Atrial fibrillation, or AF, can be frustrating to live with and challenging to treat. Medication can help control symptoms or catheter ablation may reduce episodes and improve rhythm control, but when AF persists after these treatments, surgery may be recommended.
The TT-Maze procedure is a minimally invasive surgical option for patients with persistent or long-standing atrial fibrillation. It is usually considered when AF has not responded well to medication, cardioversion or catheter ablation, or when a patient has been advised that AV node ablation and a permanent pacemaker may be the next option.
For patients in this position, a surgical review can help make sense of why the AF is continuing, what has already been tried and if surgical treatment may be suitable for you.
If you have ongoing AF after medication or ablation, ask your GP or cardiologist about a referral to Dr Adrian Pick to discuss your treatment options.
What is the TT-Maze procedure?
TT-Maze stands for totally thoracoscopic maze, which means the procedure is performed using small keyhole incisions in the chest as opposed to a large chest incision in open surgery. The procedure is designed to interrupt the abnormal electrical circuits that allow atrial fibrillation to continue. This is done by creating carefully planned lines of scar tissue, known as lesion sets, around areas of the atria where there is abnormal rhythm activity.
Abnormal electrical signals generally start near the pulmonary veins – the blood vessels that carry oxygen-rich blood from the lungs back to the heart. Catheter ablation targets this area. In more complex AF, the rhythm disturbance could involve areas beyond the pulmonary veins.
The TT-Maze procedure treats a broader pattern of electrical activity linked to AF for patients with persistent AF, long-standing AF or AF that has returned after one or more catheter ablation procedures.
How is TT-Maze different to Catheter Ablation?
Catheter ablation is performed by an electrophysiologist using catheters passed through the blood vessels, usually from the groin, to reach the inside of the heart. It is used to isolate or deactivate the areas triggering abnormal rhythm.
TT-Maze is performed by a cardiothoracic surgeon, such as Dr Adrian Pick, using keyhole access through the chest. Instead of treating AF from inside the heart using catheters, it treats the heart from the outside surface using surgical instruments and radiofrequency energy.
A traditional Maze procedure can also treat AF, but it is usually performed as part of open heart surgery. TT-Maze uses the maze concept through a minimally invasive thoracoscopic technique when clinically suitable.
TT-Maze can offer a more extensive rhythm treatment than pulmonary vein isolation alone, without requiring a full sternotomy for selected cases.
Am I a suitable candidate for TT-Maze?
TT-Maze is not suitable for everyone with atrial fibrillation. It is considered for selected patients whose AF is more complex or has not responded to other treatments. A surgical assessment might be discussed if you have:
- Persistent or long-standing atrial fibrillation
- Ongoing symptoms despite medication
- AF that has returned after catheter ablation
- Multiple previous ablation procedures
- A recommendation for AV node ablation and permanent pacing
- Difficulty tolerating rhythm medications
- A desire to explore rhythm-control options before accepting permanent AF management
Suitability depends on how long you have had AF, your previous treatment history, heart structure, overall health, stroke risk, other cardiac conditions and personal treatment goals.
Why AF can come back
Atrial fibrillation is not always caused by one isolated electrical problem. In early or intermittent AF, triggers near the pulmonary veins may be the main driver. In persistent or long-standing AF, the atria may become more electrically unstable over time.
Over time, AF can change the atria in ways that make the rhythm more likely to persist. The longer AF continues, the more difficult rhythm control can become.
This does not mean rhythm treatment is no longer possible, but that treatment needs to be matched to the type of AF and the individual patient, without the assumption that one treatment will suit every case.
What to expect at your AF assessment
A consultation for TT-Maze is not just a discussion about surgery. It is a review of the whole AF picture.
Dr Adrian Pick reviews any previous ECGs, Holter monitor results, echocardiogram findings, and scans, as well as your cardioversion history, catheter ablation reports, medication use and current symptoms. This helps determine if your AF is driven by areas that surgical treatment can target.
Assessment also considers risks that can affect AF outcomes, including blood pressure, sleep apnoea, weight, alcohol intake, diabetes, fitness and other heart conditions. Managing these does not replace procedural treatment, but is an important part of long-term care.
What are the potential benefits of TT-Maze?
TT-Maze may help restore or maintain sinus rhythm, reduce AF symptoms and reduce reliance on rhythm medications. It also opens up another treatment discussion for patients who have been told that permanent pacemaker dependency is the next likely step.
As with any heart procedure, outcomes and recovery may vary. Some patients could still require medication, further monitoring or additional treatment after surgery. The whole aim is to create a treatment plan that is realistic, personal and based on the pattern of AF to the individual.
Surgical AF care in Melbourne
Dr Adrian Pick is a Melbourne cardiothoracic surgeon with experience in minimally invasive cardiac surgery and surgical atrial fibrillation treatment. Dr Pick’s AFib Clinic provides assessment for patients with persistent or recurrent AF, including those who have not achieved lasting rhythm control with medication or catheter ablation.
For a suitable patient, TT-Maze can offer another way forward when AF has become more complex and previous treatment has not been enough.
If you have persistent atrial fibrillation or AF that has returned after ablation, ask your GP or cardiologist about a referral to Dr Adrian Pick.
This article is for general information only and should not replace medical advice from your GP, cardiologist or treating specialist. All medical and surgical procedures carry risks and outcomes vary between patients. Consult with Mr Adrian Pick MBBS, FRACS | Gen Surg, FRACS | Cardiothoracic (MED0001117736) is a Cardiothoracic Specialist for personalised treatment and advice.