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 Thoracoscopic Maze Procedure

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The Ohio State University is one of only a few institutions nationwide where maze surgery is performed using a truly minimally invasive, totally thoracoscopic maze procedure that achieves cure rates equivalent to the original Cox maze procedure developed in 1990s. Dr. John H. Sirak is a recognized innovator in this technique of replicating a complete procedure for atrial fibrillation (also known as afib or AF) that is approached through a few pencil-sized incisions in the chest. Atrial fibrillation is an abnormal heart rhythm that occurs in the upper chambers of the heart (the atria).

Approximately four million people in the United States have AF. Common symptoms include palpitations, fatigue and shortness of breath, although a significant number of patients are asymptomatic. AF is associated with an increased incidence of heart failure, and with an increased risk of stroke.

The thoracoscopic maze is the most advanced procedure for atrial fibrillation available today. Due to the procedure’s unique access to the heart, all areas responsible for atrial fibrillation (abnormal heart rhythm) are isolated into close, but separate compartments, or “boxes.” The surgery is sometimes called the Five Box Thoracoscopic Maze procedure.

What Is a Maze Procedure?

The maze procedure is a surgical treatment for atrial fibrillation. The original Cox maze procedure, developed in 1992, used an open-chest, non-beating heart approach. Multiple incisions were made in the atria in order to create electrically isolated corridors, thereby isolating atrial fibrillation from the heart and allowing normal conduction of the heart beat. Although a technically complex and invasive procedure, the Cox maze produced a published cure rate of 95%, even for persistent AF.

The five-box thoracoscopic maze, similar to the Cox maze, uses pencil-size port incisions (cuts) in the chest and is performed with a beating heart. Instead of incisions in the heart, bipolar electrical energy sources create full-thickness ablations (removal of tissue) in the atrial muscle to isolate the areas that cause atrial fibrillation.

The thoracoscopic approach gives a clear view of the heart, enabling unmatched precision without X-rays. Moreover, all ablations are thoroughly tested in real time, resulting in a complete procedure for every patient.

Why Choose Ohio State for the Thoracoscopic Maze?

Dr. Sirak is a leader in advancing the five-box thoracoscopic approach, with multiple key innovations developed first at The Ohio State University. These innovative approaches produce superior results for patients, including those with advanced atrial fibrillation.

The Ohio State University Ross Heart Hospital offers the region's only fully dedicated cardiovascular patient facility. The nursing staff is highly experienced in the care of all cardiac surgical patients.

All patients stay in spacious, state-of-the-art, private rooms which focus on each individual patient. Rather than transferring between nursing units midway through their hospitalization, patients stay in the same private room until discharged. This minimizes any inconvenience to patients and their families.

Why Would You Have a Maze Procedure?

The thoracoscopic maze is appropriate for a wide range of patients with early or advanced atrial fibrillation. Only individuals who have undergone a previous open chest procedure—either lung or heart—are excluded from candidacy for the operation, due to the scar tissue that forms as a result.

What to Expect During Your Thoracoscopic Maze Procedure

Preparing for Your Procedure

Prior to your maze procedure, you’ll meet with your doctor to discuss your medical history, the medicines you take and any questions you have about the procedure.

Once you have been scheduled for the procedure, you undergo several non-invasive tests including:

  • Chest X-ray – A radiograph or picture of the heart and lungs including blood vessels, ribs and bones of the spine.
  • Echocardiogram (also called echo) – This test uses sound waves to assess the function and structure of the heart muscle and valves.
  • Nuclear stress test – A scan that measures the blood flow to the heart muscle during rest and during activity or stress to determine if areas of the heart muscle have low blood flow or are damaged.

During Your Procedure

You are asleep and lying on your back for the procedure. Four tiny incisions are made on each side of the chest. The pericardium, or fibrous sac enclosing the heart, is opened. The thoracoscope provides clear, magnified visualization for precise identification of all key anatomy. The patient is not exposed to X-ray radiation.

Bipolar electrical energy creates controlled “burns” in the atrial (upper chamber) of the heart. It creates barriers around the tissue areas responsible for AF. The advantage of bipolar is that it heats the tissue between two electrodes. This is an important distinction from other procedures that generate heat at the point of contact with the tissue.

Electrical isolation is confirmed within each box and ablations are repeated until the five compartments are created and confirmed.

The small incisions used in the operation result in limited discomfort, which typically goes away by the second postoperative day. The thoracosopic maze takes about 3-1/2 hours to complete.

After Your Procedure

After surgery, you are cared for in one of the beautiful, state-of-the-art, private rooms in the Richard M. Ross Heart Hospital. Depending on your recovery, you will stay in the hospital for one to two days. Each room is comfortably arranged to include a pull-out sofa and private bathroom so that your loved ones can stay with you. We value and embrace family participation in every aspect of your care. Upon discharge from the hospital, you will have no activity restrictions. However, it is recommended you do not drive for two to three days after discharge to ensure the anesthesia is completely worn off. Provided you are feeling well, you should be able to return to work in approximately seven days.

At discharge, you schedule an appointment in the outpatient clinic one month after surgery. You can expect to receive a remote heart monitor at three-, six-, 13-, and 24-month intervals after surgery to assess your rhythm status.


Dr. Sirak began the thoracoscopic maze program at Ohio State University in 2006 and has treated more than 250 patients. He published the first paper on a totally thoracoscopic maze operation in the December, 2008 issue of the Annals of Thoracic Surgery.

The thoracoscopic maze was developed in December 2008. In a new paper accepted for publication in the Annals of Thoracic Surgery, the cure rate was 95% among all persistent AF patients, again off all anti-arrhythmia drugs. Moreover, one patient merely had a brief AF episode during the three-month monitoring session, but remained in normal rhythm at the six- and 13-month monitoring sessions. The other patient was mapped and treated for a right atrial flutter, which is a lesion that is not part of the operation.

Patient's Story

Read about how the total thoracoscopic maze procedure has helped change a patient's life.

Patient Resources

The Ohio State University Wexner Medical Center has put together several information resources for people who want to learn more about atrial fibrillation in general and the treatment options available at Ohio State:

Atrial Fibrillation Fact Sheet

New Patient Brochure