Surgical ablation to prevent recurrent atrial fibrillation
- Richard Lee, MD, MBA
Richard Lee, MD, MBA
- Professor of Surgery
- Co-Director, Center for Comprehensive Cardiovascular Care
- St. Louis University
- Section Editors
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
- Edward Verrier, MD
Edward Verrier, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington School of Medicine
- Bradley P Knight, MD, FACC
Bradley P Knight, MD, FACC
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
Atrial fibrillation (AF) is associated with an increased risk for stroke, heart failure, and death. An attempt to maintain sinus rhythm is made in patients based on the presence or absence of symptoms and evidence that myocardial function is being compromised. This may involve pharmacologic and nonpharmacologic strategies.
The most commonly performed invasive procedure used in an attempt to maintain sinus rhythm is catheter ablation performed by an electrophysiologist in a specially designed hospital procedure room. This technique is discussed in detail elsewhere. (See "Catheter ablation to prevent recurrent atrial fibrillation: Technical considerations".)
This chapter focuses on the surgical ablation for the prevention of recurrent atrial fibrillation. The role of nonpharmacologic strategies for rate control in AF or to minimize thrombotic risk by left atrial appendage ligation, and an overview of the management of patients with AF are presented separately. (See "Control of ventricular rate in atrial fibrillation: Nonpharmacologic therapy" and "Nonpharmacologic therapy to prevent embolization in patients with atrial fibrillation" and "Overview of atrial fibrillation".)
Work on the arrhythmic mechanisms for atrial fibrillation (AF) has led to a greater appreciation for the underlying process by which premature atrial depolarization can promote areas of microreentry within the atrium that ultimately lead to AF. (See "Mechanisms of atrial fibrillation".)
Several surgical techniques have been developed to maintain sinus rhythm. In most patients, these techniques are employed in patients who are undergoing other cardiac surgery for some other reason (valve repair or replacement, coronary bypass grafting, or corrective surgery for congenital heart disease).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Ferguson TB Jr, Cox JL. Surgery for atrial fibrillation. In: Cardiac Electrophysiology: From Cell to Bedside, 2nd ed, Zipes DP, Jalife J (Eds), Saunders, Philadelphia 1995. p.1567.
- Henn MC, Lancaster TS, Miller JR, et al. Late outcomes after the Cox maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg 2015; 150:1168.
- Cox JL, Canavan TE, Schuessler RB, et al. The surgical treatment of atrial fibrillation. II. Intraoperative electrophysiologic mapping and description of the electrophysiologic basis of atrial flutter and atrial fibrillation. J Thorac Cardiovasc Surg 1991; 101:406.
- Cox JL. The surgical treatment of atrial fibrillation. IV. Surgical technique. J Thorac Cardiovasc Surg 1991; 101:584.
- Cox JL, Boineau JP, Schuessler RB, et al. Electrophysiologic basis, surgical development, and clinical results of the maze procedure for atrial flutter and atrial fibrillation. Adv Card Surg 1995; 6:1.
- Cox JL, Boineau JP, Schuessler RB, et al. Five-year experience with the maze procedure for atrial fibrillation. Ann Thorac Surg 1993; 56:814.
- Kosakai Y, Kawaguchi AT, Isobe F, et al. Modified maze procedure for patients with atrial fibrillation undergoing simultaneous open heart surgery. Circulation 1995; 92:II359.
- Lönnerholm S, Blomström P, Nilsson L, et al. Effects of the maze operation on health-related quality of life in patients with atrial fibrillation. Circulation 2000; 101:2607.
- Cox JL, Jaquiss RD, Schuessler RB, Boineau JP. Modification of the maze procedure for atrial flutter and atrial fibrillation. II. Surgical technique of the maze III procedure. J Thorac Cardiovasc Surg 1995; 110:485.
- Barnett SD, Ad N. Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis. J Thorac Cardiovasc Surg 2006; 131:1029.
- Grady KL, Lee R, Subačius H, et al. Improvements in health-related quality of life before and after isolated cardiac operations. Ann Thorac Surg 2011; 91:777.
- Lee R, McCarthy PM, Wang EC, et al. Midterm survival in patients treated for atrial fibrillation: a propensity-matched comparison to patients without a history of atrial fibrillation. J Thorac Cardiovasc Surg 2012; 143:1341.
- Gaynor SL, Schuessler RB, Bailey MS, et al. Surgical treatment of atrial fibrillation: predictors of late recurrence. J Thorac Cardiovasc Surg 2005; 129:104.
- Nitta T, Lee R, Watanabe H, et al. Radial approach: a new concept in surgical treatment for atrial fibrillation. II. Electrophysiologic effects and atrial contribution to ventricular filling. Ann Thorac Surg 1999; 67:36.
- Nitta T, Lee R, Schuessler RB, et al. 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; 67:27.
- Nitta T, Ishii Y, Ogasawara H, et al. Initial experience with the radial incision approach for atrial fibrillation. Ann Thorac Surg 1999; 68:805.
- Ad N, Henry L, Friehling T, et al. Minimally invasive stand-alone Cox-maze procedure for patients with nonparoxysmal atrial fibrillation. Ann Thorac Surg 2013; 96:792.
- Moten SC, Rodriguez E, Cook RC, et al. New ablation techniques for atrial fibrillation and the minimally invasive cryo-maze procedure in patients with lone atrial fibrillation. Heart Lung Circ 2007; 16 Suppl 3:S88.
- Sandoval N, Velasco VM, Orjuela H, et al. Concomitant mitral valve or atrial septal defect surgery and the modified Cox-maze procedure. Am J Cardiol 1996; 77:591.
- Buber J, Luria D, Sternik L, et al. Left atrial contractile function following a successful modified Maze procedure at surgery and the risk for subsequent thromboembolic stroke. J Am Coll Cardiol 2011; 58:1614.
- Pasic M, Musci M, Siniawski H, et al. The Cox maze iii procedure: parallel normalization of sinus node dysfunction, improvement of atrial function, and recovery of the cardiac autonomic nervous system. J Thorac Cardiovasc Surg 1999; 118:287.
- Pasic M, Musci M, Siniawski H, et al. Transient sinus node dysfunction after the Cox-maze III procedure in patients with organic heart disease and chronic fixed atrial fibrillation. J Am Coll Cardiol 1998; 32:1040.
- Izumoto H, Kawazoe K, Kitahara H, Kamata J. Operative results after the Cox/maze procedure combined with a mitral valve operation. Ann Thorac Surg 1998; 66:800.
- Soni LK, Cedola SR, Cogan J, et al. Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation, but they do increase procedural morbidity. J Thorac Cardiovasc Surg 2013; 145:356.
- Mantovan R, Raviele A, Buja G, et al. Left atrial radiofrequency ablation during cardiac surgery in patients with atrial fibrillation. J Cardiovasc Electrophysiol 2003; 14:1289.
- Kottkamp H, Hindricks G, Autschbach R, et al. Specific linear left atrial lesions in atrial fibrillation: intraoperative radiofrequency ablation using minimally invasive surgical techniques. J Am Coll Cardiol 2002; 40:475.
- Krul SP, Driessen AH, van Boven WJ, et al. Thoracoscopic video-assisted pulmonary vein antrum isolation, ganglionated plexus ablation, and periprocedural confirmation of ablation lesions: first results of a hybrid surgical-electrophysiological approach for atrial fibrillation. Circ Arrhythm Electrophysiol 2011; 4:262.
- Edgerton JR, Brinkman WT, Weaver T, et al. Pulmonary vein isolation and autonomic denervation for the management of paroxysmal atrial fibrillation by a minimally invasive surgical approach. J Thorac Cardiovasc Surg 2010; 140:823.
- Beyer E, Lee R, Lam BK. Point: Minimally invasive bipolar radiofrequency ablation of lone atrial fibrillation: early multicenter results. J Thorac Cardiovasc Surg 2009; 137:521.
- Boersma LV, Castella M, van Boven W, et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial. Circulation 2012; 125:23.
- Chiappini B, Martìn-Suàrez S, LoForte A, et al. Cox/Maze III operation versus radiofrequency ablation for the surgical treatment of atrial fibrillation: a comparative study. Ann Thorac Surg 2004; 77:87.
- Stulak JM, Dearani JA, Sundt TM 3rd, et al. Superiority of cut-and-sew technique for the Cox maze procedure: comparison with radiofrequency ablation. J Thorac Cardiovasc Surg 2007; 133:1022.
- Doty JR, Doty DB, Jones KW, et al. Comparison of standard Maze III and radiofrequency Maze operations for treatment of atrial fibrillation. J Thorac Cardiovasc Surg 2007; 133:1037.
- Muneretto C, Bisleri G, Bontempi L, et al. Successful treatment of lone persistent atrial fibrillation by means of a hybrid thoracoscopic-transcatheter approach. Innovations (Phila) 2012; 7:254.
- Kiser AC, Landers MD, Boyce K, et al. Simultaneous catheter and epicardial ablations enable a comprehensive atrial fibrillation procedure. Innovations (Phila) 2011; 6:243.
- Lee R, McCarthy PM, Passman RS, et al. Surgical treatment for isolated atrial fibrillation: minimally invasive vs. classic cut and sew maze. Innovations (Phila) 2011; 6:373.
- Gillinov AM, Saltman AE. Ablation of atrial fibrillation with concomitant cardiac surgery. Semin Thorac Cardiovasc Surg 2007; 19:25.
- Budera P, Straka Z, Osmančík P, et al. Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study. Eur Heart J 2012; 33:2644.
- Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace 2012; 14:528.
- Gillinov AM, Gelijns AC, Parides MK, et al. Surgical ablation of atrial fibrillation during mitral-valve surgery. N Engl J Med 2015; 372:1399.
- Abo-Salem E, Lockwood D, Boersma L, et al. Surgical treatment of atrial fibrillation. J Cardiovasc Electrophysiol 2015; 26:1027.
- Sueda T, Imai K, Ishii O, et al. Efficacy of pulmonary vein isolation for the elimination of chronic atrial fibrillation in cardiac valvular surgery. Ann Thorac Surg 2001; 71:1189.
- de Lima GG, Kalil RA, Leiria TL, et al. Randomized study of surgery for patients with permanent atrial fibrillation as a result of mitral valve disease. Ann Thorac Surg 2004; 77:2089.
- Yuda S, Nakatani S, Kosakai Y, et al. Long-term follow-up of atrial contraction after the maze procedure in patients with mitral valve disease. J Am Coll Cardiol 2001; 37:1622.
- Kim KB, Cho KR, Sohn DW, et al. The Cox-Maze III procedure for atrial fibrillation associated with rheumatic mitral valve disease. Ann Thorac Surg 1999; 68:799.
- Handa N, Schaff HV, Morris JJ, et al. Outcome of valve repair and the Cox maze procedure for mitral regurgitation and associated atrial fibrillation. J Thorac Cardiovasc Surg 1999; 118:628.
- Fujita T, Kobayashi J, Toda K, et al. Long-term outcome of combined valve repair and maze procedure for nonrheumatic mitral regurgitation. J Thorac Cardiovasc Surg 2010; 140:1332.
- Deneke T, Khargi K, Grewe PH, et al. Left atrial versus bi-atrial Maze operation using intraoperatively cooled-tip radiofrequency ablation in patients undergoing open-heart surgery: safety and efficacy. J Am Coll Cardiol 2002; 39:1644.
- Sie HT, Beukema WP, Elvan A, Ramdat Misier AR. Long-term results of irrigated radiofrequency modified maze procedure in 200 patients with concomitant cardiac surgery: six years experience. Ann Thorac Surg 2004; 77:512.
- Gaita F, Riccardi R, Caponi D, et al. Linear cryoablation of the left atrium versus pulmonary vein cryoisolation in patients with permanent atrial fibrillation and valvular heart disease: correlation of electroanatomic mapping and long-term clinical results. Circulation 2005; 111:136.
- Deneke T, Khargi K, Grewe PH, et al. Efficacy of an additional MAZE procedure using cooled-tip radiofrequency ablation in patients with chronic atrial fibrillation and mitral valve disease. A randomized, prospective trial. Eur Heart J 2002; 23:558.
- Melo J, Santiago T, Aguiar C, et al. Surgery for atrial fibrillation in patients with mitral valve disease: results at five years from the International Registry of Atrial Fibrillation Surgery. J Thorac Cardiovasc Surg 2008; 135:863.
- McElderry HT, McGiffin DC, Plumb VJ, et al. Proarrhythmic aspects of atrial fibrillation surgery: mechanisms of postoperative macroreentrant tachycardias. Circulation 2008; 117:155.
- Cox JL, Ad N, Palazzo T. Impact of the maze procedure on the stroke rate in patients with atrial fibrillation. J Thorac Cardiovasc Surg 1999; 118:833.
- Lee R, Jivan A, Kruse J, et al. Late neurologic events after surgery for atrial fibrillation: rare but relevant. Ann Thorac Surg 2013; 95:126.
- Pet M, Robertson JO, Bailey M, et al. The impact of CHADS2 score on late stroke after the Cox maze procedure. J Thorac Cardiovasc Surg 2013; 146:85.
- Badhwar V, Rankin JS, Damiano RJ Jr, et al. The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. Ann Thorac Surg 2017; 103:329.
- MAZE PROCEDURE
- Traditional approach
- Radial approach
- Minimally invasive approach
- Limitations and complications
- ENDOCARDIAL SURGICAL ABLATION
- EPICARDIAL PROCEDURES
- COMPARISON OF METHODS
- HYBRID APPROACH
- TREATMENT FAILURES
- LONG-TERM STROKE RISK AND ANTICOAGULATION
- RECOMMENDATIONS OF OTHERS
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS