Surgical Ablation
There are several cardiac ablation options for AF treatment that may be
considered: surgical, endocardial only, or hybrid ablation. While the
focus of this review is on hybrid ablation, surgical and endocardial
ablation are described briefly as relevant for patient selection.
Surgical ablation is typically utilized when there is a concomitant
open-heart surgery for a structural issue coupled with pre-existing AF.
It is done via a median sternotomy or a right thoracotomy, both of which
require the patient undergo cardiopulmonary bypass, which is why it is
typically reserved for those undergoing cardiac surgery for concomitant
structural heart issues. The surgical ablation technique that is
considered by many to be the gold standard is the Cox-Maze procedure,
which involves bi-atrial ablation including isolation of the pulmonary
veins and left atrial posterior wall as well as left atrial appendage
(LAA) exclusion.9Published studies have reported high long-term success rates to restore
sinus rhythm and mortality benefits of Cox-Maze surgical ablation. Other
surgical ablation approaches may utilize reduced lesion sets including
those focused only on the left atrium or epicardial only ablation, which
may not achieve transmurality. Several societies have designated
concomitant surgical ablation as a Class I recommendation to perform
concomitantly during structural heart procedures such as valve
repair/replacement or
CABG.10-12 However
despite these recommendations, a study of almost 80,000 patients over
three years from a 2014 Medicare database indicated that an average of
22% of patients had concomitant AF surgical ablation, with rates
varying by specific surgery
type.13 Badhwar et al
report an increase from 52% to 61.5% of patients undergoing surgical
ablation concomitant with AF at the time of mitral valve repair in an
analysis of the Society of Thoracic Surgeons
database.10