Absolutely! I'm glad you mentioned this. I just saw a patient who just had this a year ago after three failed regular ablations by other docs and was in the hospital unfortunately with Afib recurrence again last month. So I was planning on doing a video specifically about this topic, although if you go to my videos on AFib Ablation Techniques, specifically part II, I do talk about this procedure as well. They are on my website: afibeducationcenter.com. So in regards to the Wolf Mini-Maze, remember it isn't necessarily what energy source you use or whether the ablation is done from the inside or surgically from the outside, it is "what" you do, specifically what lesion set are you doing which should be dictated by how progressed your AFib is (the Stage). The earlier your stage (refer to my video on stages of AFib) the less you need done; the more progressed your AFib stage, the more it is waking up, the stronger the antiarrhythmic medications you are failing, then the more walls are covered with AFib sources/triggers and the more advanced an ablation you need to try to get rid of most or all of your AFib. The standard method is "Pulmonary Vein Isolation" which is just ablating (whether internally or surgically externally) the four corners of the first wall which is the back wall of the left upper chamber of the heart (left atrium) where AFib always starts; this is typically Paroxysmal AFib (early stage). But when AFib progresses past this early stage into Persistent or Longstanding Persistent AFib (mid to late stages) usually the AFib sources/triggers have developed on more than just that first/back wall of the left atrium and have spread to multiple other walls, usually the side (lateral) wall, roof, floor, and in very late stages the front wall, other side wall, and in really advanced stages the right upper chamber (right atrium). So irregardless of whether you cauterize with the RF catheter or freeze with the Cryoballoon or surgically ablate or use the new Pulsed Field ablation with pulses of electricity, if all you are getting rid is of the corners of that first wall and you have say three walls filled with AFib triggers/sources, then you aren't going to get it all. So stage of progression is key. Since most Electrophysiologists only do Pulmonary Vein Isolation irregardless of the stage of progression of the patient's AFib their success rates for the later stages of Persistent and Longstanding Persistent AFib is a lowly 40-50% which is worse than flipping a coin. So often I see patients get multiple ablations by other docs where they just keep doing pulmonary vein isolation even though it isn't enough (because that is all they can do and they get paid every time they do it whether they get the result or not) then they either put them on an antiarrhythmic medication to try to suppress the remainder AFib they couldn't get rid of (see the video on Antiarrhythmic Medications) or they send them for a surgical ablation. The three types of surgical ablations is either the Cox-Maze 3, the gold standard, where the surgeons make complex external ablation lesion sets around the pulmonary veins, the whole back (posterior) wall, the side (lateral) wall, the roof, the floor, the front (anterior) wall and even some lesions in the right upper chamber of the heart (right atrium) where AFib triggers form in the very latest stages. This is a very complex lesion set that yields an 80-90% success rate irregardless of your stage of AFib but requires open heart surgery and your heart stopped on a heart-lung bypass machine. The Hybrid-Convergent ablation surgically ablates 3 walls (the roof, back wall, and floor) but also requires an EP to go in separately and complete the pulmonary vein isolation part in the four corners. Depending on your stage of AFib progression this is reasonably advanced. The Wolf Mini-Maze does about two walls in one procedure: it does the four corners (pulmonary vein isolation) and also the lateral wall. The lateral wall is where the left atrial appendage is, a pouch-like structure that serves no purpose, but interestingly is where a lot of AFib triggers/sources form and is also where 90% of clots in AFib form that lead to strokes. In the Wolf Mini-Maze they clip that structure which gets rid of the AFib electrical triggers/sources coming from there and also helps protect against stroke similar to placing a Watchman (see video on Watchman implant). In my experience I would say probably more triggers come from the left atrial appendage than the back wall and roof in the later stages of AFib so if I had to compare getting rid of 3 walls with the Hybrid Convergent ablation or 2 walls with the Wolf Mini-Maze, I would probably say they are similar or an edge to the Wolf Mini-Maze. Of course, if you have more than 2-3 walls worth of AFib triggers neither will be enough to get rid of all your AFib so stage is always most important. And remember AFib constantly grows and progresses so it will come back over time regardless of how much is gotten rid of by a procedure. Some of us (very few unfortunately) can do the pulmonary veins, the roof, the back wall, the lateral wall, and the floor all from the inside in one procedure so I don't think one necessarily has to choose between these limited options, and the recuperation would be quicker than surgery. But if that's not available in your area and you need more than the standard pulmonary vein isolation then you have to do what you have to do. The Wolf Mini-Maze people will argue that by closing the appendage you don't need to be on anticoagulation, but that's a little misleading. Blood thinners are still felt to be the gold standard in reducing risk of stroke in AFib to less than 1% (not quite zero) and closing the appendage while good still isn't quite as protective because 8-10% of clots form outside the appendage. I recently had a patient come for an AFib ablation where he had a clot in his heart not in the appendage (he wasn't taking his blood thinners religiously) and after a month of being stringently on the blood thinners the clot dissolved. If he had had an appendage closure only and been off blood thinners, he probably would've had a major stroke by now. But appendage closures whether from the inside or outside (surgically) are appropriate if you can't tolerate blood thinners or are at a high risk of bleeds. It'll probably reduce your risk to 1-2% versus less than 1%. And remember, we are just treating Afib for symptoms. As long as you don't have a clot and stroke (the most important thing), you won't die from Afib and everything else we do is just for symptoms. I hope this helps!
@@afibeducationThank you Dr Lee for your thorough and quick response to my question. One more question if I may, what are the negative effects of blood thinners in say 10-20 years …..this must be on every patients mind. Again , Thank you so much for taking time to answer my question …Im definitely a subscriber!
The good news is that there are no negative side effects of being on blood thinners long term other than an increased risk of bleeding because...well it's a powerful blood thinner. So if you cut yourself you can bleed more, you can bruise more easily, if you have a stomach ulcer this could bleed, and if you fall and hit your head you need to go to the ER and get a CT scan to make sure you aren't bleeding in your head because if you bleed in your head from the trauma and this doesn't stop this could be life threatening! Originally we used Coumadin/Warfarin for 50 years and this was difficult to take because the levels were affected by your diet and meds so one week your blood was too thin and another week it wasn't thin enough to protect against clots and strokes; so the dose had to constantly be adjusted based on monthly blood tests. See the video "Can AFib cause stroke?" Since 2010 we've had newer anticoagulants that just work without need for dose adjustment because they aren't affected by diet or meds, so this makes it a lot easier to take. The down side is that depending on your insurance they can be very expensive because there is no generic version while Coumadin is dirt cheap. However, a generic version did come out last year and is available outside the US. In the US it still hasn't been FDA approved but likely this will happen in the next 1-2 years. Your exact risk of stroke in AFib can be calculated based on a risk scoring system called the CHA2DS2VASc score with the average risk being 3-6% but the range of risk goes from
Can you comment on the Wolf Mini Maze, being done in Texas……maybe your thoughts.
Absolutely! I'm glad you mentioned this. I just saw a patient who just had this a year ago after three failed regular ablations by other docs and was in the hospital unfortunately with Afib recurrence again last month. So I was planning on doing a video specifically about this topic, although if you go to my videos on AFib Ablation Techniques, specifically part II, I do talk about this procedure as well. They are on my website: afibeducationcenter.com. So in regards to the Wolf Mini-Maze, remember it isn't necessarily what energy source you use or whether the ablation is done from the inside or surgically from the outside, it is "what" you do, specifically what lesion set are you doing which should be dictated by how progressed your AFib is (the Stage). The earlier your stage (refer to my video on stages of AFib) the less you need done; the more progressed your AFib stage, the more it is waking up, the stronger the antiarrhythmic medications you are failing, then the more walls are covered with AFib sources/triggers and the more advanced an ablation you need to try to get rid of most or all of your AFib. The standard method is "Pulmonary Vein Isolation" which is just ablating (whether internally or surgically externally) the four corners of the first wall which is the back wall of the left upper chamber of the heart (left atrium) where AFib always starts; this is typically Paroxysmal AFib (early stage). But when AFib progresses past this early stage into Persistent or Longstanding Persistent AFib (mid to late stages) usually the AFib sources/triggers have developed on more than just that first/back wall of the left atrium and have spread to multiple other walls, usually the side (lateral) wall, roof, floor, and in very late stages the front wall, other side wall, and in really advanced stages the right upper chamber (right atrium). So irregardless of whether you cauterize with the RF catheter or freeze with the Cryoballoon or surgically ablate or use the new Pulsed Field ablation with pulses of electricity, if all you are getting rid is of the corners of that first wall and you have say three walls filled with AFib triggers/sources, then you aren't going to get it all. So stage of progression is key. Since most Electrophysiologists only do Pulmonary Vein Isolation irregardless of the stage of progression of the patient's AFib their success rates for the later stages of Persistent and Longstanding Persistent AFib is a lowly 40-50% which is worse than flipping a coin. So often I see patients get multiple ablations by other docs where they just keep doing pulmonary vein isolation even though it isn't enough (because that is all they can do and they get paid every time they do it whether they get the result or not) then they either put them on an antiarrhythmic medication to try to suppress the remainder AFib they couldn't get rid of (see the video on Antiarrhythmic Medications) or they send them for a surgical ablation. The three types of surgical ablations is either the Cox-Maze 3, the gold standard, where the surgeons make complex external ablation lesion sets around the pulmonary veins, the whole back (posterior) wall, the side (lateral) wall, the roof, the floor, the front (anterior) wall and even some lesions in the right upper chamber of the heart (right atrium) where AFib triggers form in the very latest stages. This is a very complex lesion set that yields an 80-90% success rate irregardless of your stage of AFib but requires open heart surgery and your heart stopped on a heart-lung bypass machine. The Hybrid-Convergent ablation surgically ablates 3 walls (the roof, back wall, and floor) but also requires an EP to go in separately and complete the pulmonary vein isolation part in the four corners. Depending on your stage of AFib progression this is reasonably advanced. The Wolf Mini-Maze does about two walls in one procedure: it does the four corners (pulmonary vein isolation) and also the lateral wall. The lateral wall is where the left atrial appendage is, a pouch-like structure that serves no purpose, but interestingly is where a lot of AFib triggers/sources form and is also where 90% of clots in AFib form that lead to strokes. In the Wolf Mini-Maze they clip that structure which gets rid of the AFib electrical triggers/sources coming from there and also helps protect against stroke similar to placing a Watchman (see video on Watchman implant). In my experience I would say probably more triggers come from the left atrial appendage than the back wall and roof in the later stages of AFib so if I had to compare getting rid of 3 walls with the Hybrid Convergent ablation or 2 walls with the Wolf Mini-Maze, I would probably say they are similar or an edge to the Wolf Mini-Maze. Of course, if you have more than 2-3 walls worth of AFib triggers neither will be enough to get rid of all your AFib so stage is always most important. And remember AFib constantly grows and progresses so it will come back over time regardless of how much is gotten rid of by a procedure. Some of us (very few unfortunately) can do the pulmonary veins, the roof, the back wall, the lateral wall, and the floor all from the inside in one procedure so I don't think one necessarily has to choose between these limited options, and the recuperation would be quicker than surgery. But if that's not available in your area and you need more than the standard pulmonary vein isolation then you have to do what you have to do. The Wolf Mini-Maze people will argue that by closing the appendage you don't need to be on anticoagulation, but that's a little misleading. Blood thinners are still felt to be the gold standard in reducing risk of stroke in AFib to less than 1% (not quite zero) and closing the appendage while good still isn't quite as protective because 8-10% of clots form outside the appendage. I recently had a patient come for an AFib ablation where he had a clot in his heart not in the appendage (he wasn't taking his blood thinners religiously) and after a month of being stringently on the blood thinners the clot dissolved. If he had had an appendage closure only and been off blood thinners, he probably would've had a major stroke by now. But appendage closures whether from the inside or outside (surgically) are appropriate if you can't tolerate blood thinners or are at a high risk of bleeds. It'll probably reduce your risk to 1-2% versus less than 1%. And remember, we are just treating Afib for symptoms. As long as you don't have a clot and stroke (the most important thing), you won't die from Afib and everything else we do is just for symptoms. I hope this helps!
@@afibeducationThank you Dr Lee for your thorough and quick response to my question. One more question if I may, what are the negative effects of blood thinners in say 10-20 years …..this must be on every patients mind. Again , Thank you so much for taking time to answer my question …Im definitely a subscriber!
The good news is that there are no negative side effects of being on blood thinners long term other than an increased risk of bleeding because...well it's a powerful blood thinner. So if you cut yourself you can bleed more, you can bruise more easily, if you have a stomach ulcer this could bleed, and if you fall and hit your head you need to go to the ER and get a CT scan to make sure you aren't bleeding in your head because if you bleed in your head from the trauma and this doesn't stop this could be life threatening! Originally we used Coumadin/Warfarin for 50 years and this was difficult to take because the levels were affected by your diet and meds so one week your blood was too thin and another week it wasn't thin enough to protect against clots and strokes; so the dose had to constantly be adjusted based on monthly blood tests. See the video "Can AFib cause stroke?" Since 2010 we've had newer anticoagulants that just work without need for dose adjustment because they aren't affected by diet or meds, so this makes it a lot easier to take. The down side is that depending on your insurance they can be very expensive because there is no generic version while Coumadin is dirt cheap. However, a generic version did come out last year and is available outside the US. In the US it still hasn't been FDA approved but likely this will happen in the next 1-2 years. Your exact risk of stroke in AFib can be calculated based on a risk scoring system called the CHA2DS2VASc score with the average risk being 3-6% but the range of risk goes from