A Minimally Invasive Solution for Atrial Fibrillation: An Interview with Dr. John Sirak

by | Oct 3, 2022 | Issue 157, Issues | 0 comments

Throughout our lives, we rely on our hearts to maintain a steady rhythm to keep us alive and healthy. Unfortunately, for about 33 million people worldwide, that rhythm is interrupted...

Throughout our lives, we rely on our hearts to maintain a steady rhythm to keep us alive and healthy. Unfortunately, for about 33 million people worldwide, that rhythm is interrupted by a condition called atrial fibrillation (AFib), where the heart’s electrical impulses create an irregular, too-fast heartbeat. 

AFib is often treated with major, invasive heart surgery called the Cox-maze procedure. But several years ago, Dr. John Sirak developed a new, less invasive version of that surgery — the 5-box thoracoscopic maze! This revolutionary technique allows patients the benefits of the original Cox-maze procedure with fewer risks and less recovery time.


From Dr. Zhivago to Dr. Sirak

Dr. Sirak is a cardiothoracic surgeon practicing in Lima, Ohio. He arrived at a medical career through a most unusual route, which began during the Russian Revolution of the early 1900s! Decades later, his plan to become a political science professor suddenly took a sharp detour.

“I happened to see the 1963 movie, ‘Dr. Zhivago,’ starring Omar Sharif. It takes place just before the Russian Revolution in 1917. The movie depicts his character as needed by both sides of the revolution because of his medical talent. The universalism of medicine as a calling appealed to me, plus Omar Sharif was a very romantic figure,” Dr. Sirak shared.

The former political science major now had a lot of catching up to do.

“To make up for the science prerequisites for medical school that I had not taken in undergrad, I attended an intensive premedical program and compressed an entire curriculum into about 15 months,” he explained.

The hard work paid off, and he completed medical school at Case Western Reserve University, residencies at the Ohio State University and a Minimally Invasive Cardiac Surgery Fellowship. His career focus was drawn to atrial fibrillation.


About Atrial Fibrillation


What is Atrial Fibrillation?

Atrial fibrillation, or AFib, is an irregular heartbeat originating in the atria (i.e., the upper heart chambers). It interferes with the heart’s electrical impulses, increasing the heartbeat speed and making it hard for the blood to move to the lower ventricles. AFib can cause severe conditions such as blood clots, heart failure and stroke.



In addition to the irregular heart rhythm, symptoms include

  • Extreme fatigue; 
  • Heart palpitations; 
  • A fluttering feeling in the chest; 
  • Dizziness or lightheadedness; 
  • Fainting; 
  • Shortness of breath; 
  • Chest pain.



Various medications and procedures can help alleviate the effects of AFib. These include medications to control the heart’s rate and rhythm and blood thinners to reduce blood clots. Procedures use mild electrical shocks to reset the rhythm, pulmonary vein ablations (small scarring), pacemakers and atrial appendage closure. 

The Cox-maze is a major surgical procedure for AFib. It creates scar tissue (i.e., ablations) in a maze-like pattern to block the signals that bring about AFib and promote a normal heart rhythm. 

“The Cox-maze procedures have an anatomically defined set of ablations,” Dr. Sirak explained. “The objective is to isolate affected areas to prevent the spread of arrhythmia. This was open heart surgery, so the sternum was fully divided, the patient was on the heart-lung machine and the heart was arrested.”

But what if you could treat AFib without the risks and lengthy recovery time of open heart surgery?


The 5-Box Thoracoscopic Maze: A Minimally Invasive Alternative

“Particularly patients with persistent atrial fibrillation are often not effectively treated with catheter ablation, but rather need an extensive isolation of the substrate responsible for the arrhythmia,” Dr. Sirak said. “But they don’t want to undergo open heart surgery just for atrial fibrillation. This spawned the desire to develop a less invasive form of the same operation without sacrificing the principles and efficacy of the Cox maze.”

Early iterations of minimally invasive maze surgery omitted key components of the Cox maze for lack of ability to access the key anatomy. 

“The early mini-maze operations were not something that was, at least in academic circles, accepted as a legitimate treatment for persistent atrial fibrillation,” he explained.

Dr. Sirak and colleagues worked to improve the procedure. In 2008, he first performed a completely thoracoscopic maze procedure which achieved equivalence in the key technical objectives of a Cox maze, and which allowed unambiguous verification in real time of all the ablations. 

“All of the ablations are enclosed in boxes, allowing us to confirm that each portion of the anatomy is truly isolated at each step. In fact, the operation is designed such that one cannot proceed to the next step without having demonstrated electrical block in the previous,” he said. “We’re basically just making incisions large enough to accommodate a 10-millimeter port. It’s a tube inserted through this very small incision, about 1 inch long.”

The ablations include all potential sources of AFib to ensure an effective cure for persistent atrial fibrillation.

Dr. Sirak created the 5-box thoracoscopic maze, a minimally invasive operation that duplicates the effects of the more complicated Cox-maze procedure. This procedure is performed with a closed chest and on the beating heart, without a heart-lung machine.

In an interview with StopAfib.org, Dr. Sirak summarized the procedure. A combination of radiofrequency (heat-based) and cryothermic ablations act synergistically to electrically isolate the areas responsible for AFib. Every patient, no matter how advanced his/her atrial fibrillation may be, receives the same set of ablations. Enclosing the ablation in ‘boxes’ allows verification that each ablation line is intact, as even a gap of 1 mm may cause a difficult-to-treat atrial flutter. Instead of opening the sternum, the approach uses four pencil-sized incisions on each side of the chest, allowing for less discomfort and faster recovery. All patients undergo one week of continuous rhythm monitoring at 3, 6, 13 and 24 months post-surgery. The success rate is 95%, even in persistent atrial fibrillation.


Faster Recovery Times

Recovery times from this procedure vary according to any complications the patient may have. But for those with AFib but otherwise in good health, they can get on with their lives almost immediately,

“One patient was skiing with his family on post-op day six. Another was installing a bathtub on post-op day five,” Dr. Sirak shared. “Patients who tend to have a more vigorous, inflammatory response simply take longer to recover. But when patients go home, they’re not restricted from doing anything. They could run a marathon or go skydiving.”


Following a Calling

Doctors are using minimally invasive procedures on a much more regular basis, as they provide positive outcomes with less stress on the body, less recovery time and less pain and medication. As a result, patients can get back to their everyday lives sooner and enjoy the same benefits gained only after extensive surgical procedures. 

Dr. Sirak is one doctor making these benefits possible for millions of people affected by AFib. 

“It’s all about the universal appeal of medicine as a life calling. Treating patients is one of the most immediate human-to-human contacts that one can encounter. So, seeing them through the entire heart surgery experience is most gratifying. It has totally transformed my perspective on life and my value system,” he concluded.

Thanks to a trip to the past world of “Dr. Zhivago,” AFib patients are benefitting from the insights and expertise of Dr. Sirak.

Gaye Newton

Gaye Newton