonary bypass machine.

The Mini-Maze procedure is accomplished by placing a thoracoscope and thin instruments through several short incisions in the chest. The surgeon, viewing the surgical site magnified on a monitor, identifies the target area of the heart and uses short bursts of radiofrequency energy to destroy a small amount of tissue and disrupt the overactive nerves causing the rhythm disturbance. Typically, the surgeon also will remove two pieces of heart tissue that serve no useful purpose but can remain a source of trouble if left intact: The Ligament of Marshall, the remnant of a vein from fetal development, can cause atrial fibrillation even in an otherwise normal heart, and an appendage on the left atrium is a site where AF-related blood clots are likely to form.

“When the atria fibrillate, blood sits in the appendage, a little cul-de-sac on the left side of the heart. More than 95 percent of the strokes that occur in these patients are caused by blood clots that come from that little appendage,” Fontana said. “Therefore, there are two major objectives for this surgery. One is to cure the atrial fibrillation. The second is to reduce stroke risk even if A-Fib does recur. If a patient goes three months in a normal rhythm after surgery, we can begin to wean them off their blood thinners because the most significant risk related to atrial fibrillation is gone.”

Dick Helton, senior political correspondent at KNX 1070 Newsradio, used to wonder how far he would be from medical help when his next episode of atrial fibrillation would strike. “It makes you think about everything you’re going to do and how far you’re willing to stretch the umbilical cord to the hospital,” said Helton, 63, who experienced his first episode 13 or 14 years ago. He was diagnosed with paroxysmal, or intermittent, atrial fibrillation, able to go days, weeks or months with a normal rhythm, but never knowing when an episode might start. Now he has been symptom-free for more than a year and is considered cured after undergoing the Mini-Maze procedure at Cedars-Sinai on Nov. 1, 2005.

Some patients, such as Chuck Blais, 60, of Manhattan Beach, Calif., rarely if ever have a normal rhythm. He experienced intermittent AF in the mid- and late-1990s but the condition became progressively worse and once-effective medications were no longer able to control it. The avid bowler and contemporary Christian songwriter was unable to climb even a few stairs without becoming exhausted.

In 2005, Blais underwent a percutaneous ablation procedure in which a catheter is inserted into a vessel of the groin and guided to the heart. Radiofrequency energy is delivered to destroy the tissue triggering the abnormal electrical signals or to block the dysfunctional nerve pathways. The percutaneous ablation provided only temporary relief and Blais was referred to Fontana, who performed the Wolf Mini-Maze procedure on Dec. 12, 2006. Now, after years of unremitting symptoms that sapped his energy and restricted his life, Blais is beginning to dream again, thanks to the minimally invasive surgery.

“We can do the whole Mini-Maze procedure in about an hour-and-a-half,” Fontana said. “Patients are in the hospital for a day or two or three, and we’ve had some patients back swinging a golf club within a couple of weeks.”

It took Nancy Chester, an avid golfer from Newport Beach, a bit longer to get back on the golf course because she was also battling back problems while recuperating from her Sept. 26, 2006 Mini-Maze operation. Chester, who “can still hit the ball really well,” celebrates her 71st birthday on June 25, 2007. She and her husband retired about three years ago after owning and managing office buildings and executive suites.

Diagnosed with intermittent atrial fibrillation 20 years ago, Chester tried numerous medications but found them either minimally effective or causing unpleasant side effects. She eventually stopped taking drugs and practiced biofeedback to relax and wait out the episodes. In the last four or five years she would experience atrial fibrillation for about 36 hours before returning to a normal rhythm for about 24, and she was constantly fatigued.

The Mini-Maze surgery cured the condition. “It’s like a new life. My quality of life was getting so poor, this was like a miracle surgery,” she said. Now she can play 18 holes of golf without having to rest, but the first thing she did was clean the attic and garage.

“They were things I’d wanted to do for a long time,” she said. “Just being able to do it was the great part – having the energy to do it.”