New Methods in Management of Atrial Fibrilation

Abstract

urgical treatment for AF has been available for two decades since the original description of the Cox-Maze procedure. Technical advances, including novel energy delivery systems for the creation of atrial lesion sets, and a better understanding of the pathogenesis of AF have also validated surgical ablation as an efficacious concomitant procedure and, occasionally, as a standalone treatment. These advances have paved the way for the development of less invasive approaches, some of which eliminate the need for median sternotomy and CPB (Byrd et al., 2005). Despite this, there is a consensus towards the usefulness of surgical AF ablation especially in patients with structural heart disease. The report of the Heart Rhythm Society (HRS) Task Force indicates that AF ablation must be offered to all patients undergoing other cardiac surgery, as long as the risk of this concomitant procedure remains low, there is a reasonable chance of success, and the surgeon has appropriate experience in antiarrhythmia surgery. With respect to standalone surgical ablation, the HRS Task Force suggests that it may be considered for symptomatic patients willing to undergo surgery, who are either not candidates for catheter-ablation or in whom catheter ablation has failed (Topkara et al., 2006). However, since these recommendations were published in 2007 there have been no multicentre randomised clinical trials to overcome some of the reported limitations or to evaluate tangible endpoints such as functional capacity and long-term mortality. Despite encouraging long-term success rates with open interventions, the invasiveness of median sternotomy in the standalone treatment of AF continues to remain an important consideration. Conversely, whilst percutaneous catheter based techniques offer a minimally invasive approach, the long-term freedom from AF may be variable. As such, there has been growing interest in establishing a minimally invasive approach, either thoracoscopically or by minithoracotomy which may potentially offer a “middle ground”, combining the success rates of conventional open surgery with reduced procedural trauma. However, at the present time the application of these techniques is limited to a few specialist centres, and long-term outcome data is awaited before recommendations can be made (Fuster et al., 2006). In conclusion, this review highlights the widespread acceptance of both “cut and sew” and ablative techniques in the restoration of sinus rhythm, via both open and minimally invasive approaches. Equally we raise the need for well-conducted studies to establish a comparative efficacy in the different types of AF and more accurately evaluate clinical endpoints. The advances in minimally invasive technologies and robotics render the future of surgical AF management an