Contemporary Strategies in Surgical Ablation for Atrial Fibrillation: Concomitant Ablation in Patients Without Mitral Valve Disease

Both the AATS and the STS guidelines for surgical ablation of atrial fibrillation made the highest-level recommendation for surgical treatment for atrial fibrillation be added and performed concomitantly with CABG or valve surgery (1,2). While over 60% of patients with mitral valve disease are surgically ablated, patients with non-mitral valve disease and atrial fibrillation are most often not ablated at the time of CABG or AVR, with only 15%-25% reported incidence of surgical ablation (3, 4) .

This phenomenon of lack of adaptation for surgical ablation procedures, despite over two decades of excellent clinical experience, is a source for a lot of debate and discussions. My own observations identified significant gaps in the education and training of surgeons that lead to deficiencies in the understanding of the magnitude of the negative impact of atrial fibrillation on patient outcomes and to inaccurate perceptions related to the safety and efficacy of these procedures. This is especially true for patients without mitral valve disease where surgeons are reluctant to perform procedures that would not otherwise require left atriotomy. It seems that the majority of surgeons would not perform any surgical ablation or management of the left atrial appendage in such patients. It is clear that the biggest challenge we have to address is the group of patients without mitral valve disease. On top of the very low adoption of the procedures, even when surgical ablation is performed, the ablation pattern is not based on atrial fibrillation pathophysiology and the left atrial size, but on surgical flow and speed considerations only.

It has been shown, by us and others, that the Cox maze procedure is safe and effective with comparable outcomes when performed concomitant to mitral valve or non-mitral valve surgery (5). Surgeons should base the decision to perform surgical ablation procedures on atrial fibrillation pathophysiology and the benefit to patients, not on the type of concomitant procedure.

References:

1. Ad N, Damiano RJ Jr, Badhwar V, Calkins H, La Meir M, Nitta T, Holmes SD, Weinstein AA, Gillinov M. Expert consensus guidelines: Examining surgical ablation for atrial fibrillation. J Thorac Cardiovasc Surg. 2017 Jun;153(6):1330–1354.
2. Badhwar V, Rankin JS, Damiano RJ Jr, Gillinov AM, Bakaeen FG, Edgerton JR, Philpott JM, McCarthy PM, Bolling SF, Roberts HG, Thourani VH, Suri RM, Shemin RJ, Firestone S, Ad N. The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. Ann Thorac Surg. 2017 Jan;103(1):329–334.
3. Ad N, Suri RM, Gammie JS, Sheng S, O’Brien SM, Henry L. Surgical ablation of atrial fibrillation trends and outcomes in North America. J Thorac Cardiovasc Surg. 2012 Nov;144(5):1051–1060.
4. McCarthy PM, Davidson CJ, Kruse J, Lerner DJ, Braid-Forbes MJ, McCrea MM, Elmouethi AM, Furguson MA. Prevalence of atrial fibrillation before surgery and factors associated with concomitant ablation. J THorac and Cardiovasc Surg. 2020Jun;159(6):2245-2253.
5. Ad N, Holmes SD, Rongione AJ, Badhwar V, Wei L, Fornaresio LM, Massimiano PS. The long-term safety and efficacy of concomitant Cox maze procedures for atrial fibrillation in patients without mitral valve disease. J Thorac Cardiovasc Surg. 2019 Apr;157(4):1505-1514.

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