There are very few centers offering the Hybrid Surgery/Ablation approach because it’s relatively new, and because it’s extremely rare to have the tremendous expertise necessary in both catheter ablation and surgical A-Fib ablation at the same institution.
Note: Similar multidisciplinary ablation techniques are called ‘hybrid ablation technique’, ‘convergence process’, ‘Convergent Maze Procedure’ and ‘Convergent Ablation”’.
The cardiologist will probably put you on different medications (called Drug Therapy) over the next six months to a year or more to see if any of these medications will stop or control your A-Fib. But current A-Fib medications are not very effective and often have bad side effects.
In addition, time is of the essence in treating A-Fib. The longer you wait, the more your A-Fib may “remodel” your heart (i.e., change it physically and electrically). Drug therapy may not be the best option for you.
Click for graphic: Why you need a cardiac electrophysiologist (EP).
You should see a cardiac Electrophysiologist (EP)—a cardiologist who specializes in the electrical activity of the heart and in the diagnosis and treatment of heart rhythm disorders.
To be cured of your A-Fib, you need to find the best doctor for you and your treatment goals. You need a doctor who will work with you to create a treatment plan—a path to finding your cure or best outcome.
To find the right doctor for you, start by creating a list of possible doctors to consider. Seek recommendations from your GP and from other A-Fib patients (see Resources/Bulletin Boards for a list of online discussion groups). If you know nurses or support staff who work in the cardiology field or in Electrophysiology (EP) labs, they are often a great resource.
Instead of a cardiologist, you should see an cardiac Electrophysiologist (EP)—a cardiologist who specializes in the electrical activity of the heart and in the diagnosis and treatment of heart rhythm disorders.
And use the internet. To find a local Electrophysiologist yourself, we recommend the Heart Rhythm Society website and their feature called ‘Finding a Heart Rhythm Specialist’. ‘Check’ the box “to limit the results to Fellows of the Heart Rhythm Society (FHRS)”. (EPs with the FHRS designation have been recognized by their peers and are experienced heart rhythm professionals working in the field of electrophysiology and/or pacing; see more about FHRS below).
When you type in a U.S. city and state, (or country) the site gives you a list of Electrophysiologists in your area. Check for their list of specialties (not all EPs perform PVIs; some focus on pacing/pacemakers, or clinical research, for example). Look for additional information such as which medical insurance they accept.
Start your research with a notebook and a three-ring binder…to organize the information you will be collecting.
This A-Fib.com Directory of Doctors and Facilities is an evolving list of the physicians and medical centers in the U.S. and internationally treating patients with atrial fibrillation. It is offered as a service and convenience to A-Fib patients.
In addition, I’ve compiled several rosters of doctors by specialty called ‘Steve’s Lists’.
For a list of EPs with the FHRS credential listed by state and city, see Steve’s Lists: Doctors by Specialties and more specifically, US EPs with FHRS-designation Performing A-Fib Ablations by US State/City.
We strongly encourage you to get in the habit of keeping a copy of every test result you get in your three-ring binder. Don’t leave your doctor’s office or hospital without a copy of every test they perform. Or if the test result isn’t immediately available, have them mail it to you.
Your 3-ring binder, or file folder is also where to collect copies of all your lab tests, doctor visits, etc.
If you need to request copies of some medical records, read our article, How to Request Copies of your Medical Records. We give you three ways to request your medical records from your doctors and medical providers.
Later, when you are ready to interview new doctors, you will want to send each office a packet with your medical records, test results, and images or X-rays. When you arrive at the EP’s office, make sure they have indeed received your up-to-date medical records. As a back-up, bring your own three-ring binder with the originals.
Don’t rely on a single online source when researching and selecting doctors.
Credential Acronyms While researching EPs, you will notice acronyms following a physician’s name. For an explanation of these credentials and acronyms, see our article Physician Credentials.
Be cautious of all doctor informational listings you find on web sites (yes, including this one). Doctors may be listed or appear most prominently because they pay for that privilege (but not so at A-Fib.com).
Don’t depend entirely on the typical doctor informational websites or online directories. A doctor with a good lawyer can keep their name free of sanctions and board actions. And the patient surveys on these sites aren’t very scientific and lend themselves to manipulation (one can get friends or paid people to respond to the survey). Consult several sites.
Please bear in mind than not all EPs perform and have sufficient experience in Pulmonary Vein Ablation. See my “Choosing the Right Doctor: 7 Questions You’ve Got to Ask” page and my list Doctors/Facilities/Steve’s Lists/EPs Performing Pulmonary Vein Ablation’ to help find the right Electrophysiologist for you.
Over the last several years there has been an astounding and welcome growth of US centers and doctors who do Pulmonary Vein Isolation (PVI) procedures. But some are low volume centers with limited facilities and training who may do as little as 20 PVAs a year.
It’s tough to quantify experience with specific numbers. But if a doctor only does 20 PVAs a year, that may not be enough to maintain and develop ablation skills. A typical experienced EP does over 50 PVIs a year. For more see our article, Considering a Catheter Ablation? Know Complication Rates When Choosing Your Doctor.
• Where did they attend medical school?
• Where did they do their residency program?
• What board certifications have they received?
• What are their hospital affiliations?
• Where and from whom did the doctor receive special training to treat A-Fib?
• Have they lost privileges with any hospitals?
• Have they been sanctioned by any medical entity?
To research each doctor, consult the internet or your local library. The following online resources may be helpful.
• HealthGrades, Vitals, and RateMDs: independent healthcare ratings organizations which provides physician’s profile, education, awards & recognition, insurance accepted, hospital affiliations, and malpractice and sanctions. But be aware that these sites usually don’t review a doctor’s competence.
How long have you been performing Pulmonary Vein Ablation for my type of A-Fib? How experienced are you with RF and/or Cryo? How many procedures do you perform a year?
What kind of complications have you had? What kind of precautions do you take to prevent complications like Atrial Esophageal Fistula?
What kind of A-Fib ablation procedures and equipment do you use? What would you use for my type of A-Fib?
Do you refer patients to surgeons for a Cox Maze or Mini-Maze operation?
Most doctors and centers will welcome these questions and respond frankly to you. If they don’t, that may be a sign you need to look elsewhere. For a list of specific questions to ask doctors and how to interpret their answers, see my Questions for Doctors page.
Be Cautious: information from the doctor or their practice is ‘self-reporting data’. There is no independent entity to verify the doctor’s or their office’s responses to you. If it sounds too good to be true, it probably is.
If the doctor or their office seems reluctant to give you the info you need, it might be wise to talk with another doctor.
Select your top three doctors. Now you are ready to set up a consultation appointment with each doctor. Think of this as an interview. Don’t worry, doctors are also ‘interviewing’ you to determine if they can help you.
Learn what to include in your packet of medical records. Read Why You Need an A-Fib Notebook and 3-Ring Binder and Your Personal A-Fib Medical Summary.
Before your appointment, send each doctor a packet with your A-Fib-related medical records. When you arrive at the doctors offices’, make sure they have indeed received your medical records. As a back-up, bring your own originals from your three-ring A-Fib binder.
To help you scrutinize prospective doctors, we’ve written a set of 10 interview questions to help you find the right doctor for your treatment goals. Use our free PDF download, ‘Questions for Doctors Worksheet‘, to interview and question each prospective doctor.
Download the FREE PDF and save to your hard drive. Then, print a worksheet for each doctor you interview.
Never go to any doctor appointment alone. Always carry a notepad and pen to take lots of notes.
Audio recording: In addition, consider using an audio recorder to help you remember things. (Most doctors don’t mind, but always ask permission beforehand.) Many cell phones can make a recording for you.
Take Along a Trusted Friend: You may want to take along a trusted friend or family member. As needed, your ‘personal advocate’ can question the doctor for you and verify your list of questions have been answered. Afterwards they can help you evaluate the doctor’s answers, discuss anything that’s unclear and comment on the doctor’s demeanor.
Back home, compare answers and your notes about each doctor. To ‘interpret’ the doctors’ answers, see our article, “Choosing the Right Doctor: 10 Questions You’ve Got to Ask (And What Their Answers Mean)“. We’ve included the various responses you might receive, and what each response means to you when searching for the right doctor for you and your treatment goals.
Does the poor behavior also extend to how the doctor treats his staff? Patients of doctors “who don’t show respect for their medical staff have much higher rates of adverse effects, than patients of their more congenial colleagues.” “As a patient, you’re also a member of the health-care team,” explains Gerald B. Hickson, MD of Vanderbilt University Medical Center.1 If your doctor is condescending or dismisses your concerns, you’re getting poor care. If a doctor is too busy to talk with you and answer your concerns, he’s probably too busy to take care of you properly.
But do give the doctor a break. They may be having a bad day or may have heard your questions too many times before. So, say something, speak up! Or contact the patient-relations representative at the heart center. They want to know if a doctor is rude (those patients are more likely to sue!). Once a doctor’s bad behavior is called to his attention, they are likely to do better. And so will you.
A Pulmonary Vein Isolation Ablation PVA/I is the most challenging, demanding and complex catheter ablation an Electrophysiologist performs.
But surprisingly, no specific certification is required. Any EP is allowed to do PVIs. When doing your basic research, make sure the EP has obtained “Clinical Cardiac Electrophysiology” Certification. It’s surprising how many EPs never pass this exam but still do PVIs. Certification in “General Cardiology” or “Internal Medicine” are more basic and not what you’re looking for.
Patients are advised to consider the more experienced EPs in the PVI field. One indicator is the credential “FHRS” after a doctor’s name. A Fellow of the Heart Rhythm Society (FHRS), is an EP certified by the American Board of Internal Medicine (ABIM) in clinical cardiac electrophysiology (CCEP), has letters of support from current FHRS members, and has been vetted by the HRS Membership Committee. Learn about FHRS designations.
Since Pulmonary Vein Ablation (Isolation) is a relatively new procedure, select facilities and doctors who are more experienced with it. For more, see our article, Considering a Catheter Ablation? Know Complication Rates When Choosing Your Doctor.
In this author’s opinion, although certain centers and doctors are more experienced than others, there is no first and second tier of A-Fib doctors. In general, Electrophysiologists performing Pulmonary Vein Ablation (Isolation) are highly trained, experienced and technically gifted. Your chances of being cured by a PVA(I) are very good at most A-Fib medical centers.
For a list of cardiologists doing Catheter Ablation procedures, see Steve’s Lists/US EPs with FHRS-designation performing A-Fib ablations by US State/City.
After your consultation, your Electrophysiologist may recommend a Cox Maze or Mini-Maze operation for your A-Fib. Your EP will probably recommend a short list of surgeons. You will conduct the same research for finding the right surgeon as you did for finding the right EP. Unfortunately, we’re not aware of a database that lists A-Fib Surgeons by geographic area, except for the list on A-Fib.com (see Steve’s Lists/Surgeons Performing Cox-Maze and Mini-Maze Operations).
A study from the Un. of Michigan found that surgical death rates are directly related to experience with the particular operation being performed. You are four times more likely to die if your surgeon performs your operation only rarely, compared to a surgeon who performs it regularly.3 Ask your surgeon or his office how often he performs the Maze and/or Mini Maze. Call other doctors in this field to see how often they perform Mazes. Be cautious about a surgeon who performs Maze operations far less than the average.
If a surgeon specializes in exactly your condition and if 50% or more of his practice relates to your type of A-Fib, they may be a good choice.
You may also want to consider the mind set and attitudes of Surgeons vs. Electrophysiologists.
Keep in mind: a surgeon’s primary concern is in performing a successful operation, whereas EPs have devoted their careers to dealing with heart rhythm problems. The EP’s primary concern is creating a ‘treatment plan’—an organized path to finding your A-Fib cure or best outcome.
In an ideal world, a surgeon would work with and consult with an EP, especially if the surgery didn’t work. But, with certain exceptions, that generally isn’t the case today.
For more about surgeons and EPs performing procedures together, see our Treatments/Maze/Mini-Maze/Hybrid Procedures page.
You may also want to read: Advantages of the Convergent Procedure by Kiser/Mounsey, and Boston AF 2011/Edgerton “Hybrid Ablation (Combining Surgery with Catheter Ablation) for Persistent A-Fib“.
Steve has prepared these lists of doctors treating atrial fibrillation patients by specialty to help you find doctors with a particular expertise.
Notice: Unlike other directories, A-Fib.com offers no preferential listings or placement. No doctor or facility pays, provides services, etc. to be listed. We accept no fee, benefit or value of any kind for listing a specific doctor or medical center. A-Fib.com is not affiliated with any practice, medical center or physician.
If you know the name of the doctor or practice, use the “Search our site” box (upper right on this page) to get to the right Directory page. Then, open your browser’s ‘Find on Page’ feature (‘CTRL+F’) to locate the name on the page.
Disclaimer: this directory is provided for informational purposes only. We make no endorsement of a specific physician or medical facility. Choosing a physician is an important decision and should be based upon your own investigation of each physician’s training, education and experience. These listings offer you the opportunity to locate and contact a healthcare professional directly.
A-Fib.com is your independent source of unbiased information about Atrial Fibrillation, resources and treatments.
In the first trimester or two of our time in the womb, The Left Atrial Appendage (LAA) was originally our left atrium (LA). When the final real Left Atrium (LA) formed gradually from the conjunction and evolutionary development of the four pulmonary veins, the actual LA chamber grew and ballooned out, pushing the smaller remnant LA up to the left top of the Left Atrium where it became became known as the Left Atrial Appendage (LAA) with its own functions and behaviors.
One considered advantage of the Mini-Maze operations is that the Left Atrial Appendage (LAA) is closed or cut off. Most A-Fib blood clots which cause stroke come from the Left Atrial Appendage. By closing off the LAA, most but not all risk of stroke is eliminated even if you are still in A-Fib.
AtriCure has developed a version of the AtriClip which can be used in Mini-Maze surgery.
Should the LAA be routinely cut out, stapled shut or closed off in all A-Fib patients?
The rationale for closing off the LAA is that, in case the operation fails which happens occasionally, the patient is still protected from having an A-Fib stroke. 90%-95% of A-Fib strokes come from clots which originate in the LAA. In A-Fib, blood stagnates in the LAA and clots tend to form.
Another important consideration, even if a person is no longer in A-Fib, is that closing off the LAA may still prevent a stroke. The LAA is where most clots originate. If a surgeon is already working on the heart, why not close off the LAA and reduce the patient’s chance of having a future stroke? (If a surgeon didn’t close off the LAA, they could be sued if a patient later had a stroke, even if the patient was no longer in A-Fib.) Life (no stroke) is more important for most people than a possible reduced exercise intolerance.
In the future even people without A-Fib may have their Left Atrial Appendage closed off if it prevents or reduces the risk of a stroke. This may become a way to prevent stroke in older people, particularly women, who are more at risk of stroke as we age. There are currently a variety of devices, surgical and non-surgical, which can do this. LAA closure may become an important new way to reduce strokes, particularly in the elderly.
Some question the need or benefit of removing the Left Atrial Appendage (LAA) if someone is no longer in A-Fib. For a patient made A-Fib free, would their heart function better or more normally if they still had their LAA?
The LAA functions like a reservoir or decompression chamber or a surge tank on a hot water heater to prevent surges of blood in the left atrium when the mitral valve is closed.4 Without it, there is increased pressure on the pulmonary veins and left atrium which might possibly lead to heart problems later.
Cutting out or stapling shut the LAA also reduces the amount of blood pumped by the heart and may result in exercise intolerance for people with an active life style. (In dogs the LAA provides 17.2% volume of blood pumped.5) This is usually not a problem for patients with Persistent (Chronic) A-Fib, whose LAA has stopped contracting along with the fibrillating atrium.
Cutting out or stapling shut the LAA won’t affect their cardiac output. But this may not be the case for patients with Paroxysmal A-Fib who still have large amounts of normal rhythm and whose LAA still functions normally.
But would a non-functioning LAA return to normal when someone with, for example, longstanding persistent (Chronic) A-Fib becomes A-Fib free?
I’m not aware of any surgeons (or EPs) who do pre- and post-LAA closure measurements of exercise ability, heart pumping function, etc. with and without the LAA.
The LAA also has a high concentration of Atrial Natriuretic Factor (ANF) granules which help to reduce blood pressure.6 Some preliminary research indicates that when the LAA is closed or cut off, the Right Atrial Appendage produces more ANF to compensate for the lost of the LAA.
Editor’s comment: If you are thinking of having a Cox Maze or Mini-Maze, discuss removing the LAA with the surgeon. Ask if they close off the Left Atrial Appendage and with what: sutures, stapler or the AtriClip.
Cardiac surgeons continually strive toward less invasive procedures which avoid approaches like full median sternotomies and thoracotomies. However, reports of minimally invasive cardiac surgical procedures may include hemi-sternotomies, mini-thoracotomies, or full median sternotomies without cardiopulmonary bypass.
True minimally invasive procedures must not only be defined by the size of the incision, but also by the invasiveness into the patient’s daily lifestyle and the impact on their quality of life.
There are a variety of techniques and devices in use for the surgical treatment of atrial fibrillation (AF). The current gold standard for the surgical treatment has been the Cox cut and sew maze procedure. There have been variations through the years leading to a host of other surgical AF procedures, such as the Wolf mini-maze1, practiced by many surgeons. Other techniques create myocardial lesions using some form of radiofrequency energy, laser, cryothermy or high-frequency ultrasound. All of these techniques require access to the heart through either a full sternotomy or less-invasive approaches with incisions on the left and/or right side of the chest. Some techniques require cardiopulmonary bypass and sometimes cardioplegia to stop the heart entirely.2,3 Until recently, no current technique or device provided access to the posterior left atrium directly.
Pericardioscopy is a totally endoscopic technique that provides direct visualization of, and access to, the epicardial surface of the beating heart without the need for cardiopulmonary bypass or prolonged postoperative recovery. Unlike a subxyphoid approach, pericardioscopy provides access to the heart via the central tendon of the diaphragm. This allows direct vision of the posterior cardiac structures with minimal hemodynamic compromise. Such access and visualization of the epicardial cardiac surface has enabled epicardial ablation techniques, like the Convergent Procedure, as a treatment for atrial fibrillation.4,5 Pericardioscopy eliminates the need for sternotomy or thoracotomy when access to the epicardial surface is necessary.
The surgical treatment of atrial fibrillation (AF) is based upon the creation of an anatomical pattern of myocardial scar. The Corridor Procedure 6, the Radial Maze Procedure,6 and the Cox maze I-III7,8 are anatomical patterns designed to disrupt the re-entry circuits of AF by dividing the atria into non-conductive segments. Electrophysiologists, in comparison, use endocardial catheters and electrodes to identify the triggers causing AF and direct their treatments towards these foci of abnormal electrical activity in the atria. The individual success of these approaches, either surgical or endocardial, has been limited by technical complexity and/or less than desirable outcomes.
A truly successful and adoptable AF treatment has always seemed to be just out of reach. The acclaimed gold standard cut and sew maze procedure reports exceptional outcomes but remains a complex procedure that is rarely performed.9,10 The mini-maze11 and pulmonary vein isolation12reduce procedural complexity by decreasing the number of lesions and by eliminating cardiopulmonary bypass. However, both the surgeons and the cardiologists have demonstrated that when treatment is limited to the left atrium, outcomes suffer as a consequence.13,14 The endocardial, catheter-based AF ablations, not unlike the surgical procedures, remain long and technically difficult procedures performed by relatively few electrophysiologists. The high rate of repeat procedures and less than desirable long-term outcomes have been disappointing.15 Unfortunately, surgeons and cardiologists seldom collaborate in the development of new technologies and innovative approaches to overcome these individual procedural shortcomings.
The Convergent Procedure has been developed by a multidisciplinary team of cardiologist and cardiac surgeons to address the procedural and communication barriers. The Convergent Procedure is the simultaneous creation of a surgeon’s PEX epicardial ablation pattern and electrophysiologist’s endocardial ablation pattern (Figure 1).
The surgeon’s ability to effectively create visible, and therefore contiguous, epicardial ablation lines has greatly reduced the amount of endocardial tissue which must be ablated to complete a successful trans-septal catheter procedure. The integration of a surgeon’s anatomical approach to AF with the physiological approach of the electrophysiologist’s has led to the development of the Convergent Procedure.
4. Decreased length of hospital stay and the number of repeat ablation procedures.
At the UNC Center for Heart & Vascular Care, we have created a multidisciplinary service that integrates the care of Arrhythmia patients. Evaluation of each case by the multidisciplinary team of arrhythmia experts ensures an individualized, yet consensus, treatment plan. Without this integrated approach, the best treatment option may not be available or may require much longer wait times, more travel and more inconvenience and delay for the patient.
The patient’s clinical presentation is vitally important to developing the multidisciplinary treatment plan. Left atrial size, AF type and AF duration are significant contributory factors. We advocate a 24-hour Holter monitor on all patients under evaluation to document the degree of AF burden. Additional evaluation includes a trans-thoracic echocardiogram and cardiac catheterization or stress test to exclude structural heart disease in the setting of AF.
Patients with paroxysmal AF and a left atrium greater than 4.5 cm and those with persistent and long-standing persistent AF demonstrate the best outcomes when a bi-atrial lesion pattern is created. Surgeons who have experience with minimally invasive approaches choose the ablation technology best suited for their technique. Whichever approach and device is used, a comprehensive lesion pattern of contiguous and transmural lesions are essential. Persistence and intra-operative verification of lesion and pattern integrity is crucial. The Convergent Procedure has established new criteria for lesion integrity by the verification of procedural completion by endocardial electrophysiologic metrics. The Convergent Procedure is not complete until pulmonary vein isolation and posterior left atrial exclusion is confirmed, the coronary sinus is ablated, and a cavo-tricuspid isthmus lesion is created. These metrics provide confidence of procedural success and set new standards for the hybrid treatment of persistent and long-standing persistent AF.
There have been many minimally invasive approaches to treat AF, all based primarily upon the original work by Cox and his maze procedure. By integrating electrophysiology and cardiac surgery in a hybrid AF treatment, new procedural and perioperative standards have been established at our institution. The initial outcomes utilizing this multidisciplinary approach are excellent and patient satisfaction is overwhelmingly positive.