Maze Procedure: Everything You Need to Know

Updated on 2024-01-21 15:07:39 0 0

By Mark Gurarie

Medically reviewed by Anisha Shah, MD

Maze procedure (also known as the “Cox Maze procedure”) is a surgery that takes on atrial fibrillation (AFib), which is the clinical term for rapid and irregular heartbeat. While AFib itself isn’t life-threatening, it greatly increases the chance of stroke and can cause congestive heart failure (CHF), while also leading to other symptoms.

Traditionally an open-heart procedure, nowadays minimally-invasive options are also available. In either case, this is a major surgery, and undergoing it requires a good deal of preparation, planning, and recovery. If you’re considering Maze procedure, it’s essential to know what you can expect.

This procedure is an option for people who don't respond well to nonsurgical therapies. It can also be performed alongside other heart surgeries, such as heart bypass surgery (coronary artery bypass graft).1

What Is Maze Procedure?

AFib arises when the upper chambers of the heart (called the atria) start sending out disorganized electrical signals, leading to an irregular heartbeat.2 Essentially, it’s a kind of “short-circuiting” of the heart.

The aim of the Maze procedure is to change the electrical patterns by intentionally causing scarring on the surface of the atria to direct the signals. In some cases, healthcare providers may also reshape or remove the left atrial appendage, a flap of tissue in the left atrium, to prevent blood clots.3 This is an inpatient procedure that requires significant recovery in the hospital.

Originally performed as an open-heart surgery—which relies on the use of a heart-lung bypass machine—nowadays, Maze procedure can also be performed using minimally-invasive techniques. These involve using specialized surgical cameras and multiple smaller incisions rather than one large one.4

Once the problematic area is identified, ablation and cryoablation techniques are most often used; the former relies on producing extreme heat to scar the surface of the atria, while the latter employs extreme cold. If this isn’t feasible, surgeons use a small scalpel to make a series of small cuts in the atria to create the necessary scarring.

Contraindications

As you’d expect with any surgery, there are some populations that may not be good candidates for Maze procedure. Contraindicators can include:5

History of heart surgery (heart bypass surgery, heart transplant, etc.)
History of lung surgery (cancer removal, lung transplant)
AFib symptoms for over 10 years
Left atrial diameter above 6.5 centimeters (cm)

Potential Risks

While the Maze procedure, especially when performed using ablation, is considered safe and effective, this surgery has some risks, including:14

Excessive bleeding
Infection at surgical site or incision(s)
Blood clots (increasing risk of stroke and heart attack)
Kidney failure
Development of other abnormal heart rhythms
Recurrence of AFib

Purpose of Maze Procedure

Maze procedure is primarily a treatment for AFib, a conditioned characterized by:2

Rapid, irregular heartbeat
Fluttering sensations in the chest
Fatigue
Dizziness
Shortness of breath
Weakness
Chest pain and pressure

However, as AFib often accompanies other heart issues, there are several diagnoses that call for this surgery, sometimes alongside others:5

Persistent AFib alone: AFib can vary in terms of severity, with many cases being asymptomatic. If symptoms are present and medications or other treatments for more persistent AFib don’t resolve it, the Maze procedure will be considered as a standalone treatment.
Heart valve diseases: AFib can also accompany problems with the mitral valve, aortic valve, or other valves that separate chambers of the heart. These potentially very dangerous conditions can lead to stenosis (a narrowing of the valve or artery) and blood regurgitation (in which blood may backup into the lungs). Maze procedure may often accompany surgery for these conditions.
Coronary artery disease (CAD): When arteries in the heart become narrowed or blocked, serious heart problems can result, up to and including heart attack and congestive heart failure. This, too, can lead to AFib, and Maze surgery may be employed alongside bypass surgery, stenting, or other approaches to CAD.

And what sorts of tests do you undergo to diagnose AFib and other heart issues? Here’s a quick breakdown:4

Physical and consultation: You’ll talk to the practitioner about your symptoms and undergo an assessment of baseline health signs.
Chest X-ray: This common imaging approach lets healthcare providers assess the heart.
Electrocardiogram (EKG): This non-invasive test assesses heart rhythm and health by
measuring electrical activity.
Stress test: Accompanying EKG are tests of breathing, heart rate, blood pressure, and other measures while you’re undergoing different levels of physical activity.6
Holter monitoring: This is essentially a monitor of heart electrical patterns for a 24- to 48-hour period. Patients wear patches connected to a small portable recorder while performing their normal, daily activities.
Lab work: A panel of blood and urine tests will also be assessed.

Some patients may require additional testing per the healthcare provider’s discretion.

How to Prepare

For the patient, preparation for Maze procedure means understanding what will be expected beforehand, as well as the logistics of planning for a hospital stay. Given the scope of this surgery, this pre-operative preparation is essential to success. The more ready you and your family are, the better off you’ll be.

Location

As noted, whether performed laparoscopically or as an open-heart procedure, Maze procedure takes place in the operating room (OR) of a hospital. There, you’ll find a great deal of equipment, including:7

Magnetic resonance imaging (MRI): Imaging using this approach, which relies on radiowaves and magnetic fields to produce two or three-dimensional imagery, will be necessary to guide the surgery.
Angiography: This is an essential a form of X-ray imaging that screens blood flow in the heart.
Monitors: As this surgery is performed while you’re on general anesthesia, you will be connected to monitors of important vital signs.
Heart-lung machine: The heart will need to be stopped for a portion of the surgery as healthcare providers perform treatment, so you’ll be connected to a heart-lung machine that breathes and circulates blood for you.
Standard equipment: The standard operating room needs to be very well lit, so lights are a prominent feature. You’ll be placed on an adjustable operating table, and you’ll see tables of surgical instruments.
Endoscope/laparoscope: When minimally-invasive procedures are used, these adjustable surgical tubes with cameras at the end are guided to the affected area. This provides real-time video of the area to help the surgery team in their work.

What to Wear

When you go to the hospital for Maze procedure, you should dress with practicality and comfort in mind. Keep in mind that you’ll be wearing a hospital gown during the procedure and recovery. Here’s what you
should keep in mind as you get ready:8

Sweatpants or shorts
Loose-fitting shirt
Slippers or easy to slip on shoes
Post-surgery bra (with front or shoulder Velcro tabs or hooks)
A robe
Comfortable clothes for the ride home

Food and Drink

In the run-up to surgery, you’ll also need to be mindful about what you’re eating and drinking. Alongside broader dietary changes that may be recommended to boost overall health, you’ll also need to steer clear of all food and drink after midnight the night before Maze procedure.1

You can take medications (as directed) with small sips of water. The presence of food or liquid in the digestive system increases the risk of general anesthesia complications.

Medications

In consultations prior to this surgery, it will be important for you and your healthcare provider to talk about medications that you’re taking, as well as those you’ll need to take. In some cases, you may be prescribed:

Anticoagulant drugs (blood thinners): Medications that thin the blood, such as Coumadin (warfarin), Eliquis (apixaban), or heparin, among others, may be prescribed for you to take in the three weeks leading up to surgery.6 This reduces the risk of blood clots; however, you’ll be asked to stop taking them 48 to 72 hours before the procedure.
Chlorhexidine (CHG) soap: Your healthcare provider may also recommend that you use a special, antiseptic soap to wash before the procedure. This will help prevent infection of any incision sites, and it's available over-the-counter at most drug stores or pharmacies.1

In addition, your practitioner may also ask you to modify your dosage or stop taking altogether certain medications for two to three days before surgery. Let them know if you’re taking:1

Non-steroidal anti-inflammatory drugs (NSAIDs): Over-the-counter painkillers like Advil (ibuprofen) and Aleve (naproxen) can increase the risk of excessive bleeding. This also includes some prescription medications, such as the arthritis drugs meclofenamate and etodolac, among others.
Diabetes medications: Your practitioner may need to adjust dosages of medications you’re taking for type 2 diabetes, such as Glucotrol XL (glipizide), nateglinide, and repaglinide, among others.
Herbs and supplements: Some vitamins and herbal products should also be avoided, including garlic, ginger, and feverfew pills or powders, as well as fish oil, cod liver oil, and vitamin E tablets, as well as a number of others.

Make sure to tell your healthcare provider exactly what prescribed or over-the-counter drugs you’re taking, as well as any other supplements that are part of your regimen.

What to Bring

Regardless of whether you have an open-heart or minimally-invasive Maze procedure, you’ll have to plan for a hospital stay. In the former case, patients typically need five to seven days of recovery in the hospital, though if you have the latter, you may need less time.6 What should you bring along? Here’s a quick packing list:8

Insurance card
Government-issued ID
Health proxy information (authorizing a loved one to
make medical decisions)
Books, magazines, tablet, e-reader
Basic toiletries (toothbrush, toothpaste, etc.)
An extra pillow
List of medications and supplements you’re taking
List of any allergies or longstanding medical conditions you have
A notebook or journal (for note-taking)
Cell phone and charger

It’s also important to ensure that you’ve arranged for transportation back home from the procedure, as you won’t be able to drive for some time following surgery.

Pre-Op Lifestyle Changes

In preparation for Maze procedure, your healthcare provider may also encourage you to make some important lifestyle changes:9

Quit smoking: It’s absolutely essential that you quit smoking or using tobacco products before surgery due to the increased risk of post-operative complications. If you are a smoker, talk to your practitioner about tools that can help you stop the habit, something which will yield numerous other health benefits.
Exercise: Incorporating healthy habits, such as a regular fitness routine, will be essential after surgery, and, in some cases, healthcare providers will ask you to start working on this before the operation. In particular, obesity has been linked with higher risk and complication rates, so losing weight can also help. At the bare minimum, aim for daily walks, runs, bike rides, or swimming sessions.
Diet: Regulating diet before surgery can also help with weight reduction, while also helping manage related conditions, such as high blood pressure, high cholesterol, and others. You may be told to emphasize healthy proteins and fresh fruits and vegetables, while working to reduce salt
intake.
Beverages: Caffeine and alcohol can also worsen AFib symptoms, so you may need to steer clear of these as you get ready for surgery.

What to Expect on the Day of Surgery

Performed in the operating room (OR) of a hospital, Maze procedure is a significant procedure that’s often paired with other surgeries. Understanding what happens on that crucial day is important, so don’t hesitate to ask your healthcare provider questions and express any concerns you have about your treatment.

Before the Surgery

After you come in for your treatment, the first stop fill be the pre-operative evaluation room. Here, practitioners and/or staff will perform several important tests and provide consultation:10

Physical: The first step will be to perform a standard evaluation of important measures, such as heart rate, blood pressure, body temperature, and others. At this point, you’ll also be asked about allergies, medications you’re taking, as well as any other health issues.
X-ray: On the day of surgery, you may need to have an X-ray performed as well; this will serve as a reference for the surgeons.
Blood tests: Lab work of blood samples will also be performed the day of surgery, so samples will need to be collected.
EKG: If not performed recently, you may have to undergo a final EKG evaluation.
Exercise test: The healthcare provider may ask you to perform physical activities, while your heart activity is monitored. If this indicates ischemia (insufficient blood supply to the heart muscles), an angioplasty
procedure will be performed alongside surgery.
Consultation with anesthesiologist: You’ll meet with the anesthesiologist, who will determine the appropriate and safe dosage for you. You may be connected to a catheter delivering the medication in the pre-op room or upon arriving in the operating room.

As you’re undergoing testing and evaluation prior to surgery, make sure to voice any questions or concerns you have about what’s happening.

During the Surgery

The Maze procedure itself takes about an hour; however, when preparation and initial recovery are factored in, you can expect to be in the operating room for three to four hours.4 Who’s in the room with you, and who performs the work? Here’s what your medical team will look like:11

Cardiac surgeon: Work will be lead by a surgeon specializing in cardiac care, who will be focused on making precise incisions, and working carefully to perform the procedure itself.
Anesthesiologist: As noted, an anesthesiologist will also be present to ensure you’re getting the correct amounts of general anesthesia and track your progress.
Perfusionist: This is the specialist that operates the heart-lung machine that breathes and moves blood for you while your heart is temporarily stopped. Not every Maze procedureapproach requires bypass.
OR nurses and technicians: Specially trained nurses and technicians will also be working alongside the surgeon, anesthesiologist, and other professionals. They’ll also be in charge of monitoring your progress.
ICU nurses: As you recover in the intensive care unit (ICU), registered nurses who focus on care during recovery from surgery will be checking on your progress.
Physical therapists/rehab nurses: In some cases, you’ll need to work with a physical therapist or rehab nurse to build up strength as you recover in the hospital.

There are both open and minimally-invasive approaches to Maze procedure. With improvements in technology, the latter are gaining in popularity as they require less in the way of overall recovery time (two to four days in hospital versus about a week).6 That said, these techniques fundamentally work the same way, and the primary difference has to do with how healthcare providers go about accessing the heart.

The open-heart approach, referred to as traditional Maze procedure, can be broken into several steps:4

Staging: Once you’re taken to the operating and are put to sleep using general anesthesia, the medical team will mark out the site of incision: right in the middle of the chest.
Incision: In open surgery, once the incision is made, the ribs are separated, to allow healthcare provider access to the heart.
Bypass: You’ll be placed on a heart-lung machine, which served the function of breathing and moving blood for you while your heart is being operated upon.
Cardiac arrest: Once you’re connected to the heart-lung machine, your heart will be temporarily stopped.
Scarring/ablation: Using either a scalpel or ablation techniques (extreme heat or cold), the surgeon will then target the affected area to scar it. Essentially, the scarring creates a maze-like impression (hence the name) on the upper left atrium that prevents erratic electrical signals.
Additional procedures: When Maze procedure is performed alongside other heart surgeries, such as coronary artery bypass graft (CABG), these will be performed. Surgeons also will remove or exclude the atrial flap, to reduce the risk of stroke.
Finishing up: The final step of surgery involves restarting the heart, getting you off of the heart-lung machine, repositioning the ribs and other structures, and then suturing or stapling everything shut.

Among the popular minimally-invasive approaches is the “mini-Maze procedure.” Instead of opening up the chest, healthcare providers use several smaller incisions to run laparoscopes and endoscopes (adjustable surgical tubes with cameras at the end), to access the area and guide the work. Scars are created the same way, by using ablation or surgical tools.3 Medical professionals will determine which approach is better for your case.

After the Surgery

All told, following Maze procedure, you should expect a five-to-seven-day stay in the hospital. After the operation, you’ll wake up in the intensive care unit (ICU), where you’ll recover for up to two days (sometimes more). This is a critical period, so what can you expect? Here’s a rundown:6

Breathing assistance: When you come to after surgery, you’ll be connected to breathing tubes as well as a ventilator. About six hours after the procedure, the medical team will take these out.
Careful monitoring: You’ll be connected to several machines that will monitor your progress continually, including a heart monitor, as well as machine evaluating blood pressure, body temperature, and other vitals. In addition, daily X-rays are taken while you’re in ICU.
Fluids and nutrition: While in ICU, you’ll receive necessary fluids and nutrients via IV.
Pain management: To help with pain following surgery, you’ll also be connected via IV to medication that you can deliver yourself. You’ll get training on how to use it, with the goal of getting to a point where pain can be managed orally.
Catheters and IVs: While in ICU, you’ll also have a tube in the chest for drainage, as well as urinary catheter to drain the bladder. The former of these will be regularly assessed to ensure there’s no blockage.

If there are no complications, by the second or third day, you should become eligible to transfer to your hospital room. It’s at this point that most catheters and IVs are taken out. In the hospital room, you’ll stay for two to three more days, until you’re ready to go home. Once out of ICU, here’s what you can expect:6

Activity: In order to prevent blood clots, you’ll be asked to stand up and walk around (with assistance) periodically during recovery, and this should be a priority once you’re out of the ICU. If you’re having trouble, be sure to seek out help from hospital staff.
Eating solid foods: Once your breathing tube is removed and it is assured that swallowing is intact and functional, you'll be able to resume eating solid foods.
Breathing exercises: When you’re no longer receiving breathing assistance and the chest catheter is removed, a physical therapist will need to work with you to strengthen your lungs and prevent fluid buildup.
Health/nutrition counseling: Many patients also receive counseling about dietary and lifestyle changes they can make to boost their heart health.

Once your condition is stable, you can manage any post-operative pain with oral medications, and move independently or with minimal assistance, you’ll be ready to go home.

Recovery

Given the scale and scope of Maze procedure, it’s little wonder that recovery at home is extensive. All told, complete recovery is expected to take six months, though most return to normal activities much sooner.12

Initial follow-up: You’ll be asked to come back into the hospital seven to 10 days following your discharge. At this point, your heart will be monitored and your incisions checked to make sure everything is healing well. At this point, any staples and sutures used to close you up will be removed.
Medications: In some cases, some AFib symptoms continue during recovery as a result of inflammation in the heart. As such, your healthcare provider may place you on medications, such as beta blockers, anticoagulants, calcium channel blockers, or antiarrhythmics.
Appointment with cardiologist: At four to six weeks, you’ll have a second follow-up, at which point a cardiologist will check your heart rhythm to ensure you’re not still experiencing AFib symptoms. In addition, practitioners will make sure the scarring on the heart as well as incisions are healing properly.
EKG appointments: You’ll also need to come in for EKG evaluation at three, six, and 12 months after the procedure, and once annually after that. These monitor long-term health of the heart.
Cardiac rehabilitation: Enrolling in a cardiac rehabilitation program after open-heart surgery can have many positive effects and is generally recommended.

In terms of the timeline of recovery, while there will always be some variation. Here’s when you can expect to return to normal activities:6

Driving: You can get behind the wheel only after receiving your healthcare provider’s approval. Typically, it’ll be four to six weeks before you can drive again.
Sexual activities: Medical professionals recommend you wait three to four weeks before taking part in any sort of sexual activities.
Heavy impact/lifting: You must avoid lifting anything heavier than 20 pounds or engaging in contact sports until your sternum has healed. This typically takes six to eight weeks. Light exercise, such as walking, will be encouraged throughout recovery.
Return to office work: Those that work in offices or more sedentary jobs are usually able to return to work within four to six weeks.
Return to manual labor: If your work requires heavier lifting or more physical labor, you may need up to 12 weeks of recovery before you return.

During recovery, it’s also essential to keep an eye out for signs of complications or other issues.

If you notice any of the following, call your healthcare provider:12

AFib symptoms returning (rapid, fluttering heart rate, palpitations)
High fever or chills
Cough or breathing problems Redness, swelling, or discharge from incision(s)
Persistent nausea and/or vomiting
Uncontrollable pain (despite medications)
Headache
Inability to urinate
Pain or burning while urinating
Pain and swelling in the legs

When to Call 911

Be sure to call 911 if you experience:12

Sudden chest pains
Sudden shortness of breath
Visual disturbances
Problems speaking
Numbness or weakness on one side of the body

Healing

Ensuring that the heart recovers properly is only part of the story; critical to a successful outcome is ensuring that incisions heal properly. Complete healing takes one to two months, and there may be soreness around your incisions, as well as itchiness, tightness, and numbness there. Your healthcare provider will give you specific guidelines for incision care, but here’s a quick rundown:13

Clean and dry: Keep incisions clean and dry, and let your practitioner know if there is any discharge. If there is none, it’s OK to let bandages and dressing come off on their own, and don’t try to reattach. Don’t use creams, lotions, or salves.
Showering: If your incision or incisions are healing and there is no discharge, you’re encouraged to take quick daily showers (no more than 10 minutes). If you have stitches in your chest, for the first two weeks at home, stand facing away from the showerhead. Make sure the water is not too hot or too cold.
Bathing: If you have the option to shower rather than take bath, you’re better off. That said, baths in warm water are OK, so long as you avoid soaking in the tub for more than 10 minutes.
Soap and water: Wash incisions using only unscented bar soap (not body wash), water, and a washcloth. Use a gentle, up-and-down motion, and pat the area to dry. Don’t use lotions, creams, salves, or any other products on these affected areas.

Coping With Recovery

Given the extended duration of recovery after Maze procedure—not to mention the many ways this treatment can impact your life—it’s no wonder post-surgery mental health challenges often occur. According to the American Heart Association, about 25% of patients experience clinical depression following heart surgery. They have some tips for what you can do to take on this issue:14

Develop a regular routine: As you recover, creating a schedule for yourself can be a good way to add a sense of structure during a chaotic time. This means planning regular exercise, mealtimes, and bedtimes, all of which have been linked with better mental health outcomes.
Be realistic about expectations: Educate yourself about Maze procedure and talk to your healthcare provider about the kinds of outcomes you can expect. Try not to fixate on the challenges and struggles, and make it a point to celebrate the milestones of recovery.
Seek help from family and friends: Don’t hesitate to reach out to loved ones or family members for support as you recover. Ultimately, the path towards good health is one you’re better off not taking alone.
Consider counseling: Your hospital may have programs devoted specifically to helping with post-cardiac surgery patients; ask your healthcare provider if this is the case. It’s also worth looking into post-surgery counseling with a therapist, group therapy sessions, or even online forums and social media groups.

Possible Future Surgeries

Though highly effective in resolving AFib, there’s still a chance of recurrence of the condition following Maze procedure. While it’s not unusual for some symptoms to persist in the first three months following surgery, these are treatable and should resolve as the heart heals.6

However, in cases where surgery hasn’t succeeded or other heart problems have emerged, other procedures are necessary. These include:9

Catheter ablation: This treatment relies on the types of ablation techniques that are employed in Maze procedure; however, instead of surgery, healthcare providers insert an adjustable catheter into a major vein and run it to the heart.
Pacemaker: In some cases, practitioners will employ catheter ablation to stop the function of the atrioventricular node, which influences heart activity. In its stead, they insert a pacemaker, which is a device that uses electricity to regulate heart rhythm.

Lifestyle Adjustments

Successful recovery from Maze procedure can also be promoted by making several significant lifestyle changes, including:6

Smoking cessation will go a long way into promoting a healthier heart, among other benefits.
Reducing alcohol consumption is also a good way to prevent AFib symptoms from returning.
Avoiding caffeine as coffee or other such drinks can lead to irregular heartbeat.
Steering clear of stimulant-heavy medications, such as daytime cold/flu medicine, or anything with ephedrine.
Weight loss/maintaining a healthy weight can be helpful in reducing the stress placed on your heart.
Adopting a regular fitness regimen can be instrumental in promoting better heart health.
Emphasizing a balanced diet that features vegetables and fruits, healthy fiber, and healthy proteins, while steering clear of salts and sugars.

14 Sources

Boston University School of Medicine. Maze procedure patient information.

American Heart Association. What is atrial fibrillation (Fib or AF)?.

Cleveland Clinic. Heart surgery for atrial fibrillation (MAZE).

Johns Hopkins Medicine. Atrial fibrillation surgery.

Harky A, Bithas C, Shi Kai Chan J, Snosi M, Pousios D, D Muir A. Surgical treatment of atrial fibrillation: cutting through the edges. Braz J Cardiovasc Surg. 35(3). doi:10.21470/1678-9741-2019-0057

Costello A. Maze procedure for atrial fibrillation: recovery, test, blood, tube, pain, complications, time, infection. Surgery Encyclopedia.

Pearson M. Hybrid operating room basics. Facilities Guidelines Institute.

American Heart Association. Make your winning post-surgery recovery plan.

Department of Surgery. Atrial fibrillation. University of California San Francisco.

van Laar C, Geuzebroek GS, Hofman FN, Van Putte BP. The totally thoracoscopic left atrial maze procedure for the treatment of atrial fibrillation. Multimed Man Cardiothorac Surg. 2016:mmv043. doi:10.1093/mmcts/mmv043

The Society for Cardiovascular Angiography and Interventions. Your care team during coronary bypass surgery. Seconds Count.

State University of New York Upstate Medical University. Maze procedure: Cardiac surgery.

Cleveland Clinic. Incision care.

American Heart Association. Post surgery milestones: managing your mood, expectations and goals.