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Description of the Wolf Mini-maze performed on Dick Inglis on January 5, 2006 in Cincinnati OH

Part  I

 

Deciding what to do

 

Beginning in May, 2005, I had episodes of AF as follows:

 

May 2005:

First episode converted naturally after two weeks;

Late August:

Second episode successfuly DC cardioverted;

Early September:

Third episode DC cardioverted. I was put on 20 mgs sotolol 2x/day (The more usual dose of 40 mg 2x/day brought my heart rate down too much);

Mid October:

Fourth episode: Because anti-arrhythmia medications are toxic and potentially unpleasant or dangerous, I decided to take a rate limiting medication (diltiazem) while I searched for a more lasting solution.

 

Because my last episode did not convert naturally,  my AF would be considered to be "continuous" (using Dr Cox’s intermittent-continuous dichotomy), but not chronic (of long duration), since the continuous segment had lasted three months and the whole series of episodes had lasted just over seven months.

 

At the time, my AF appeared to be “lone” -- that is, without any contributing factors such as high blood pressure, structural heart problems, etc. --  although this turned out to be wrong.

 

So, I would be looking for a procedure – ablation or surgery – that would have the best success rate for continuous AF. And the fact both that my AF was non-chronic (short-duration) and apparently lone (not maintained by something like high blood pressure, thyroid dysfunction, cardiac disease, valvular disease, etc) meant both that my chances for success were relatively good and that no doctor would be likely to reject me as a candidate for his procedure.

 

I should mention here that all my information about AF – especially information about procedures with potential for cure – came from the internet. I live in a small city in Washington State, and my cardiologist, one of two in town, is bright and capable. But, there is no way he would have the time to thoroughly research the full range of possible treatments for AF. When I told him I was interested in something that might cure my AF and asked him where he would go in my position, he said, without hesitation, “The Cleveland Clinic”. Knowing what I know now, this was pretty good advice. I am not sure how specific he might have been if I had pressed him (Natale?, Schweikert? someone else on the ablation rotation?, or Gillanov, a surgeon?)  but I wanted to explore the full range of possibilities myself.

 

I was first interested in catheter-approach ablation (CA) and put together a list of places gleaned from various sources (for example, the minimaze.org site). This initial list included The Cleveland Clinic (CCF), University of Oklahoma, Washington University, and the Mayo Clinic. I contacted all these places (and several more) and asked questions about number of procedures done, success rates, and other details of the procedures.

 

A full description of my process of choice would be too long for this post, so I will deal with it separately. Suffice it to say: 1) I became impressed with the apparent advantages of the surgical approach over CA; and, 2) I decided that the Wolf mini-maze performed by Dr Wolf at University Hospital in Cincinnati offered the best combination of doctor experience, lesion set, success rate, and invasiveness that I could find. Knowing what I know now about the questions to ask and about the range of possibilities in addition to those I explored, I might  have chosen differently.  

 

Leading up to operation day

 

I filled in the online form at the Wolf minimize site at wolfminimaze.com. (Although this is Dr Wolf’s main presence on the internet, the site was created and is maintained by George Rabe, an energetic and super-satisfied patient of Dr Wolf’s.).   I talked to Pam, Audrey who are on Dr Wolf's staff, and to Dr Wolf about a variety of matters, and ended up being scheduled for surgery at 7:30 am on January 5th, 2006.

 

The crew there, who include Pam (working on statistics & ?), Audrey, the coordinator, and Carol and Sandy, who are nurse practitioners, are very capable and very easy to work with. Dr Wolf himself is very relaxed, confident and attentive.

 

We arrived in town two days before the operation, giving my wife and me time to settle in for pre-op testing the day before the operation. In my case, since I had a recent stress test and “echo”, the testing was limited to a 64-slice CAT scan to check on atrial size and to give Dr Wolf the lay of the land. I would be admitted to the hospital the night before, ostensibly for a heparin drip, but (I was told) really so that all the admitting and some of the pre-op work could be done the night before. The pre-op night in the hospital was uneventful, the nurse was great. I was finally here, and I was eager to get going!

 

Here my timeline overlaps with that of Cheryl, who gives an excellent and detailed account of her 12/13/2005 Wolf mini-maze at:

 

http://www.afibbers.com/forum/read.php?f=6&i=21976&t=21976#reply_21976.

 

My Wolf mini-maze

 

Early on operation day, I was wheeled down to the pre-op area for some preparations that would be done while I was conscious. The one I remember was the placement of the arterial line in my neck. This being a teaching hospital, a resident anesthetist was given a crack at me. His attempt to place the line in my neck was unsuccessful so it was put in an artery just below my clavicle – a more comfortable location as far as I am concerned. I think certain areas were shaved while still awake  (-:  .

 

While I was asleep, I would have been intubated before the operation and extubated at the end.  I was also catherized.

 

I should mention that there was nothing about the operation itself that made me anxious. I was more concerned about whether it would be successful, and, since I am a poor sleeper, about being exhausted and depressed by the combination of the stress of the operation and lack of sleep in the hospital. (I believe that people have different degrees of tolerance for pain and of anxiety reactivity built in so there is no reason to feel either proud or ashamed by these reactions.) I was also helped by the fact that my wife is an OR nurse and one of my brothers is a doctor, so I am familiar with medical matters. In any case, I looked forward to the anesthesia as a bit of a vacation, and looked forward to waking up in NSR.

 

While I was asleep….

 

[ You may want to skip this section. It presents information about the operation, but nothing about my reaction to it.]

 

Here is an outline of  Dr Wolf did -- and presumably what any surgeon doing a Wolf mini-maze would do. For a fuller description, you can see a live web cast of an operation – not mine!!! – at

http://www.or-live.com/healthalliance/1217/ .

You can compare these steps to those of other surgical procedures you might be considering.

 

Dr Wolf makes three incisions on each side of the rib cage: a 3-4” incision that extends from underneath the armpit to a bit forward of it, I think below the 3rd rib. Two smaller incisions  for a scope and/or tools below are further down at about the 7th rib on each side. The larger incision allows the surgeon to actually see a lot of what he is doing, which is considered an advantage over the totally endoscopic procedure. The ribs are not spread.

 

One can argue about whether this procedure is minimally invasive or not. It is done epicardially, without opening the heart, without cracking the sternum and without using the heart-lung machine. On the other hand, each lung is partially deflated and cuts of several inches are made in the pericardium to expose the outer surface of the heart. (The seriousness of these cuts is indicated by the prescription for about 3 weeks of Prednisone to prevent pericarditis.) It seems to me that the Wolf mini-maze falls between a totally endoscopic procedure like the Saltman micromaze

 (http://www.ctsnet.org/sections/clinicalresources/adultcardiac/expert_tech-11.html )

and a variety of procedures that do the complete or essential set of Cox lesions

 

In each of the following steps, Dr Wolf (or his EP assistant ?) test for the presence of unwanted circuits and also test to make sure that the aberrant circuits they discover have been successfully deactivated.

 

  • isolates the pulmonary veins

  • deactivates ganglionated plexi

  • snips the Ligament of Marshall

  • removes the Left Atrial Appendage

All the preceding have been found to be the location of undesirable circuits.

 

As noted above, he removes the Left Atrial Appendage (LAA), which is considered to be a likely spot for stroke-causing clots to form. (Doing this is now the subject of some controversy; see

 http://www.chestjournal.org/cgi/content/full/124/6/2356 .)

 

There is very active discussion about lesion sets. Which set is best for what type of AF?  Does the LAA have functions that will be missed when it is removed?

 

Dr Wolf uses the Atricure RF device, which he helped develop and whose advantages you can hear described if you watch the webcast whose link is given above. For example, lesion transmurality is assured and ablation temperature is kept down because blood is squeezed out of the tissue, which means that circulating blood will not cool the area, leading to the need for higher tip temperatures in order to produce the scar.

 

In addition to the above steps, Dr Wolf placed pacing electrodes, chest-drainage tubes and tubes to deliver pain medication from “medication balls” in their appropriate locations inside the body..

 

The pacing electrodes kept my heart rate at 80 beats per minute for a brief period (a day or so) after the operation.

 

I did not convert to NSR naturally during the operation, but was easily converted at the end with what I take to be a relatively small jolt.

 

What happened next …

 

I was wheeled up to my room in CICU, which is intensive care for patients coming out of heart surgery. I was out of bed sitting in the chair for a couple of hours, but I was tired and weak. The next day I was in the chair for several hours, and took a couple of walks around the unit.

 

The plan was for me to stay there for one, maybe two nights, and the go to the step-down unit. The important difference between the two is that in CICU the10 tubes into your body and the five electrodes stuck on your chest are plugged into the wall or into machines in back of you, so you cannot move from your bed without being unplugged and then re-plugged into a portable monitor. In the step-down unit, some of the tubes will have been removed and the remainder will be plugged into a portable monitor. This immobility coupled with the shortness of the bed for my 6’ 2” frame, my reluctance to call the nurse for a lot of unplugging and re-plugging, plus the nausea which I will explain below, and the trouble sleeping were the sources of  discomfort (unless you include hospital food!!!). Incision pain was well controlled by the pain balls, which are about the size of a large orange, with tubes running in through the incisions and which are in bags that can be slung over your shoulder when you move. For other pain, Tylenol was enough.

 

Because of a series of unusual circumstances, I spent four nights imprisoned in my bed: one in CICU, and three in CCU. The reason for this was that on the day after my operation, they discovered that four of my coronary coronary arteries were blocked: 80% in one too small to clear or stent, two with minor blockage (10% and 20%),  and one with 60% blockage that  was stented. How this was discovered is a whole story in itself (high calcium score on the CAT, raised ST segment on the EKG, and high blood enzymes that indicate damage to the heart. The high calcium score indicates only potential for blockage; the other two can result from the operation, so the signs were not definitive.) In any case, action was taken;  my AF was not “lone” anymore! (I also suffered more nausea than usual because of the additional anesthesia.)

 

The hospital nurses were great, very likeable and very capable, as were the residents. The hospital seemed very well run. The Marriot hotel just down the street is a wonderful place to stay, and offers an inexpensive “caring rate” for relatives of hospital patients.

 

Physical recovery

 

And so I was discharged, in NSR , with a pocket bulging full of medications related to AF and to CAD:  diltiazem, Plavix, Zocor, prednisone, baby aspirin – I think that’s it. I also began taking Mg and taurine, in addition to the fish oil, folic acid, selenium and the Vit C that I had already been taking.

 

Since I was not on an antiarrhythmic medication  when came in, I was continued on diltiazem. Dr Wolf surprised me by assuring me that whether or not people are on an antiarrhythmic for a period of time post-op – as is often the case-- does not make a difference in rate of cure.

 

My recovery was set back a bit by the fact that I had two heart procedures on consecutive days, and by the restrictions connected to the balloon angioplasty. It also may have been affected by the Mg I was taking, which before had always made me feel tired, but which I was determined to take at least until my heart got over being irritable and reactive from the operation(s)).

 

Prednisone had a positive side effect, which was to give me a steady flow of energy and good spirits for 2+ weeks in spite of physical weakness from the operation.

 

Disappointment!!! One week after the operation, I went back into continuous AF. Dr Wolf assured me whether or not this occurs has no correlation with the final outcome. Neither, as I mentioned above,  does whether you continue to take anti-arrhythmic medication post-op.                I want to believe him…     

 

My question was: Is this post-op AF of a different quality from the pre-op version? If so, will it tend to disappear when the reason for its existence – heart irritability/reactivity caused by the operation(s) --  is gone, or will it at least tend not to recur after cardioversion? Or, does this AF consist of new circuits that will persist after the effects of the operations have worn off. Are these circuits ones that were not detected and ablated by the Wolf lesion set?

 

Dr Cox would probably say that something had been left out -- the LA isthmus lesion he considers essential in curing continuous AF but that cannot be done epicardially because the energy source must pass through the circumflex coronary artery, and it is my understanding that only HIFU can do this epicardially without harming the vessel. (The Cox mini-maze procedure of course does include this lesion.)

 

I asked Dr Wolf (before I lost my week-long NSR) about what is done when someone goes back into AF after the operation. He said that he does nothing for one month. If it continues for two months, he usually takes some action, depending on the nature and frequency of the AF.

 

I assume the next step might be cardioversion alone – with which he has said he has had good luck -- "Sometime the heart needs a little bump to put it back into NSR", and I have converted successfully twice before. Then, if that doesn’t last, cardioversion + meds. If that doesn’t last, touch-up ablation. (Descriptions of the Stereotaxis Niobe® Magnetic Navigation System suggest that it can make it safer to ablate areas that were out of reach before. This makes a touch-up ablation a more appealing possibility. The system is in use at the University of Oklahoma, Washington University in St Louis, and a number of other places, but not necessarily for atrial fibrillation.) Or he might suggest CV + meds to begin with. 

 

In January, I began taking a whole slew of medications and supplements: Plavix to reduce the risk of re-stenosis in the artery that was stented; Zocor, a statin; lisinopril, an ACE inhibitor, and diltiazem and metoprolol to reduce my AF heart rate. I upped my fish oil to 4 gms DHA/EPA, my COQ10 to 100 mgs (to counter the COQ10 lowering effect of Zocor), and began taking magnesium and taurine, and watching my potassium intake -- as well as taking some other supplements that I had taken before.

 

I have been more-or-less tired almost all of the time -- initially from the operation and then and now from the AF, the beta-blocker and possibly the magnesium. I went back to working out after the first week, and have gradually increased time and intensity, trying to stay under 130-140 bpm except for brief periods. Exercise is unpleasant, whereas before it was very satisfying. Certainly neither exercise or my overall quality of life is anything like it was pre-AF. I certainly couldn't do a triathlon in this condition!

 

March 2006: I am still awaiting the next step after almost two months after the operation. At the time I was to contact him, Dr Wolf had to have back surgery and has been unavailable for consultation.

 

I am hoping for the best, of course, but I have been in AF for over five months -- except for a week's break right after the operation.  I cannot imagine being free of it. I cannot imagine how people live with it for years.

 

I know that I am much better off than many, but I cannot see living with AF or taking a toxic medication with unpleasant side effects that may well become ineffective in a couple of years.

 

We’ll see what happens next.

 

Part II will cover whatever is done for my post-op AF.  I should be able to communicate with Dr Wolf at the beginning of April.

 

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