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HCM & AFib, Ablation or maze?
Looking for opinions on having an ablation or a maze procedure for AFib with HCM. I'm leaning toward the idea of a maze type of procedure (Wolf Procedure) vs ablation. With HCM already causing scaring on the inside of our hearts it doesn't make sense to me to cause more with an ablation?
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For hypertrophic cardiomyopathy with atrial fibrillation, catheter ablation is often the first option, while surgical ablation (Maze or Mini Maze) is a more definitive but invasive alternative for patients who don't respond to catheter ablation or are already undergoing open-heart surgery. The best choice depends on individual health, the complexity of the AFib, and whether other heart surgeries are needed.
Catheter Ablation
What it is: A minimally invasive procedure where catheters are guided through blood vessels to deliver energy (heat or cold) to create scar tissue, blocking abnormal electrical signals.
Pros: Less invasive than open-heart surgery.
Cons: Recurrence rates for AFib in HCM patients are higher compared to those without HCM, and multiple procedures may be needed.
Surgical Ablation (Maze)
What it is: A surgical procedure, often referred to as Cox Maze, that involves making precise cuts or using energy to create a maze-like pattern of scar tissue in the heart's upper chambers. It can be performed with open-heart surgery or a minimally invasive approach (Mini Maze).
Pros: More effective than catheter ablation for long-term rhythm control, with success rates of 80-90%. Can be combined with other heart surgeries, such as valve repair or coronary artery bypass surgery, in the same procedure.
Cons: More invasive than catheter ablation, with a longer recovery time.
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2 ReactionsHow long did you have HCM before it became obstructive?
Mine is not obstructive, yet.
Better that it is not obstructive. I couldn't believe it when mine became obstructive early this year.
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1 ReactionAre you having new or different symptoms or find out from an ECHO or MRI or some other test that it's become obstructive?
@tommy901
Hi Tommy, I have registered on the Hypertropic Cardiomyopathy and Heart Rhythms groups.
I have an enlarged LA as a result (in all probability) of a lifetime of endurance activities: NovaScotia/Maine/rough water sea kayaking, marathons, etc).
Probable MI 9/22. 10/23 StressTest: cannot exclude mild ischemia of small extent involving the apical anterior wall Recent 3/26 CAC 217, but most all in LAD 187. 10/23. I am fairly sure that's when this began. It is a typical Athletes Heart pattern. LA already stretched. Vulnerable to a strenuous effort at 74 yrs.
That schooch too much.
Afib rxed 10/23 LA 51ml afib 24% NO SYMPTOMS until 2/26. I asked my cardiologist about possible cardioversion. I did not realize her response was fueled by conservative (perhaps old school thinking). She slide sideways and said, 'Not now.....rate control is perfect. mostly 120s/70s, HR always 58 - 68..'
I was in need of "Oh, you are doing fine"
I began to wake up and ACTIVELY seek other input in 9/25. NOW, I was in 100% afib.
First, there was a cardiologist who IMMEDIATELY wanted to do a cardioversion (which was a procedure he was licensed to do). I had begun to research. I knew the reported success of that with a NOW 60ml LA was 0.
I sought an EP's eval in Charlotte 1/26 (a more urban center). He was clear, reasonable. He did NOT advise ablation. In his notes, he emphasized continued perfect control/no symptoms.
On THIS 2/26, I first experienced symptoms. To ME, it was a doozy. 3 days of
left sided moderate 'jabs', total medialstinal fullness, palpitations, random/changing every 20 mins. nasal congestion (venous backup? nasal membranes) which forced me to spend much of day doing deep breathing to feel adequately aerated.
Back in Weaverville, 3/26, I had gotten a 'new' cardiologist who SAID he respected CClinic in our initial visit.
I had decided to seek 'expert' advise 1) now that symptoms had begun and 2) now that I understood the major difference a 60ml LA makes in afib treatment. Of course Cleveland added its testing to existing data. The Wville MD wanted a 14 day Holter to consider med management. I can give that data if you like.
I am focused on CC's 4/26 ECHO which shows:
CURRENT ef=60% (from 72% 12/25 ECHO for EP)
RA = 8
E/e = 8
E/a =3.07
TR peak Vel = 2.7
TR Peak Grad = 30
I have researched to find logical explanation why these numbers reflect a structural sound 'athlete's' heart, not a restrictive failure.
But the squeeze can't keep it up forever. That's why I am fairly sure a Cox 4 at maybe 80% chance of success is the only reasonable chance. Otherwise, its CHF, major thromboembolism or procedures which NO MATTER WHAT THEY CLAIM can not truly get good visualization for a biatrial lesion set and LAA clamping with a LA that big. A robotic approach has limitations. "Trying to flip or maneuver a robotic camera and instruments to meticulously burn the necessary lines on the right atrium and vena cavae through the same tiny ports is a logistical nightmare. Also a robot relies on a single-point pen or wand, which struggles to replicate that firm clamping force across thick, athletic atrial tissue." Mini thoracotomy "Uses direct vision and specialized hand-held bipolar radiofrequency clamps allows the surgeon to physically clamp the atrial tissue, ensuring a "transmural" (full-thickness) scar line. BUT
"When working through a tight space between the ribs (a right mini-thoracotomy), the surgeon's angle of approach to the left side of the heart is physically constrained. It is much harder to maneuver the rigid clamping tool all the way around the left pulmonary veins and back toward the left atrial appendage." There is also difficulty freezing a perfect mitral isthmus line.
In conclusion, it seems an important factor that, "a surgeon may decide that for a 77-year-old patient, a faster, highly efficient 45-minute open-chest procedure is safer for the brain, kidneys, and body than a highly tedious, 90-minute restricted-view thoracotomy."
That is a lot of my story. Oh BTW, the most recent cardiologist who said he respected CC?...he said HE " disagreed with their advise, b/c HE BELIEVED IN DOING NO HARM???!!! " He could not tell me what he DID advise as a treatment plan which ALSO showed an awareness of how the enlarged LA changes the "living a long, happy life with afib" statement he made. I MUST find a local cardiologist who is open to various options and is able to give neutral pro/con evaluation.
You are the only commenter I see who may have some suggestions of where/how to find my cohort. The ELA makes treating the afib difficult. Getting supportive/helpful advise is difficult. Even finding a supportive informed local cardiologist is hard. Ideas? Thank you for your time. Susan
Hi, I'm not sure your email was meant for me. I did read it and got a
little lost in the details(which I totally understand given all of the
issues I have with my own heart) but if one of your main concerns is afib
you may want to research the Wolf Procedure which is done at Houston
Methodist in Houston, TX. There is a very helpful Facebook forum called The
Wolf Procedure - Live AFib free. Good luck.
Brian
@lobribc
Thank you Brian. I was fascinated by the simplicity of the Wolf Procedure when I looked into it. Watched the videos, read several papers of theirs. What I have learned is that - with an enlarged LA, one can NOT ONLY do the pulmonary lesion set. THAT is what the Wolf procedure does.
I loved the idea that as one of the vidoes stated, "You don't have to worry about the posterior LA backwall". Well, that area contains the cells that go rouge very early in most athlete's enlarging LA situation. Additionally with DOUBLE the size of the general population's LARGEST LA volume, there is soooooooo much more tissue to develop erratic signals. The mitral isthmus is a real conduction line. Not addressed in Wolf.
I liked the idea of a wolf procedure. Good for many people. Quite adequate for many situations if your specifics fit. Thanks
Susan.
@beauchamp Hello Susan, you are trying to get some feedback from other participants in this HCM discussion. We do not give any medical advice in these discussions, that's the job of the professionals, we do share experiences and as you definitely asked, suggestions. Are you getting care at a COE (Center of Excellence)? It's a very important way to receive treatment along with a longer-term plan to get you back on track to your regular life. Most of us are very unfamiliar with the abbreviations and acronyms you used as well as the detailed description of your experiences. May I suggest you contact the Hypertrophic Cardiomyopathy Association 4hcm.org and do an intake interview very soon. They help many people like us who at some point say "I MUST find a local cardiologist who is open to various options and is able to give neutral pro/con evaluation" as well as offer concrete suggestions to get the specific care you need. BTW, I was 3 weeks shy of my 76th birthday when I had a septal myectomy, us older people who are in otherwise good health, follow good habits and are active are generally good candidates for intervention. Do give us updates on how your journey through this!