Surgical Techniques Used for the Treatment of Atrial Fibrillation

Abstract

The use of surgical lesion sets for the treatment of atrial fibrillation has been increasing, particularly in patients with complicated anatomical substrates and those undergoing concomitant surgery. Preferences in terms of lesion set, surgical approach and ablation technology vary by center. This review discusses both the surgical techniques and the outcomes for the most commonly performed procedures in the context of recent consensus guidelines. The Cox-Maze IV, pulmonary vein isolation, extended left atrial lesion sets, the hybrid approach and ganglionated plexus ablation are each reviewed in an attempt to provide insight into current clinical practice and patient selection

Surgical ablation for atrial fibrillation

“…No unidirectional device has been able to uniformly create transmural lesions that have likely affected procedural success. At this time, there is no standardized approach to this procedure, with multiple groups performing a combination of lesions summarized in Table 2 [23]. …”

“…Most groups perform epicardial pulmonary vein isolation by way of a radiofrequency clamp in addition to various other lesions (Table 2) [23]. It is important with the mitral isthmus line that the lesion be completed both endocardially and epicardially because epicardial ablation alone is not trans-mural and leaves patients susceptible to the development of atrial flutter.…”

Executive Summary of the II Brazilian Guidelines for Atrial Fibrillation

“…This mixed approach is aimed to patients with persistent AF or long-standing persistent AF, to whom the use of one of these techniques alone would be unsatisfactory. 66-73 …”

Finding Our Way through the Maze

“…Due to the technical complexity and increased cardiopulmonary bypass time required to perform a traditional cut‐and‐sew Cox‐Maze III operation, many attempts have been made over the last three decades to simplify the procedure . From the Cox‐Maze IV onward, the traditional incisions have been replaced with linear ablation techniques using a variety of energy sources such as unipolar and bipolar radiofrequency energy and cryothermy, performed both endocardially and/or epicardially, and via surgical approaches either on‐ or off‐pump …”

“…Nonetheless, the sternotomy, cardiopulmonary bypass, and cardioplegic arrest along with the associated operative risks and the “pain and recovery” from open heart surgery remains a hefty price for the treatment of AF alone and as such, there is a growing role for “minimally invasive” surgical approaches using novel energy delivery devices such as epicardial/endocardial hybrid and staged procedures, and variations on epicardial radiofrequency ablation via closed‐chest transdiaphragmatic ports, bilateral thoracoscopies, and lateral mini‐thoracotomies. The efficacy of these less‐invasive surgical approaches and alternative lesion sets requires further evaluation in prospective observational studies and randomized trials . These alternative lesion sets represent simplifications of the cut‐and‐sew Cox‐Maze III and often include only epicardial pulmonary vein isolation.…”