<s>
The	O
mini-maze	B-Algorithm
procedures	O
are	O
cardiac	O
surgery	O
procedures	O
intended	O
to	O
cure	O
atrial	B-Application
fibrillation	I-Application
(	O
AF	O
)	O
,	O
a	O
common	O
disturbance	O
of	O
heart	O
rhythm	O
.	O
</s>
<s>
James	O
Cox	O
,	O
MD	O
,	O
and	O
associates	O
developed	O
the	O
"	O
maze	O
"	O
or	O
"	O
Cox	O
maze	O
"	O
procedure	O
,	O
an	O
"	O
open-heart	O
"	O
cardiac	O
surgery	O
procedure	O
intended	O
to	O
eliminate	O
atrial	B-Application
fibrillation	I-Application
,	O
and	O
performed	O
the	O
first	O
one	O
in	O
1987	O
.	O
</s>
<s>
During	O
the	O
late	O
1990s	O
,	O
operations	O
similar	O
to	O
the	O
Cox	O
maze	O
,	O
but	O
with	O
fewer	O
atrial	O
incisions	O
,	O
led	O
to	O
the	O
use	O
of	O
the	O
terms	O
"	O
minimaze	B-Algorithm
"	O
,	O
"	O
mini	B-Algorithm
maze	I-Algorithm
"	O
and	O
"	O
mini-maze	B-Algorithm
"	O
,	O
although	O
these	O
were	O
still	O
major	O
operations	O
.	O
</s>
<s>
Until	O
recently	O
this	O
was	O
not	O
thought	O
possible	O
;	O
as	O
recently	O
as	O
2004	O
,	O
Dr.	O
Cox	O
defined	O
the	O
mini-maze	B-Algorithm
as	O
requiring	O
an	O
endocardial	O
approach	O
:	O
</s>
<s>
In	O
2002	O
Saltman	O
performed	O
a	O
completely	O
endoscopic	B-Application
surgical	O
ablation	B-Algorithm
of	O
AF	O
and	O
subsequently	O
published	O
their	O
results	O
in	O
14	O
patients	O
.	O
</s>
<s>
Their	O
method	O
came	O
to	O
be	O
known	O
as	O
the	O
minimaze	B-Algorithm
or	O
microwave	O
minimaze	B-Algorithm
procedure	I-Algorithm
,	O
because	O
microwave	O
energy	O
was	O
used	O
to	O
make	O
the	O
lesions	O
that	O
had	O
previously	O
been	O
performed	O
by	O
the	O
surgeon	O
's	O
scalpel	O
.	O
</s>
<s>
This	O
came	O
to	O
be	O
known	O
as	O
the	O
Wolf	O
minimaze	B-Algorithm
procedure	I-Algorithm
.	O
</s>
<s>
Today	O
,	O
the	O
terms	O
"	O
minimaze	B-Algorithm
"	O
,	O
"	O
mini-maze	B-Algorithm
"	O
,	O
and	O
"	O
mini	B-Algorithm
maze	I-Algorithm
"	O
are	O
still	O
sometimes	O
used	O
to	O
describe	O
open	O
heart	O
procedures	O
requiring	O
cardiopulmonary	O
bypass	O
and	O
median	O
sternotomy	O
,	O
but	O
more	O
commonly	O
they	O
refer	O
to	O
minimally	O
invasive	O
,	O
epicardial	O
procedures	O
not	O
requiring	O
cardiopulmonary	O
bypass	O
,	O
such	O
as	O
those	O
developed	O
by	O
Saltman	O
,	O
Wolf	O
,	O
and	O
others	O
.	O
</s>
<s>
The	O
"	O
maze	O
"	O
lesions	O
are	O
made	O
epicardially	O
by	O
using	O
radiofrequency	O
,	O
microwave	O
,	O
or	O
ultrasonic	B-Application
energy	O
,	O
or	O
by	O
cryosurgery	O
.	O
</s>
<s>
Completely	O
Endoscopic	B-Application
Microwave	O
Ablation	B-Algorithm
of	O
Atrial	B-Application
Fibrillation	I-Application
on	O
the	O
Beating	O
Heart	O
Using	O
Bilateral	O
Thoracoscopy	O
:	O
The	O
microwave	O
minimaze	B-Algorithm
requires	O
three	O
5mm	O
to	O
1cm	O
incisions	O
on	O
each	O
side	O
of	O
the	O
chest	O
for	O
the	O
surgical	O
tools	O
and	O
the	O
endoscope	O
.	O
</s>
<s>
These	O
tubes	O
are	O
joined	O
,	O
then	O
used	O
to	O
guide	O
the	O
flexible	O
microwave	O
antenna	O
energy	O
source	O
through	O
the	O
sinuses	O
behind	O
the	O
heart	O
,	O
to	O
position	O
it	O
for	O
ablation	B-Algorithm
.	O
</s>
<s>
Video-assisted	O
Bilateral	O
Epicardial	O
Bipolar	O
Radiofrequency	O
Pulmonary	O
Vein	O
Isolation	O
and	O
Left	O
Atrial	O
Appendage	O
Excision	O
:	O
The	O
Wolf	O
minimaze	B-Algorithm
requires	O
one	O
5cm	O
and	O
two	O
1cm	O
incisions	O
on	O
each	O
side	O
of	O
the	O
chest	O
.	O
</s>
<s>
The	O
clamp	O
is	O
subsequently	O
positioned	O
on	O
the	O
left	O
atrium	O
near	O
the	O
left	O
pulmonary	O
veins	O
for	O
ablation	B-Algorithm
.	O
</s>
<s>
Surgical	O
ablation	B-Algorithm
of	O
atrial	B-Application
fibrillation	I-Application
with	O
off-pump	O
,	O
epicardial	O
,	O
high-intensity	B-Architecture
focused	I-Architecture
ultrasound	I-Architecture
:	O
Although	O
the	O
HIFU	B-Architecture
minimaze	B-Algorithm
is	O
performed	O
epicardially	O
,	O
on	O
the	O
normally	O
beating	O
heart	O
,	O
it	O
is	O
also	O
usually	O
performed	O
in	O
conjunction	O
with	O
other	O
cardiac	O
surgery	O
,	O
and	O
so	O
would	O
not	O
be	O
minimally	O
invasive	O
in	O
those	O
cases	O
.	O
</s>
<s>
An	O
ultrasonic	B-Application
device	O
is	O
positioned	O
epicardially	O
,	O
on	O
the	O
left	O
atrium	O
,	O
around	O
the	O
pulmonary	O
veins	O
,	O
and	O
intense	O
acoustic	O
energy	O
is	O
directed	O
at	O
the	O
atrium	O
to	O
destroy	O
tissue	O
in	O
the	O
appropriate	O
regions	O
near	O
the	O
pulmonary	O
veins	O
.	O
</s>
<s>
The	O
mechanism	O
by	O
which	O
AF	O
is	O
eliminated	O
by	O
curative	O
procedures	O
such	O
as	O
the	O
maze	O
,	O
minimaze	B-Algorithm
,	O
or	O
catheter	O
ablation	B-Algorithm
is	O
controversial	O
.	O
</s>
<s>
Supporting	O
this	O
is	O
the	O
finding	O
that	O
targeting	O
these	O
autonomic	O
sites	O
improves	O
the	O
likelihood	O
of	O
successful	O
elimination	O
of	O
AF	O
by	O
catheter	O
ablation	B-Algorithm
.	O
</s>
<s>
The	O
minimaze	B-Algorithm
procedures	I-Algorithm
are	O
alternatives	O
to	O
catheter	O
ablation	B-Algorithm
of	O
AF	O
,	O
and	O
the	O
patient	O
selection	O
criteria	O
are	O
similar	O
.	O
</s>
<s>
Patients	O
are	O
considered	O
for	O
minimaze	B-Algorithm
procedures	I-Algorithm
if	O
they	O
have	O
moderate	O
or	O
severe	O
symptoms	O
and	O
have	O
failed	O
medical	O
therapy	O
;	O
asymptomatic	O
patients	O
are	O
generally	O
not	O
considered	O
.	O
</s>
<s>
Previous	O
cardiac	O
surgery	O
provides	O
technical	O
challenges	O
due	O
to	O
scarring	O
on	O
the	O
outside	O
of	O
the	O
heart	O
,	O
but	O
does	O
not	O
always	O
preclude	O
minimaze	B-Algorithm
surgery	I-Algorithm
.	O
</s>
<s>
Long-term	O
success	O
of	O
the	O
minimaze	B-Algorithm
procedures	I-Algorithm
awaits	O
a	O
consensus	O
.	O
</s>
<s>
Attaining	O
a	O
consensus	O
is	O
hindered	O
by	O
several	O
problems	O
;	O
perhaps	O
the	O
most	O
important	O
of	O
these	O
is	O
incomplete	O
or	O
inconsistent	O
post-procedure	O
follow-up	O
to	O
determine	O
if	O
atrial	B-Application
fibrillation	I-Application
has	O
recurred	O
,	O
although	O
many	O
reasons	O
have	O
been	O
considered	O
.	O
</s>
<s>
It	O
has	O
been	O
clearly	O
demonstrated	O
that	O
longer	O
or	O
more	O
intensive	O
follow-up	O
identifies	O
much	O
more	O
recurrent	O
atrial	B-Application
fibrillation	I-Application
,	O
hence	O
a	O
procedure	O
with	O
more	O
careful	O
follow-up	O
will	O
appear	O
to	O
be	O
less	O
successful	O
.	O
</s>
<s>
For	O
more	O
recent	O
minimaze	B-Algorithm
procedures	I-Algorithm
,	O
only	O
relatively	O
small	O
and	O
preliminary	O
reports	O
are	O
available	O
.	O
</s>
<s>
With	O
those	O
caveats	O
in	O
mind	O
,	O
it	O
can	O
be	O
said	O
that	O
reported	O
short-term	O
freedom	O
from	O
atrial	B-Application
fibrillation	I-Application
following	O
the	O
radiofrequency	O
(	O
"	O
Wolf	O
"	O
)	O
procedure	O
ranges	O
from	O
67%	O
to	O
91%	O
with	O
longer-term	O
results	O
in	O
a	O
similar	O
range	O
,	O
but	O
limited	O
primarily	O
to	O
patients	O
with	O
paroxysmal	B-Application
atrial	I-Application
fibrillation	I-Application
.	O
</s>
