Hybrid Catheter & Surgical Ablation

Hybrid Catheter and Surgical Ablation is a new and innovative treatment option for patients with chronic or difficult to treat atrial fibrillation (AF). HyCASA is innovative because it is the first AF treatment which truly integrates a surgical and a catheter approach into a single procedure.

During HyCASA, the cardiac surgeon and the electrophysiologist work side by side to identify the source of AF and create a pattern of scar on the heart, shown below, to treat these problems. The entire procedure is performed with small incisions, miniature cameras, and instruments with small catheters and electrodes.

The co-disciplinary treatment of AF extends beyond the treatment room. A team of arrhythmia experts develop a unique treatment plan for each individual patient based upon clinical criteria. A specialized nurse coordinator navigates patients through their treatment plan to completion.

HyCASA is not just a procedure to treat AF, it is a commitment our team makes to the patient to eliminate AF and regain a normal heart rhythm again.


Andy C. Kiser, MD
Paul Mounsey, MD

Advantages of Hybrid Catheter and Surgical Ablation

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 entirely2,3. Until recently, no current technique or device provided access to the posterior left atrium directly.

Trans Abdominal Cardiac Surgery (TRACS) is a 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. Much like a subxyphoid approach, TRACS provides access to the heart without entering the abdomen and without an incision between the ribs or through the sternum. This allows direct vision of the anterior and posterior cardiac structures with minimal hemodynamic compromise. Such access and visualization of the epicardial cardiac surface has enabled epicardial ablation techniques, like Hybrid Catheter and Surgical Ablation (HyCASA), to isolate the left and right atria as a treatment for atrial fibrillation4,5. TRACS eliminates the need for sternotomy or thoracotomy when access to the epicardial surface is necessary.

Hybrid Catheter and Surgical Ablation (HyCASA): Simultaneous Endocardial and Epicardial Ablation

The surgical treatment of atrial fibrillation (AF) is based upon the creation of an anatomical pattern of myocardial scar. The Corridor Procedure6, the Radial Maze Procedure7, and the Cox maze I-III8,9, 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 performed10,11. The mini-maze1 and pulmonary vein isolation12 reduce 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 consequence13,14. 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 disappointing15. Unfortunately, surgeons and cardiologists seldom collaborate in the development of new technologies and innovative approaches to overcome these individual procedural shortcomings.

Hybrid Catheter and Surgical Ablation (HyCASA) has been developed by a multidisciplinary team of cardiologist and cardiac surgeons to address the procedural and communication barriers. HyCASA is the simultaneous creation of a surgeon’s PEX epicardial ablation pattern and electrophysiologist’s endocardial ablation pattern (Figure 1).

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 HyCASA.

This convergence of technologies and expertise provides or allows for:

  1. the creation of a complete, bi-atrial, endocardial and epicardial ablation pattern without a chest incision or cardiopulmonary bypass;
  2. intra-operative metrics to confirm procedural success;
  3. integrated patient care by cardiology and cardiac surgery; and
  4. decreased length of hospital stay and the number of repeat ablation procedures.

An Integrated Approach to the AF Patient

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.

The consensus opinion by the Heart Rhythm Society Task Force states that, “stand-alone AF surgery should be considered for symptomatic AF patients who prefer a surgical approach, have failed one or more attempts at catheter ablation, or are not candidates for catheter ablation.” Left atrial size and AF duration are important factors in this decision process. When the left atrium is larger than 6.0 cm or the duration of AF is greater than 5 years, the long term success for the Cut and Sew maze procedure are under 80% (Figure 2). It is difficult for the electrophysiologist to consistently and effectively complete pulmonary vein isolation when the left atrium is greater than 5.0 cm. Therefore, when a patient has paroxysmal AF and the left atrium is under 4.5-5.0 cm, we recommend percutaneous catheter ablation. In this population, simple pulmonary vein isolation may be effective in over 80% of patients16.

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. HyCASA has established new criteria for lesion integrity by the verification of procedural completion by endocardial electrophysiologic metrics. HyCASA 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.

Figure 2.


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.

1Wolf RK, Schneeberger EW, Osterday R, Miller D, Merrill W, Flege JB Jr, Gillinov AM. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg. 2005; 130:797-802

2Henry L, Ad N. The Maze procedure: a surgical intervention for ablation of atrial fibrillation. Heart Lung. 2008 Nov-Dec;37(6):432-9.

3Chitwood WR Jr, Wixon CL, Elbeery JR, Moran JF, Chapman WH, Lust RM., Video-assisted minimally invasive mitral valve surgery, J Thorac Cardiovasc Surg. 1997 Nov;114(5):773-80; discussion 780-2

4Kiser AC, Wimmer-Greinecker G, Chitwood WR. Totally extracardiac maze procedure performed on the beating heart. Ann Thorac Surg 2007;84:1783-85

5Kiser AC, Wimmer-Greinecker G, Kapelak B, Bartus K, Sadowski J. Paracardioscopic ex-maze procedure for atrial fibrillation. Innovations 2008; 3:117.

6Defauw JJ, Guiraudon GM, van Hemel NM, Vermeulen FE, Kingma JH, de Bakker JM. Surgical therapy of paroxysmal atrial fibrillation with the "corridor" operation. Ann Thorac Surg. 1992; 53(4):564-70.

7Nitta T, Lee R, Schuessler RB, Boineau JP, Cox JL. Radial approach: a new concept in surgical treatment for atrial fibrillation I. Concept, anatomic and physiologic bases and development of a procedure. Ann Thorac Surg. 1999 Jan;67(1):27-35.2

8Cox JL, Schuessler RB, D'Agostino HJ Jr, et al.The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg. 1991 Apr;101(4):569-83.

9Cox JL, Boineau JP, Schuessler RB, et al. Modification of the Maze procedure for atrial flutter and atrial fibrillation: I. Rationale and surgical results. J Thorac and Cardiovasc Surg 1995; 110:485-495.

10Prasad SM, Maniar HS, Camillo CJ, et al. The Cox maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures. J Thorac Cardiovasc Surg. 2003; 126(6):1822-8.

11Kosakai Y. Treatment of atrial fibrillation using the maze procedure: the Japanese experience. Sem Thor Cardiovasc Surg. 2000; 12:44-52.

12Edgerton JR, Edgerton ZJ, Weaver T, et al. Minimally Invasive Pulmonary Vein Isolation and Partial Autonomic Denervation for Surgical Treatment of Atrial Fibrillation. Ann. Thorac. Surg. July 2008; 86:35-39.

13Barnett SD, Ad N. Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis. J Thorac Cardiovasc Surg. 2006 May;131(5):1029-35.

14Calo I, Lamberti F, Loricchio ML, et al. Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a prospective and randomized study. J Am Coll Cardiol 2006;47:2504-2512.

15Cappato R, Calkins H, Chen SA, et al. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation. 2005;111:1100-1105.

16Haissaguerre M, Jais P, Shah DC, Takahashi A, et al. Spontaneous initiation of atiral fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998; 339:659-666.

A Total Solution

The atrial fibrillation (AF) population is growing

Hybrid Catheter and Surgical Ablation (HyCASA) offers a solution combining the best of surgical and catheter techniques for treating chronic AF types.

From 2005 to 2050 it is estimated that patients suffering AF in the United States will grow from 5 million to 16 million. This increase is largely due to an aging population.

AF has often been thought of as a benign disease. It is not. Current estimates indicate that AF is responsible for up to 25% of all strokes, or 140,000 strokes annually. AF has an associated mortality rate of 4.5% per year.

More recently, AF has been described as a degenerative disease that may be associated with cardiac dysfunction and early heart failure.

Current AF treatments have limited success. Current guidelines stress symptomatic treatment of atrial fibrillation only.

Rate and rhythm drugs

The first line of treatment for AF is rate or rhythm control drugs. Rate control drugs are not an AF treatment because they slow the rate of the ventricle but leave the patient in AF. They are intended to alleviate symptoms and do not address the primary risks of stroke and death associated with AF. Rhythm drugs can temporarily return the patient to sinus rhythm, but side effects often limit a patient’s time on these drugs. Additionally, it is estimated that 75% of AF patients become refractory to anti-arrhythmic drugs within five years.

Surgical and catheter ablations/pulmonary vein isolation (PVI) techniques for paroxysmal patients.

The gold-standard for the surgical treatment of atrial fibrillation, commonly called a Cox maze procedure, requires an invasive procedure that requires stopping the heart and bypass. This technically challenging procedure is not often performed, but does offer good success. The Cox maze procedure makes bi-atrial lesions through Pulmonary Vein Isolation (PVI) and right-sided lesions on the heart to prevent commonly occurring, post-operative arrhythmias. Recent data suggests that pulmonary vein isolation (PVI) alone (often referred to as a mini-maze) is applicable to less than 1% of the AF population and has some of the same drawbacks as the full-maze procedure. Therefore, a pattern based on the Cox maze procedure addresses the requirement for a bi-atrial lesion set and HyCASA is based on this lesion set.

Catheter ablation offers a minimally invasive way to treat atrial fibrillation by way of PVI and right-sided lesions or PVI alone, but has a variable success rate for first procedures and has a high re-do rate. There are also some significant, though infrequent, risks to structures outside of the heart intrinsic to catheter ablation that arise from the endovascular nature of the technique. However, there is only one device approved in the US for the treatment of atrial fibrillation and it is for catheter ablation. Additionally, catheter ablation and the associated mapping technologies offer the means to positively identify sites of origin for atrial fibrillation.

Significant confusion exists about the efficacy of PVI procedures, regardless of how it is performed. There is a lack of standard reporting methods, and many studies confound results by using various definitions of success. These include patients who continue to use anti-arrhythmic drugs, and patients that have been frequently electrically cardioverted post-operatively.

Catheter based outcomes often include repeat procedures as a definition of success. Results with isolated PVI are obscured by the reporting of results and outcomes using a combination of therapies. Results for isolated PVI are significantly lower than reported when considered in the absence of combination therapies.

HyCASA is a treatment solution for patients with all types of AF that do not need concomitant repair.

Modeled after cut and sew maze

HyCASA is intended to replicate the Cox maze surgical procedure, which is recognized as the gold-standard for the treatment of all types of AF. The cut and sew maze is a comprehensive, bi-atrial pattern that has an overall reported efficacy rate of approximately 75% at two years. The cut and sew maze, however, is a complicated and highly invasive procedure performed on a stopped heart during open cardiac surgery.

Potential advantages of HyCASA versus the Cox maze procedure

  • Performed on the inside and the outside of a beating heart, without bypass
  • Treatment metrics can be established since the heart continues beating and the electrical activity is uninterrupted
  • Intra-operative metrics may suggest improved long-term outcomes
  • A truly minimally invasive procedure. There is no intrusion into the chest cavity
  • Potential for shorter hospital stays and faster recovery


Andy C. Kiser, MD
Paul Mounsey, MD


In the 1980’s pioneering surgeon Dr. James Cox began research into the creation of a surgical technique to treat atrial fibrillation. This research led to the Cox maze procedure; the gold standard for the surgical treatment of atrial fibrillation. The Cox maze provides for the definitive treatment of AF, but is a technically complex, open heart, on-bypass procedure that has made it a less then common procedure.

Improvements on the procedure led, through multiple variations, to the Cox maze III and IV procedures that are more commonly done, but still invasive and with many of those complications associated with procedures requiring bypass.

Percutaneous catheter-based ablation has become a viable treatment option for many cardiac arrhythmias. In fact, the only device approved for the treatment of AF in the United States is a catheter ablation device. Additionally, much of the technological advancement in catheter-based treatments has led to significant improvements in measurement, mapping and guidance abilities. It is now possible to merge a high-resolution X-ray image of the heart with electronic landmarks to create an extremely accurate map of the heart permitting targeted and accurate placement of catheter ablation devices. However, even with all of the technological improvements, Catheter Ablation still has a high ‘re-do’ rate and the first-time success rate is markedly variable.

The Beginning of Hybrid Catheter and Surgical Ablation
Previously known as the Convergent Procedure

Dr. Andy Kiser & Dr. Mark Landers

In January, 2009, Dr. Andy Kiser and Dr. Mark Landers assembled an international team of renowned Surgeons and Cardiologists in Krakow, Poland to explore new ways to treat atrial fibrillation. This team consisted of Dr. Rodney Horton and Dr. Andrew Hume from St. David’s Hospital in Austin, TX, Dr. David Haines from Beaumont Hospital in Detroit, MI, and Dr. Borut Gersak, Dr. Maiaz Sinkovec, and Dr. Andrej Pernat from University Medical Center in Ljubljana, Slovenia. They performed the first Convergent Procedure for atrial fibrillation, bringing together the expertise of cardiac surgeons and electrophysiologists for the treatment of atrial fibrillation.

In 2014, the UNC Center for Heart & Vascular Care, the UNC School of Medicine, and UNC Health Care began using the term Hybrid Catheter and Surgical Ablation (HyCASA) instead of the Convergent Procedure as HyCASA provides a more accurate description of the procedure.

HyCASA allows doctors from different fields of medicine to work side-by-side to simultaneously treat atrial fibrillation.

Until now, catheter ablation and surgery were offered as part of the many treatment options for AF. Following the ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation¹, patients had few non-pharmacological choices; either endocardial ablation or some form of surgical procedure. Many of the medications for atrial fibrillation have significant side effects and frequently failed requiring moving from one drug to another. Now, with HyCASA, patients can have another option that offers the best treatment from all of the specialties, reducing many of the less desirable aspects.

The Hybrid Catheter and Surgical Ablation procedure, pioneered by Dr. Kiser, offered a beating-heart, off-bypass surgical solution to patients with chronic AF.

Pictured (left to right) are Drs. Horton, Haines, Kiser, Bartus, and Hume performing the first convergent procedure in Krakow, Poland. Dr. Krzysztof Bartus and Prof. Jerzy Sadowski from the Jagiellonian University, Department of Cardiovascular Surgery and Transplantology in Krakow, Poland were instrumental in organizing the world’s first hybrid catheter and surgical procedure for atrial fibrillation.

In an effort to further improve on the success of the ablation procedures, Dr. Kiser and a group of dedicated Cardiologists, Nurses and Physician Assistants have sought ways to reduce the less desirable aspects of the procedure, such as incisions in the chest.

Catheter ablation has had significant improvements in recent years, but practitioners have sought ways to reduce the amount of radiation received and the time spent on the entire procedure.

During HyCASA, the surgeons complete their part on the outside surface of the heart. Then the electrophysiologist make an electrical map of the inside of the heart to search for any residual areas which may require further treatment. The electrophysiologist uses a special ablation catheter placed in the large vein in the leg to perform their portion of HyCASA. They are then able to create additional lesions on the inside of the heart in locations that the surgeons are unable to reach without stopping the heart or cutting into the heart. These additional lesions further eliminate atrial fibrillation and prevent it from recurring.

This picture demonstrates the effectiveness of the HyCASA. The area in red is the posterior left atium atrium, the site where the majority of triggers for atrial fibrillation are located. The red color indicates that this area has little, if any, residual electrical activity. This demonstrates the elimination of the electrical problems which cause atrial fibrillation.

This picture (right) demonstrates the effectiveness of the HyCASA. The area in red is the posterior left atrium, the site where the majority of triggers for atrial fibrillation are located. The red color indicates that this area has little, if any, residual electrical activity. This demonstrates the elimination of the electrical problems that cause atrial fibrillation.

Electrophysiologic studies (EPS) and intra-cardiac mapping clearly demonstrate the effectiveness of HyCASA. This allows for less procedure time and less fluoroscopy (radiation) exposure during catheter ablation. For the surgeon, HyCASA reduces the overall operative time, avoids chest incisions and lung deflation, and uses only three miniature abdominal incisions in addition to the access for the catheter ablation.

For the patient, it means less pain, smaller scars and offers a shorter hospital stay and a greater overall procedural success.

¹ Fuster V, Rydén LE, Cannom DS, et al, ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). Circulation. 2006;114:e257-e354

Outcomes and Comparisons

Focal versus wavelet AF

For patients with focal AF, their arrhythmia is a result of a small grouping of cells, foci, sending erratic electrical signals. It is believed that often these foci are located in the pulmonary veins and thus the growth of pulmonary vein isolation (PVI) techniques. Physicians have assumed that focal AF is the primary cause of paroxysmal AF. However, there is no diagnostic to determine this, and wavelet AF can cause paroxysmal AF.

In wavelet patients, AF is caused by macro reentrant circuits that can be located across both atria. Therefore, the cut and sew maze procedure was developed to create a comprehensive lesion pattern across both atria in order to interrupt these electrical signals. Given that the maze pattern works on wavelet patients, it is expected to be even more effective for focal patients than a mini-maze technique.

The exact cause of atrial fibrillation is not well understood. Most researchers believe that AF is due primarily to errant electrical signals within the heart that cause the atria to beat asynchronously with the rest of the heart. Research suggests these erratic electrical signals can originate from a small grouping of cells on or near the pulmonary veins or more generally originate from various areas in the heart. AF that originates from a single source, or foci, of cells is called focal AF. AF that originates from various locations in the left and right atria is termed wavelet AF. Historically, the assumption has been that arrhythmias triggered by focal points within the pulmonary veins are primarily associated with paroxysmal AF. However, there is currently no method to determine if AF is focal or wavelet in nature and wavelet AF may also be paroxysmal in some patients.

Structural heart disease (Coronary Artery Disease, Mitral and Aortic Valve Disease) is associated with the development of AF. Often patients with some type of structural heart disease require heart surgery. During open heart surgery, patients who have AF related to structural heart disease can undergo an ablation procedure to treat their AF at the same time.

What type of AF do you have?

Between 83%-87% of all AF patients have wavelet AF. The breakdown between focal and wavelet paroxysmal patients is unknown, but whether AF is focal or wavelet and whether AF is paroxysmal, persistent, long-standing persistent, or permanent is important to determining the best treatment options for the AF patient.

Comparison of Outcomes

When evaluating outcomes for AF treatment options, carefully evaluate the results based upon:

  • the type of AF;
  • the duration of AF;
  • the size of the left atrium;
  • how the results are reported (% in normal rhythm; % freedom from AF; % not taking antiarrhythmic medications [AADs])
  • how long the patient is evaluated to determine success (10 second ECG; 24 hour Holter monitor; 7 day monitor)

* Gallagher MM, Camm AJ. Classification of atrial fibrillation. PACE. 1992;20:1603-1605

Frequently Asked Questions

What is Hybrid Catheter and Surgical Ablation (HyCASA)?

Hybrid Catheter and Surgical Ablation (HyCASA) is a comprehensive (full maze), bi-atrial lesion pattern that is created epicardially (on the outside surface of the heart) and endocardially (on the inside surface of the heart) while the heart is beating and the patient is off bypass. It is unique because HyCASA integrates the expertise of arrhythmia specialist in cardiac surgery and in electrophysiology in a single, minimally invasive procedure.

Is this just another mini-maze?

The answer is a resounding no. A mini-maze, or pulmonary vein isolation (PVI), is primarily a procedure to treat focal, or paroxysmal, patients who do not have structural heart disease, and who represent less than 15% of AF patients. The HyCASA pattern is a comprehensive lesion pattern that treats both the left and the right atria and is modeled after the cut and sew maze. As such, HyCASA is a potential solution for chronic AF, those patients with persistent and permanent as well as those with symptomatic paroxysmal atrial fibrillation.

Why is a new treatment alternative necessary?

It is estimated that over 40% of atrial fibrillation patients have exhausted all existing treatment alternatives. More than 75% of patients are refractory to drugs within five years, and existing PVI techniques are applicable to only a small portion of the AF population. Surgical and catheter PVI ablations combined address less than 1% of the AF population annually. HyCASA was developed to provide a solution for those patients with difficult to treat, chronic AF.

Can the HyCASA pattern be created in a minimally invasive procedure?

Yes, the HyCASA pattern can be created during a minimally invasive stand-alone procedure. It is truly minimally invasive. The chest is never entered because the procedure is done with a single small incision in the abdomen and with a catheter inserted in a large vessel in the groin. Patients can return to normal activity soon after the procedure, which includes flying and returning to work.

What is TRACS?

TRACS, sometimes referred to as cardioscopy or paracardioscopy, was developed to provide direct access and visualization of the heart. This enables the surgeon to create an extensive epicardial lesion pattern on a beating heart in a closed-chest, minimally invasive procedure.

How is access to the heart enabled through TRACS?

A small incision beneath the sternum allows access to the heart without dividing the sternum (the middle bone in the front of the chest) or entering the space between the ribs. Specially designed instruments provide visualization of the heart surface and a coagulation device is inserted to create a lesion pattern that isolates the electricity of the left and right atria.

Why hasn't HyCASA been available until now?

Until recently, techniques to access the surface of the beating heart had to be performed in an operating room. Because HyCASA is performed with a small incision that does not enter the abdomen or the space around the lungs, the procedure can be performed in a hybrid procedure room where cardiac surgeons and electrophysiologists are now able to work together to treat AF.

Who is the ideal candidate for HyCASA?

The best candidates for HyCASA are the patients who are symptomatic and have failed after taking medications to stop their AF.

Will I be able to stop taking Coumadin?

Perhaps. This decision is only made after careful evaluation and discussions with your Cardiologist.

How long is the Procedure?

Generally, the procedure lasts for 3-5 hours. The procedure is performed while the patient is asleep under anesthesia. During this time, the surgeon and the electrophysiologists create a standard pattern of scar the inside and the outside of the left and right atria. Once completed, the pattern is tested by attempting to cause AF, to make sure the procedure is complete.

How long will I be in the hospital?

It depends. Most patients are discharged on day 3 or 4 of their stay. Patients that are not local to the area remain in the local area for a week after discharge. Since the chest is not normally opened, flying is not usually an issue in the post-operative period.

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