Open and Thoracoscopic Approaches To Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures) - CAM 70114

Description:
Atrial Fibrillation 
Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by disorganized atrial activation with ineffective atrial ejection. The underlying mechanism of AF involves the interplay between electrical triggering events that initiate AF and the myocardial substrate that permits propagation and maintenance of the aberrant electrical circuit. The most common focal trigger of AF appears to be located within the cardiac muscle that extends into the pulmonary veins. The atria are frequently abnormal in patients with AF and demonstrate enlargement or increased conduction time. Atrial flutter is a variant of AF. 

Treatment 
The first-line treatment for AF usually includes medications to maintain sinus rhythm and/or control the ventricular rate. Antiarrhythmic medications are only partially effective; therefore, medical treatment is not sufficient for many patients. Percutaneous catheter ablation, using endocardial ablation, is an accepted second-line treatment for patients who are not adequately controlled on medications and may also be used as first-line treatment. Catheter ablation is successful in maintaining sinus rhythm for most patients, but long-term recurrences are common and increase over time. Performed either by open surgical techniques or thoracoscopy, surgical ablation is an alternative approach to percutaneous catheter ablation. 

Open Surgical Techniques 
The classic Cox maze III procedure is a complex surgical procedure for patients with AF. It involves sequential atriotomy incisions that interrupt the aberrant atrial conduction pathways in the heart. The procedure is also intended to preserve atrial pumping function. It is indicated for patients who do not respond to medical or other surgical antiarrhythmic therapies and is often performed in conjunction with correction of structural cardiac conditions such as valve repair or replacement. This procedure is considered the criterion standard for the surgical treatment of drug-resistant AF, with a success rate of approximately 90%. 

The maze procedure entails making incisions in the heart that: 

  • Direct an impulse from the sinoatrial node to the atrioventricular node; 
  • Preserve activation of the entire atrium; and 
  • Block re-entrant impulses responsible for AF or atrial flutter. 

The classic Cox maze procedure is performed on a nonbeating heart during cardiopulmonary bypass. Simplification of the maze procedure has evolved with the use of different ablation tools such as microwave, cryotherapy, ultrasound, and radiofrequency energy sources to create the atrial lesions instead of employing the incisional technique used in the classic maze procedure. The Cox maze IV procedure involves the use of radiofrequency energy or cryoablation to create transmural lesions analogous to the lesions created by the “cut-and-sew” maze. 

Minimally Invasive (Thoracoscopic) Techniques 
Less invasive, transthoracic, endoscopic, off-pump procedures to treat drug-resistant AF have been developed. The evolution of these procedures involves both different surgical approaches and different lesion sets. Alternative surgical approaches include mini-thoracotomy and total thoracoscopy with video assistance. Open thoracotomy and mini-thoracotomy employ cardiopulmonary bypass and open-heart surgery, while thoracoscopic approaches are performed on the beating heart. Thoracoscopic approaches do not enter the heart and use epicardial ablation lesion sets, whereas the open approaches use either the classic “cut-and-sew” approach or endocardial ablation. 

Lesion sets may vary independent of the surgical approach, with a tendency toward less extensive lesion sets targeted to areas most likely to be triggers of AF. The most limited lesion sets involve pulmonary vein isolation and exclusion of the left atrial appendage. More extensive lesion sets include linear ablations of the left and/or right atrium and ablation of ganglionic plexi. Some surgeons perform left atrial reduction in cases of left atrial enlargement. 

The type of energy used for ablation also varies; radiofrequency energy is most commonly applied. Other energy sources such as cryoablation and high-intensity ultrasound have been used. For our purposes, the variations on surgical procedures for AF will be combined under the heading of “modified maze” procedures. 

Hybrid Techniques 
“Hybrid” ablation refers to the use of both thoracoscopic and percutaneous approaches in the same patient. Ablation is performed on the outer surface of the heart (epicardial) via the thoracoscopic approach, and on the inner surface of the heart (endocardial) via the percutaneous approach. The rationale for a hybrid procedure is that a combination of both techniques may result in a complete ablation. Thoracoscopic epicardial ablation is limited by the inability to perform all possible ablation lines because the posterior portions of the heart are not accessible via thoracoscopy. Percutaneous, endoscopic ablation is limited by incomplete ablation lines that often require repeat procedures. By combining both procedures, a full set of ablation lines can be performed, and incomplete ablation lines can be minimized. 

The hybrid approach first involves thoracoscopy with epicardial ablation. Following this procedure, an electrophysiologic study is performed percutaneously followed by endocardial ablation as directed by the results of electrophysiology. Most commonly, the electrophysiology study and endocardial ablation are done immediately after the thoracoscopy as part of a single procedure. However, some hybrid approaches perform the electrophysiology study and endocardial ablation on separate days, as directed by the electrophysiology study. 

Regulatory Status 
Several radiofrequency ablation systems have been cleared for marketing by the U.S. Food and Drug Administration through the 510(k) process for cardiac tissue ablation (product code OCL). Table 1 provides a select list. 

Table 1. Radiofrequency Ablation Approved by the Food and Drug Administration   

Device Manufacturer 510(k) Date
EPi-Sense Guided Coagulation System Atricure April 2021
Medtronic DiamondTemp™ System Medtronic Jan 2021
Cobra Fusion Ablation System AtriCure Feb 2019
Medtronic Cardioblate® System Medtronic Jan 2002
Cardima Ablation System Cardima Jan 2003
Epicor™ Medical Ablation System Epicor Medical Feb 2004
Isolator™ Transpolar™ Pen AtriCure Jun 2005
Estech COBRA® Cardiac Electrosurgical Unit Endoscopic Technologies Dec 2005
Coolrail™ Linear Pen AtriCure Mar 2008
Numeris® Guided Coagulation System with VisiTrax® nContact Surgical Feb 2009
EPi-Sense® Guided Coagulation System with VisiTrax® nContact Surgical Nov 2012

A number of cryoablation systems, which may be used during cardiac ablation procedures, have also been cleared for marketing, including those in Table 2. 

Table 2. Cryoablation Systems Approved by the Food and Drug Administration 

Device Manufacturer 510(k) Date
Cryocare® Cardiac Surgery System Endocare Mar 2002
SeedNet™ System Galil Medical May 2005
SurgiFrost® XL Surgical CryoAblation System CryoCath Technologies; now Medtronic Jul 2006
Isis™ cryosurgical unit Galil Medical Mar 2007
Artic Front Advance™ and Arctic Front Advance Pro™ and the Freezer Max™ Cardiac Cryoablation Catheters Medtronic Jun 2020

Society Guidelines 
The Society of Thoracic Surgeons 2017 clinical practice guideline for the surgical treatment of atrial fibrillation (AF): 

Mitral Valve Operations and Concomitant Surgical Ablation: 

  • Surgical ablation for AF can be performed without additional risk of operative mortality or major morbidity, and is recommended at the time of concomitant mitral operations to restore sinus rhythm. (Class I, Level A) 

Aortic Valve and CABG Operations with Concomitant Ablation: 

  • Surgical ablation for AF can be performed without additional risk of operative mortality or major morbidity, and is recommended at the time of concomitant isolated AVR, isolated CABG, and AVR plus CABG operations to restore sinus rhythm. (Class I, Level B nonrandomized) 

Stand-Alone Surgical Ablation for AF: 

  • Surgical ablation for symptomatic AF in the absence of structural heart disease that is refractory to class I/III antiarrhythmic drugs or catheter-based therapy is reasonable as a primary stand-alone procedure to restore sinus rhythm (Class IIA, Level B) 
  • Surgical ablation for symptomatic persistent or longstanding persistent AF in the absence of structural heart disease is reasonable as a stand-alone procedure using the Cox-Maze III/IV lesion set compared with PVI alone. (Class IIA, Level B nonrandomized) 
  • Surgical ablation for symptomatic AF in the setting of left atrial enlargement (≥ 4.5 cm) or more than moderate mitral regurgitation by PVI alone is not recommended. (Class III no benefit, Level C expert opinion)

Policy 
The maze or modified maze procedure, performed on a non-beating heart during cardiopulmonary bypass with concomitant cardiac surgery, is considered MEDICALLY NECESSARY for the treatment of symptomatic, atrial fibrillation or flutter.

The use of an open maze or modified maze procedure performed on a non-beating heart during cardiopulmonary bypass without concomitant cardiac surgery is considered MEDICALLY NECESSARY for treatment of symptomatic, atrial fibrillation or flutter EITHER of the following are met: 

  • Atrial fibrillation is refractor to at least one class I/III antiarrhythmic drugs, OR;
  • Atrial fibrillation is refractory to catheter-based therapy having had at least one unsuccessful catheter-based ablation

Hybrid ablation (defined as a combined percutaneous and thoracoscopic approach) and minimally invasive, off-pump maze procedures (i.e., modified maze procedures), including those done via mini-thoracotomy, may be considered MEDICALLY NECESSARY for the treatment of symptomatic persistent atrial fibrallation or flutter when all below are met:

  • Atrial fibrillation is refractory to at least one class I/III antiarrhythmic drugs and/or catheter based therapy, AND;
  • Both the surgeon and electrophysiologist agree that the procedure is an appropriate treatment.

All other indications are investigational/unproven therefore considered NOT MEDICALLY NECESSARY, as there is insufficient evidence to support a general conclusion concerning the health outcome of benefits associated with this procedure.

Policy Guidelines
Given the availability of less-invasive alternative approaches to treat atrial fibrillation, performing the maze procedure without concomitant cardiac surgery should rarely be needed.

Per the 2017 Expert Consensus Statement by the Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society (Calkins et al, 2017, referenced in the Supplemental Information section), the indication for concomitant open or closed surgical ablation, stand-alone, and hybrid surgical ablation of atrial fibrillation is symptomatic disease refractory or intolerant to at least 1 Class I or III antiarrhythmic medication.

Coding
See the Codes table for details.

Benefit Application

Rationale
Summary of Evidence 
For individuals who have symptomatic AF or flutter who are undergoing cardiac surgery with bypass who received a Cox maze or a modified maze procedure, the evidence includes several randomized controlled trials (RCTs) and nonrandomized comparative studies, along with systematic reviews of these studies. Relevant outcomes are overall survival, medication use, and treatment-related morbidity. Several small RCTs have provided most of the direct evidence confirming the benefit of a modified maze procedure for patients with AF who are undergoing mitral valve surgery. These trials have established that the addition of a modified maze procedure results in a lower incidence of atrial arrhythmias following surgery, with minimal additional risks. Observational studies have supported these RCT findings. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. 

For individuals who have symptomatic, drug-resistant AF or flutter who are not undergoing cardiac surgery with bypass who receive minimally invasive, off-pump thoracoscopic maze procedures, and the evidence includes RCTs and observational studies, some of which identify control groups. Relevant outcomes are overall survival, medication use, and treatment-related morbidity. Most of the direct evidence comparing surgical AF ablation with percutaneous catheter ablation comes from one RCT (FAST) that used video-assisted thoracoscopy in patients with antiarrhythmic drug-refractory atrial fibrillation with left atrial dilatation and hypertension, 67% of which had previously failed CA. In FAST, at one year, thoracoscopic ablation had higher success at maintaining sinus rhythm (36.5% for CA and 65.6% for surgical ablation), but also reported higher adverse event rates compared with CA. At 7 years, outcomes were consistently improved with thoracoscopic ablation, but interpretation of those findings is limited by important flaws in study conduct. In contrast, findings from a small single-center RCT in patients with no previous CA suggested no significant benefit with minimally invasive thoracoscopic ablation and more major complications. The case series have generally reported high success rates, and a few with matched comparison groups have reported higher success 
rates with surgical treatment than with catheter ablation. However, most series lacked a control group, generally only reported short-term outcomes, and did not consistently report adverse events. Therefore, this evidence does not permit definitive conclusions whether a specific approach is superior to the other. Factors, such as previous treatment, the probability of maintaining sinus rhythm, the risk of complications, contraindications to anticoagulation, and patient preference, may all affect the risk-benefit ratio for each procedure.

For individuals who have symptomatic, drug-resistant AF or flutter who are not undergoing cardiac surgery with bypass who receive hybrid thoracoscopic and endocardial ablation procedures, the evidence includes a nonrandomized comparative study and single-arm case series. Relevant outcomes are overall survival, medication use, and treatment-related morbidity. The studies have suggested that hybrid ablation procedures are associated with high rates of freedom from AF. 

Definitions

ATRIAL FLUTTER is a cardiac arrhythmia marked by rapid (about three hundred beats per minute) regular atrial beating, and, usually, a regular ventricular response. 

ATRIOVENTRICULAR (AV) NODE is an area of specialized cardiac muscle that receives the cardiac impulse from the sinoatrial (SA) node and conducts it to the AV bundle and then to the Purkinje fibers and the walls of the ventricles. The AV node is located in the septal wall between the left and right atria. 

ATRIUM is the upper chamber of each half of the heart. Atria is the plural of atrium. 

MYOCARDIUM is the middle layer of the walls of the heart, composed of cardiac muscle. 

SINOATRIAL (SA) NODE is a specialized group of cardiac muscle cells in the wall of the right atrium at the entrance to the superior vena cava. These cells depolarize spontaneously and rhythmically to initiate normal heartbeats. 

SUPRAVENTRICULAR TACHYCARDIA (SVT) is any cardiac rhythm with a rate exceeding one hundred (100) beats per minute that originates above the branching part of the atrioventricular bundle, that is, in the sinus node, atria, or AV junction. 

TACHYCARDIA is an abnormally rapid heart rate, greater than one hundred (100) beats per minute.

References

  1. Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. Jul 11 2006; 114(2): 119-25. PMID 16818816
  2. Colilla S, Crow A, Petkun W, et al. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. Oct 15 2013; 112(8): 1142-7. PMID 23831166
  3. Kornej J, Börschel CS, Benjamin EJ, et al. Epidemiology of Atrial Fibrillation in the 21st Century: Novel Methods and New Insights. Circ Res. Jun 19 2020; 127(1): 4-20. PMID 32716709
  4. Benjamin EJ, Levy D, Vaziri SM, et al. Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. JAMA. Mar 16 1994; 271(11): 840-4. PMID 8114238
  5. Heeringa J, van der Kuip DA, Hofman A, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J. Apr 2006; 27(8): 949-53. PMID 16527828
  6. Heckbert SR, Austin TR, Jensen PN, et al. Differences by Race/Ethnicity in the Prevalence of Clinically Detected and Monitor-Detected Atrial Fibrillation: MESA. Circ Arrhythm Electrophysiol. Jan 2020; 13(1): e007698. PMID 31934795
  7. Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. Jan 01 2018; 20(1): e1-e160. PMID 29016840
  8. Huffman MD, Karmali KN, Berendsen MA, et al. Concomitant atrial fibrillation surgery for people undergoing cardiac surgery. Cochrane Database Syst Rev. Aug 22 2016; 2016(8): CD011814. PMID 27551927
  9. Phan K, Xie A, Tian DH, et al. Systematic review and meta-analysis of surgical ablation for atrial fibrillation during mitral valve surgery. Ann Cardiothorac Surg. Jan 2014; 3(1): 3-14. PMID 24516793
  10. Reston JT, Shuhaiber JH. Meta-analysis of clinical outcomes of maze-related surgical procedures for medically refractory atrial fibrillation. Eur J Cardiothorac Surg. Nov 2005; 28(5): 724-30. PMID 16143540
  11. Gillinov AM, Gelijns AC, Parides MK, et al. Surgical ablation of atrial fibrillation during mitral-valve surgery. N Engl J Med. Apr 09 2015; 372(15): 1399-409. PMID 25853744
  12. Budera P, Straka Z, Osmančík P, et al. Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study. Eur Heart J. Nov 2012; 33(21): 2644-52. PMID 22930458
  13. Van Breugel HN, Nieman FH, Accord RE, et al. A prospective randomized multicenter comparison on health-related quality of life: the value of add-on arrhythmia surgery in patients with paroxysmal, permanent or persistent atrial fibrillation undergoing valvular and/or coronary bypass surgery. J Cardiovasc Electrophysiol. May 2010; 21(5): 511-20. PMID 19925605
  14. Saint LL, Damiano RJ, Cuculich PS, et al. Incremental risk of the Cox-maze IV procedure for patients with atrial fibrillation undergoing mitral valve surgery. J Thorac Cardiovasc Surg. Nov 2013; 146(5): 1072-7. PMID 23998785
  15. Kim KC, Cho KR, Kim YJ, et al. Long-term results of the Cox-Maze III procedure for persistent atrial fibrillation associated with rheumatic mitral valve disease: 10-year experience. Eur J Cardiothorac Surg. Feb 2007; 31(2): 261-6. PMID 17158057
  16. Gerdisch M, Lehr E, Dunnington G, et al. Mid-term outcomes of concomitant Cox-Maze IV: Results from a multicenter prospective registry. J Card Surg. Oct 2022; 37(10): 3006-3013. PMID 35870185
  17. Damiano RJ, Badhwar V, Acker MA, et al. The CURE-AF trial: a prospective, multicenter trial of irrigated radiofrequency ablation for the treatment of persistent atrial fibrillation during concomitant cardiac surgery. Heart Rhythm. Jan 2014; 11(1): 39-45. PMID 24184028
  18. Gaita F, Ebrille E, Scaglione M, et al. Very long-term results of surgical and transcatheter ablation of long-standing persistent atrial fibrillation. Ann Thorac Surg. Oct 2013; 96(4): 1273-1278. PMID 23915587
  19. Watkins AC, Young CA, Ghoreishi M, et al. Prospective assessment of the CryoMaze procedure with continuous outpatient telemetry in 136 patients. Ann Thorac Surg. Apr 2014; 97(4): 1191-8; discussion 1198. PMID 24582049
  20. McCarthy PM, Gerdisch M, Philpott J, et al. Three-year outcomes of the postapproval study of the AtriCure Bipolar Radiofrequency Ablation of Permanent Atrial Fibrillation Trial. J Thorac Cardiovasc Surg. Aug 2022; 164(2): 519-527.e4. PMID 33129501
  21. van Laar C, Kelder J, van Putte BP. The totally thoracoscopic maze procedure for the treatment of atrial fibrillation. Interact Cardiovasc Thorac Surg. Jan 2017; 24(1): 102-111. PMID 27664426
  22. Yi S, Liu X, Wang W, et al. Thoracoscopic surgical ablation or catheter ablation for patients with atrial fibrillation? A systematic review and meta-analysis of randomized controlled trials. Interact Cardiovasc Thorac Surg. Dec 07 2020; 31(6): 763-773. PMID 33166993
  23. Phan K, Phan S, Thiagalingam A, et al. Thoracoscopic surgical ablation versus catheter ablation for atrial fibrillation. Eur J Cardiothorac Surg. Apr 2016; 49(4): 1044-51. PMID 26003961
  24. Boersma LV, Castella M, van Boven W, et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial. Circulation. Jan 03 2012; 125(1): 23-30. PMID 22082673
  25. Castellá M, Kotecha D, van Laar C, et al. Thoracoscopic vs. catheter ablation for atrial fibrillation: long-term follow-up of the FAST randomized trial. Europace. May 01 2019; 21(5): 746-753. PMID 30715255
  26. Pokushalov E, Romanov A, Elesin D, et al. Catheter versus surgical ablation of atrial fibrillation after a failed initial pulmonary vein isolation procedure: a randomized controlled trial. J Cardiovasc Electrophysiol. Dec 2013; 24(12): 1338-43. PMID 24016147
  27. Adiyaman A, Buist TJ, Beukema RJ, et al. Randomized Controlled Trial of Surgical Versus Catheter Ablation for Paroxysmal and Early Persistent Atrial Fibrillation. Circ Arrhythm Electrophysiol. Oct 2018; 11(10): e006182. PMID 30354411
  28. Haldar S, Khan HR, Boyalla V, et al. Catheter ablation vs. thoracoscopic surgical ablation in long-standing persistent atrial fibrillation: CASA-AF randomized controlled trial. Eur Heart J. Dec 14 2020; 41(47): 4471-4480. PMID 32860414
  29. Kwon HJ, Choi JH, Kim HR, et al. Radiofrequency vs. Cryoballoon vs. Thoracoscopic Surgical Ablation for Atrial Fibrillation: A Single-Center Experience. Medicina (Kaunas). Sep 26 2021; 57(10). PMID 34684060
  30. Mahapatra S, LaPar DJ, Kamath S, et al. Initial experience of sequential surgical epicardial-catheter endocardial ablation for persistent and long-standing persistent atrial fibrillation with long-term follow-up. Ann Thorac Surg. Jun 2011; 91(6): 1890-8. PMID 21619988
  31. Stulak JM, Dearani JA, Sundt TM, et al. Ablation of atrial fibrillation: comparison of catheter-based techniques and the Cox-Maze III operation. Ann Thorac Surg. Jun 2011; 91(6): 1882-8; discussion 1888-9. PMID 21619987
  32. Wang J, Li Y, Shi J, et al. Minimally invasive surgical versus catheter ablation for the long-lasting persistent atrial fibrillation. PLoS One. 2011; 6(7): e22122. PMID 21765943
  33. Lawrance CP, Henn MC, Miller JR, et al. A minimally invasive Cox maze IV procedure is as effective as sternotomy while decreasing major morbidity and hospital stay. J Thorac Cardiovasc Surg. Sep 2014; 148(3): 955-61; discussion 962-2. PMID 25048635
  34. De Maat GE, Pozzoli A, Scholten MF, et al. Surgical minimally invasive pulmonary vein isolation for lone atrial fibrillation: midterm results of a multicenter study. Innovations (Phila). 2013; 8(6): 410-5. PMID 24356430
  35. Massimiano PS, Yanagawa B, Henry L, et al. Minimally invasive fibrillating heart surgery: a safe and effective approach for mitral valve and surgical ablation for atrial fibrillation. Ann Thorac Surg. Aug 2013; 96(2): 520-7. PMID 23773732
  36. Cui YQ, Li Y, Gao F, et al. Video-assisted minimally invasive surgery for lone atrial fibrillation: a clinical report of 81 cases. J Thorac Cardiovasc Surg. Feb 2010; 139(2): 326-32. PMID 19660413
  37. Edgerton JR, Brinkman WT, Weaver T, et al. Pulmonary vein isolation and autonomic denervation for the management of paroxysmal atrial fibrillation by a minimally invasive surgical approach. J Thorac Cardiovasc Surg. Oct 2010; 140(4): 823-8. PMID 20299028
  38. Han FT, Kasirajan V, Kowalski M, et al. Results of a minimally invasive surgical pulmonary vein isolation and ganglionic plexi ablation for atrial fibrillation: single-center experience with 12-month follow-up. Circ Arrhythm Electrophysiol. Aug 2009; 2(4): 370-7. PMID 19808492
  39. Pruitt JC, Lazzara RR, Ebra G. Minimally invasive surgical ablation of atrial fibrillation: the thoracoscopic box lesion approach. J Interv Card Electrophysiol. Dec 2007; 20(3): 83-7. PMID 18214660
  40. Sirak J, Jones D, Sun B, et al. Toward a definitive, totally thoracoscopic procedure for atrial fibrillation. Ann Thorac Surg. Dec 2008; 86(6): 1960-4. PMID 19022018
  41. Speziale G, Bonifazi R, Nasso G, et al. Minimally invasive radiofrequency ablation of lone atrial fibrillation by monolateral right minithoracotomy: operative and early follow-up results. Ann Thorac Surg. Jul 2010; 90(1): 161-7. PMID 20609767
  42. Wudel JH, Chaudhuri P, Hiller JJ. Video-assisted epicardial ablation and left atrial appendage exclusion for atrial fibrillation: extended follow-up. Ann Thorac Surg. Jan 2008; 85(1): 34-8. PMID 18154774
  43. Yilmaz A, Geuzebroek GS, Van Putte BP, et al. Completely thoracoscopic pulmonary vein isolation with ganglionic plexus ablation and left atrial appendage amputation for treatment of atrial fibrillation. Eur J Cardiothorac Surg. Sep 2010; 38(3): 356-60. PMID 20227287
  44. Yilmaz A, Van Putte BP, Van Boven WJ. Completely thoracoscopic bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg. Aug 2008; 136(2): 521-2. PMID 18692667
  45. Geuzebroek GS, Bentala M, Molhoek SG, et al. Totally thoracoscopic left atrial Maze: standardized, effective and safe. Interact Cardiovasc Thorac Surg. Mar 2016; 22(3): 259-64. PMID 26705300
  46. Vos LM, Bentala M, Geuzebroek GS, et al. Long-term outcome after totally thoracoscopic ablation for atrial fibrillation. J Cardiovasc Electrophysiol. Jan 2020; 31(1): 40-45. PMID 31691391
  47. Harlaar N, Oudeman MA, Trines SA, et al. Long-term follow-up of thoracoscopic ablation in long-standing persistent atrial fibrillation. Interact Cardiovasc Thorac Surg. Jun 01 2022; 34(6): 990-998. PMID 34957518
  48. Ad N, Henry L, Hunt S, et al. The outcome of the Cox Maze procedure in patients with previous percutaneous catheter ablation to treat atrial fibrillation. Ann Thorac Surg. May 2011; 91(5): 1371-7; discussion 1377. PMID 21457939
  49. Castellá M, Pereda D, Mestres CA, et al. Thoracoscopic pulmonary vein isolation in patients with atrial fibrillation and failed percutaneous ablation. J Thorac Cardiovasc Surg. Sep 2010; 140(3): 633-8. PMID 20117799
  50. MacGregor RM, Bakir NH, Pedamallu H, et al. Late results after stand-alone surgical ablation for atrial fibrillation. J Thorac Cardiovasc Surg. Nov 2022; 164(5): 1515-1528.e8. PMID 34045056
  51. Mhanna M, Beran A, Al-Abdouh A, et al. Hybrid convergent ablation versus endocardial catheter ablation for atrial fibrillation: A systematic review and meta-analysis. J Arrhythm. Dec 2021; 37(6): 1459-1467. PMID 34887950
  52. Eranki A, Wilson-Smith AR, Williams ML, et al. Hybrid convergent ablation versus endocardial catheter ablation for atrial fibrillation: a systematic review and meta-analysis of randomised control trials and propensity matched studies. J Cardiothorac Surg. Aug 13 2022; 17(1): 181. PMID 35964093
  53. DeLurgio DB, Crossen KJ, Gill J, et al. Hybrid Convergent Procedure for the Treatment of Persistent and Long-Standing Persistent Atrial Fibrillation: Results of CONVERGE Clinical Trial. Circ Arrhythm Electrophysiol. Dec 2020; 13(12): e009288. PMID 33185144
  54. Lee KN, Kim DY, Boo KY, et al. Combined epicardial and endocardial approach for redo radiofrequency catheter ablation in patients with persistent atrial fibrillation: a randomized clinical trial. Europace. Oct 13 2022; 24(9): 1412-1419. PMID 35640923
  55. van der Heijden CAJ, Weberndörfer V, Vroomen M, et al. Hybrid Ablation Versus Repeated Catheter Ablation in Persistent Atrial Fibrillation: A Randomized Controlled Trial. JACC Clin Electrophysiol. Jan 10 2023. PMID 36752455
  56. Jan M, Žižek D, Geršak ŽM, et al. Comparison of treatment outcomes between convergent procedure and catheter ablation for paroxysmal atrial fibrillation evaluated with implantable loop recorder monitoring. J Cardiovasc Electrophysiol. Aug 2018; 29(8): 1073-1080. PMID 29722468
  57. DeLurgio DB, Blauth C, Halkos ME, et al. Hybrid epicardial-endocardial ablation for long-standing persistent atrial fibrillation: A subanalysis of the CONVERGE Trial. Heart Rhythm O2. Feb 2023; 4(2): 111-118. PMID 36873309
  58. La Meir M, Gelsomino S, Lucà F, et al. Minimally invasive surgical treatment of lone atrial fibrillation: early results of hybrid versus standard minimally invasive approach employing radiofrequency sources. Int J Cardiol. Aug 20 2013; 167(4): 1469-75. PMID 22560495
  59. Kress DC, Erickson L, Choudhuri I, et al. Comparative Effectiveness of Hybrid Ablation Versus Endocardial Catheter Ablation Alone in Patients With Persistent Atrial Fibrillation. JACC Clin Electrophysiol. Apr 2017; 3(4): 341-349. PMID 29759446
  60. Maclean E, Yap J, Saberwal B, et al. The convergent procedure versus catheter ablation alone in longstanding persistent atrial fibrillation: A single centre, propensity-matched cohort study. Int J Cardiol. Mar 15 2020; 303: 49-53. PMID 32063280
  61. Mannakkara NN, Porter B, Child N, et al. Convergent ablation for persistent atrial fibrillation: outcomes from a single-centre real-world experience. Eur J Cardiothorac Surg. Dec 02 2022; 63(1). PMID 36346176
  62. Kiankhooy A, Pierce C, Burk S, et al. Hybrid ablation of persistent and long-standing persistent atrial fibrillation with depressed ejection fraction: A single-center observational study. JTCVS Open. Dec 2022; 12: 137-146. PMID 36590727
  63. Bisleri G, Rosati F, Bontempi L, et al. Hybrid approach for the treatment of long-standing persistent atrial fibrillation: electrophysiological findings and clinical results. Eur J Cardiothorac Surg. Nov 2013; 44(5): 919-23. PMID 23475587
  64. Gehi AK, Mounsey JP, Pursell I, et al. Hybrid epicardial-endocardial ablation using a pericardioscopic technique for the treatment of atrial fibrillation. Heart Rhythm. Jan 2013; 10(1): 22-8. PMID 23064043
  65. Gersak B, Pernat A, Robic B, et al. Low rate of atrial fibrillation recurrence verified by implantable loop recorder monitoring following a convergent epicardial and endocardial ablation of atrial fibrillation. J Cardiovasc Electrophysiol. Oct 2012; 23(10): 1059-66. PMID 22587585
  66. La Meir M, Gelsomino S, Lorusso R, et al. The hybrid approach for the surgical treatment of lone atrial fibrillation: one-year results employing a monopolar radiofrequency source. J Cardiothorac Surg. Jul 19 2012; 7: 71. PMID 22812613
  67. Muneretto C, Bisleri G, Bontempi L, et al. Successful treatment of lone persistent atrial fibrillation by means of a hybrid thoracoscopic-transcatheter approach. Innovations (Phila). 2012; 7(4): 254-8. PMID 23123991
  68. Muneretto C, Bisleri G, Bontempi L, et al. Durable staged hybrid ablation with thoracoscopic and percutaneous approach for treatment of long-standing atrial fibrillation: a 30-month assessment with continuous monitoring. J Thorac Cardiovasc Surg. Dec 2012; 144(6): 1460-5; discussion 1465. PMID 23062968
  69. Pison L, La Meir M, van Opstal J, et al. Hybrid thoracoscopic surgical and transvenous catheter ablation of atrial fibrillation. J Am Coll Cardiol. Jul 03 2012; 60(1): 54-61. PMID 22742400
  70. Zembala M, Filipiak K, Kowalski O, et al. Minimally invasive hybrid ablation procedure for the treatment of persistent atrial fibrillation: one year results. Kardiol Pol. 2012; 70(8): 819-28. PMID 22933215
  71. Geršak B, Zembala MO, Müller D, et al. European experience of the convergent atrial fibrillation procedure: multicenter outcomes in consecutive patients. J Thorac Cardiovasc Surg. Apr 2014; 147(4): 1411-6. PMID 23988287
  72. Civello KC, Smith CA, Boedefeld W. Combined endocardial and epicardial ablation for symptomatic atrial fibrillation: single center experience in 100+ consecutive patients. J Innovations Cardiac Rhythm Manage. 2013;August.
  73. Tonks R, Lantz G, Mahlow J, et al. Short and Intermediate Term Outcomes of the Convergent Procedure: Initial Experience in a Tertiary Referral Center. Ann Thorac Cardiovasc Surg. Feb 20 2020; 26(1): 13-21. PMID 31495813
  74. Badhwar V, Rankin JS, Damiano RJ, et al. The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. Ann Thorac Surg. Jan 2017; 103(1): 329-341. PMID 28007240
  75. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. Jul 09 2019; 74(1): 104-132. PMID 30703431
  76. Ad N, Damiano RJ, Badhwar V, et al. Expert consensus guidelines: Examining surgical ablation for atrial fibrillation. J Thorac Cardiovasc Surg. Jun 2017; 153(6): 1330-1354.e1. PMID 28390766

Coding Section  

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Codes Numbers Description
CPT 33254 

Operative tissue ablation and reconstruction of atria, limited (e.g., modified maze procedure) 

  33255

Operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure); without cardiopulmonary bypass 

  33256

Operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure); with cardiopulmonary bypass 

  33257

Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (e.g., modified maze procedure) (List separately in addition to code for primary procedure)

  33258

Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (e.g., maze procedure), without cardiopulmonary bypass (List separately in addition to code for primary procedure)

  33259

Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (e.g., maze procedure), with cardiopulmonary bypass (List separately in addition to code for primary procedure) 

  33265 

Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (e.g., modified maze procedure), without cardiopulmonary bypass 

  33266

Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure), without cardiopulmonary bypass 

ICD-10-CM (effective 10/01/15) 148.0 Atrial fibrillation and flutter code range
  148.1 Permanent atrial fibrillation
  I48.11 Longstanding persistent atrial fibrillation
  I48.19 Other persistent atrial fibrillation
  I48.20 Chronic atrial fibrillation, unspecified
  I48.21 Permanent atrial fibrillation
  I48.3 Typical atrial flutter 
  I48.4 Atypical atrial flutter

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.  

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community,and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2014 Forward     

10/08/2024 Annual review, no change to policy intent. Updating references.
02/05/2024 Interim review, updating the entire policy with expanded coverage statement allowing for hybrid ablation when clinical criteria is met.
10/11/2023 Annual review, no change to policy intent. Updating background, regulatory, rationale and references.
10/06/2022 Annual review, no change to policy intent. Updating Regulatory Status, rationale and references

10/01/2021 

Annual review, no change to policy intent. Updating rationale and references. 

10/01/2020 

Annual review, no change to policy intent. Updating rationale and references. 

10/03/2019 

Annual review, policy statements 2 and 3 rewritten to state: Minimally invasive, off-pump maze procedures (i.e., modified maze procedures), including those done via mini-thoracotomy, are investigational and/or unproven and are therefore considered NOT  MEDICALLY NECESSARY for treatment of atrial fibrillation or flutter. Hybrid ablation (defined as a combined percutaneous and thoracoscopic approach) is investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY for the treatment of atrial fibrillation or flutter.

10/03/2018 

Annual review, no change to policy intent. Updating rationale, no other changes. 

10/02/2017 

Annual review, removed "symptomatic, drug-resistant" as descriptors in the policy statement, no change to the policy intent. Updating background, description, regulatory status, rationale and references. 

10/10/2016 

Annual review, no change to policy intent. Updating background, description, rationale and references. 

10/15/2015 

Annual review, policy statement updated, the phrase "without concomitant cardiac surgery" was removed from the first bullet and the follwing statement was added: “not medically necessary” statement for Maze done without concurrent cardiac surgery.

10/06/2014

Annual review. No change to policy intent. Updated background, rationale and references. Added coding section.

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