What Is a Maze Procedure?

The Maze procedure is a type of heart surgery that treats atrial fibrillation (AFib)—a common type of arrhythmia (irregular heartbeat) that causes your heart to beat irregularly and sometimes more rapidly than normal. Also known as the Cox-Maze procedure, this surgery involves creating a maze-like pattern of scar tissue in the atria (upper heart chambers) to restore your normal heart rhythm.

There are several techniques a cardiothoracic surgeon (or, a doctor specializing in surgeries of the heart and other organs in the chest) may perform to carry out a Maze procedure, including open-heart surgery or minimally invasive techniques. The specific technique that your surgeon uses will depend on the severity of your atrial fibrillation symptoms and whether you have another heart condition that requires surgical treatment. 

For most people, the Maze procedure is considered a safe and highly effective treatment for AFIb. Between 90% and 95% of people who undergo the surgery stop having symptoms of AFib within one year after the procedure.

Purpose 

The primary purpose of the Maze procedure is to restore normal heart rhythm in people with atrial fibrillation. The surgery also helps lower the risk of complications associated with uncontrolled AFib, such as blood clots, stroke, dementia, and heart failure.

Generally, healthcare providers recommend the Maze procedure when other treatments, such as catheter ablation or medication, have been ineffective. Surgeons sometimes perform the Maze procedure as a standalone surgery. But in other cases, they may perform the Maze procedure when you are having open heart surgery to treat another heart condition, such as coronary artery disease or valve disease.

Types of Maze Procedures

There are different surgical approaches for performing a Maze procedure. The type of procedure your surgeon recommends depends on several factors, including whether you have another heart condition requiring surgical treatment, your overall health, and the provider's expertise and experience with each technique.

Cox-Maze III

The Cox-Maze III procedure involves a surgeon making an incision (or, cut) in your chest to access the heart (open-heart surgery). The surgeon then uses surgical tools to create a specific pattern of incisions in the heart's upper chambers (known as the atria) and closes the incisions with sutures (stitches). When the incisions heal, scar tissue blocks abnormal electrical signals from the heart, which restore normal heart rhythm.

Cox-Maze IV

Surgeons use energy sources such as radiofrequency or cryotherapy (a type of freezing technique) to ablate (or, destroy) the small pieces of heart tissue that are causing AFib during a Cox-Maze IV procedure. The ablation leads to maze-like scarring on the heart that blocks abnormal electrical heart signals and restores your normal heart rhythm. 

Your surgeon may perform the Cox-Maze IV procedure in one of two ways:

• Open heart surgery: Your surgeon makes a cut in your chest to access your heart.
• Minimally invasive procedure: Known as the "mini-maze" procedure, this allows your surgeon to make three to four small incisions on each side of your chest to access your heart. Your surgeon will insert tools, including a video camera and ablation devices, through these small incisions to reach the heart without opening up your chest fully.

How Does It Work? 

Undergoing surgery, even minimally invasive procedures, may make you feel anxious. Understanding what happens before, during, and after a Maze procedure can help you feel prepared and ready for the procedure and healing process. 

Before the Procedure

Before the Maze procedure, you will undergo a comprehensive evaluation to assess your health and ensure you are a good candidate for the surgery. This involves a physical examination and certain tests, such as:

• Blood tests
• Chest X-ray
• Computed tomography (CT) scan
• Stress test
• Electrocardiogram (ECG)

If your test results indicate that you are a good candidate, you will meet with your surgeon to discuss the procedure and its potential risks and benefits. This is a good opportunity to ask questions and ensure you have the information you need to make an informed decision. At this appointment, your surgeon will give instructions regarding any dietary or activity restrictions and whether you need to stop taking any medications (e.g., blood thinners) in the days leading up to the procedure. 

During the Procedure

The process for the Maze procedure differs depending on whether you are having open-heart surgery or a minimally invasive procedure. 

Open-Heart Maze Procedure 

An open-heart procedure involves your surgeon making a 6 to 8-inch incision in your chest and opening your rib cage to access your heart. You will be under general anesthesia for this procedure and will not feel any pain while you are sleeping. During the surgery, a heart-lung bypass machine will keep blood flowing away from your heart and throughout the rest of your body so your surgeon can see your heart clearly to perform the procedure.

Using surgical tools or an energy source (e.g., a radiofrequency device), the surgeon will destroy a small amount of heart tissue in the upper chambers of your heart and pulmonary veins to create scar tissue in a "maze-like" pattern. This action blocks abnormal electrical impulses from your heart to promote a normal heart rhythm.

Once your surgeon has completed the maze, they will remove the heart-lung bypass machine, and your heart will begin beating on its own, restoring blood flow to your heart and the rest of your body.

Mini Maze Procedure 

A mini maze procedure is minimally invasive and takes between 2 to 4 hours to complete. During this procedure, you will be under anesthesia (asleep).

To perform a mini maze, your surgeon will make several small incisions on the side of your chest between the ribs. They will insert a thoracoscope (a thin tube that has a light and video camera attached to it), which allows your surgeon to see your heart and inside your chest. They will create the "maze" pattern using radiofrequency energy or cryotherapy to destroy abnormal heart cells. Once the maze is complete, your surgeon will close the incisions with stitches.

After the Procedure

Once the procedure is complete, you will be in the hospital intensive care unit (ICU), where healthcare providers can closely monitor your blood pressure, heart rate, and other vital signs for a day or longer.

Depending on whether your Maze procedure was open-heart or minimally invasive, you may either go home or stay in another part of the hospital (outside of the ICU) to continue your recovery for another few days to a week or longer. During your hospital stay, you may receive extra oxygen through a face mask and pain medication to manage pain on and around your incision(s).

Before you go home, your healthcare provider will give you instructions on how to care for your incision(s), signs of infection or other complications to watch for, and how to manage medications they prescribe, such as blood thinners to prevent blood clots or diuretics (water pills) to control swelling.

Recovery times for this procedure vary, depending on the exact surgery you underwent. Open-heart surgeries typically require 6 to 8 weeks for full recovery. But mini-maze procedure recovery times are generally shorter.

Some people continue to experience atrial fibrillation symptoms for a few weeks or months after a Maze procedure. This is normal and sometimes develops due to inflammation or swelling around your heart. When this occurs, your healthcare provider may prescribe antiarrhythmic drugs to control your heartbeat.

Risks and Precautions 

The Maze procedure is considered a safe and effective treatment for atrial fibrillation. Like any surgery, it carries some risks, such as:

• Bleeding and blood loss
• Blood clots
• Infection at the incision site
• Breathing problems 
• Arrhythmia (irregular heartbeat) 
• Edema (swelling)
• Pneumonia
• Kidney failure
• Memory loss or trouble concentrating
• Stroke 
  

The risks of a mini maze procedure include: 

• Pneumothorax (collapsed lung) 
• Blood loss or heavy bleeding
• Pericardial effusion (fluid build-up in the chest) 
• Pericarditis (inflammation of the heart) 
• Stroke 

In some cases, the Maze procedure can damage the heart's natural pacemaker (known as your sinus node), which may require the implantation of an artificial pacemaker to regulate the heart's rhythm.

How to Prepare for a Maze Procedure

Being well-prepared for a Maze procedure can help reduce any anxiety you have about your upcoming surgery and ensure your procedure and recovery go as smoothly as possible.

Before Surgery

It can be helpful to prepare your home so everything is easily accessible and ready for your arrival after you are discharged from the hospital. This may include:

• Preparing meals and freezing them so you can defrost and microwave food later
• Setting up a bed on the first floor of your home so you don't have to climb stairs 
• Asking a friend or family member to stay with you for a week or two following the procedure to help take care of your home, run errands, and take you to follow-up appointments
• Having items you need within reach (e.g., water bottle, phone, medications, comfort items) 

Since part of your recovery will take place in the hospital, you may want to pack a hospital bag with items you may need during your stay, including:

• Cell phone and charger
• Notebook for taking notes during conversations with healthcare providers 
• Extra pillow
• Books, an e-reader, a tablet, or magazines to keep yourself entertained

The cost of a Maze procedure varies depending on your insurance coverage and the type of Maze procedure you will be receiving. Call your health insurance provider before the procedure to discuss your coverage and estimated out-of-pocket costs. Even with insurance coverage, out-of-pocket expenses may be financially challenging. Many states offer financial assistance programs that may help cover the cost of your procedure, medications, and recovery care.

On the Day of Surgery

Your healthcare provider will ask you to avoid food and drinks for approximately 12 hours before the procedure or after midnight on the day of your procedure. Bring your insurance card, photo identification, prescription medications, and any other paperwork your healthcare provider or the hospital requested. Once you check in, the hospital will put an ID bracelet on your wrist and ask you to change into a hospital gown and slippers and remove all jewelry.

You can ask a family member or friend to support you at the hospital. Depending on the hospital's policy, your support person should be able to stay with you until you go back for surgery and see you after the procedure once you are in recovery. 

Results 

The Maze procedure is highly effective, and some people may experience almost immediate improvements in their symptoms. For others, the surgery still works but may take a few more months to get the expected results.

Your healthcare provider will monitor your progress to determine the effectiveness of the procedure, which typically involves: 

• Electrocardiogram (ECG): You will undergo an ECG test at three, six, and 12 months post-procedure to measure the electrical activity of your heart and ensure the procedure is successful.
• Holter monitor: You may need to wear a Holter monitor—a device that measures your heart rhythm for 24 to 48 hours at a time. This allows your healthcare provider to measure your heart rhythm patterns over a longer period than an ECG. 

Although the Maze procedure effectively restores normal heart rhythm in most cases, some people may experience a recurrence of AFib episodes a year after the procedure. If AFib recurs, your healthcare provider will discuss other treatment options. 

A Quick Review 

The Maze procedure is an effective, safe treatment option for atrial fibrillation (AFib). The procedure restores normal heart rhythm by creating a "maze" of scar tissue on the heart's upper chambers, which blocks the electrical signals from abnormal heart cells that cause AFib. 

Your healthcare provider may recommend a Maze procedure if other treatments, like medication, do not effectively control your AFib symptoms. The procedure may be an open-heart surgery that requires a 6 to 8-week recovery period or a minimally invasive (mini-maze) procedure with shorter recovery times. Your exact surgery plan will depend on whether you have another heart condition, your overall health, and your surgeon's experience.