What are the indications for a maze procedure in adults with symptomatic atrial fibrillation, particularly those with a history of cardiovascular disease or other risk factors who have not responded to treatments such as medication (e.g. beta blockers, anti-arrhythmic medications) or cardioversion?

Indications for Maze Procedure

The maze procedure should be considered in patients with symptomatic atrial fibrillation undergoing cardiac surgery for other indications (Class IIa recommendation), and may be performed as a stand-alone minimally invasive procedure in symptomatic patients after catheter ablation failure (Class IIb recommendation). 1

Primary Indications

Concomitant Cardiac Surgery (Strongest Indication)

• Surgical ablation of AF should be considered in patients with symptomatic AF undergoing cardiac surgery (Class IIa, Level A evidence) 1
• This applies particularly to patients undergoing:
  • Mitral valve surgery (repair or replacement) 2, 3
  • Coronary artery bypass grafting 1
  • Other structural cardiac repairs 1, 4
• The procedure achieves 75-95% freedom from AF over 15 years when combined with mitral valve surgery 1

Symptomatic AF Refractory to Medical Management

The maze procedure is indicated when patients have failed conservative treatments including: 2, 5

• Antiarrhythmic medications (beta blockers, amiodarone, other agents)
• Electrical cardioversion
• Rate control strategies

Specific Clinical Scenarios

History of systemic embolism is a compelling indication, particularly when combined with other cardiac surgery 2, 3

Contraindications to anticoagulation make the maze procedure particularly valuable, as successful restoration of sinus rhythm may reduce stroke risk 2, 3

Highly symptomatic AF not well managed with other approaches, especially in younger patients who face decades of potential AF-related complications 1, 2

Stand-Alone Maze Procedure (More Limited Role)

Minimally invasive surgical ablation without concomitant cardiac surgery may be performed in symptomatic patients after catheter ablation failure (Class IIb, Level C evidence) 1

This represents a more selective indication because: 2

• Only 5.3% of AF surgical ablations in the Society of Thoracic Surgeons database were stand-alone procedures
• The procedure requires cardiopulmonary bypass when performed as traditional open surgery 1
• Catheter ablation is typically preferred as second-line therapy after medication failure

Asymptomatic AF (Weaker Indication)

Surgical ablation may be performed in asymptomatic AF patients undergoing cardiac surgery if feasible with minimal risk (Class IIb, Level C evidence) 1

This weaker recommendation reflects uncertainty about benefit in asymptomatic patients, though preventing atrial remodeling and thromboembolic events may justify the approach 1

Patient Selection Factors

Favorable Characteristics

Success rates are higher in patients with: 1

• Smaller left atrial size
• Younger age
• Shorter AF duration (paroxysmal > persistent > permanent)
• Absence of hypertension
• No sleep apnea

Unfavorable Characteristics

The following reduce success but are not absolute contraindications: 1

• Large left atrium (>5.3 cm)
• Advanced age
• Long-standing permanent AF
• Uncontrolled hypertension
• Sleep apnea

Expected Outcomes

Efficacy

• Freedom from atrial tachyarrhythmias: 89-93% at 6-12 months 2
• Freedom from AF without antiarrhythmic drugs: 78-79% at 12 months 2
• Long-term success: 75-95% over 15 years 1
• Quality of life improves significantly to general population levels by 12 months 6

Risks

• Mortality <1% for isolated procedure, higher when combined with other cardiac surgeries 1, 2
• Permanent pacemaker requirement: <10% with modern techniques (historically 4-40%) 7, 4, 8
• Other complications include bleeding, atrial dysfunction, and fluid retention 2

Critical Caveats

Anticoagulation decisions must be based on stroke risk profile (CHA₂DS₂-VASc score), not on whether sinus rhythm is maintained, as AF may recur asymptomatically 1

The procedure does not eliminate the need for long-term anticoagulation in high-risk patients, even when sinus rhythm is successfully restored 1

Consider timing carefully in younger patients: allowing AF to persist for years causes electrical and structural remodeling that may make future rhythm control impossible 1