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