Letter From the Guest Editor: Surgical Atrial Fibrillation - What We Must Do and What We Can Do

For the CTSNet Guest Editor Series, "Surgical Atrial Fibrillation - What We Must Do and What We Can Do," we asked Marc W. Gerdisch, MD, to bring together videos that broaden our perspective on atrial fibrillation. Learn more about Dr. Gerdisch by reading his Featured Profile interview.

• There are eight contributor videos in this series. Six videos were released between May 14 and May 21, 2021, and two additional videos were added in November, 2021. Video titles are listed below this letter from the guest editor.
• On Saturday, May 22, CTSNet hosted Dr. Gerdisch and three of his contributors for a live discussion to culminate this series. Watch the archived live roundtable discussion.

Dear CTSNet Reader,

“Surgical Atrial Fibrillation - What We Must Do and What We Can Do” is intended as a body of presentations cementing fundamentals of surgeons’ ability to very effectively treat atrial fibrillation and broadening our perspective on surgeons’ role in rhythm disorders. The burden of proof is no longer on surgeons who propose ubiquitous, aggressive surgical concomitant treatment of atrial fibrillation, but instead on those who deny it to their patients. Every heart surgeon should have a cogent understanding of how Dr. Cox and colleagues arrived at the Cox Maze, the purpose of the lesions, and perhaps most importantly how to achieve success. Diligent attention to detail is an absolute requirement, and knowledge of the necessary elements leads to focus and success. I suppose my hope is that all heart surgeons become arrhythmia enthusiasts, as a part of their zeal to restore people to health and longevity.

Imaginative paths to either simpler or less invasive surgical arrhythmia procedures have been born from the career of Dr. Cox as the father of arrhythmia surgery. The challenge becomes how we keep the Cox Maze as our North Star, while increasing the bandwidth of arrhythmia surgery. There are two barriers, both identified by Dr Cox long ago. The first is a means for surgeons to offer some level of rational treatment of atrial fibrillation under varying combinations of surgeon experience and patient complexity. To reach the goal, the operation would have to have iterations of lesser difficulty and, in fact, sometimes sacrifice a modicum of success for a measure of safety. To everyone’s good fortune, the Cox Maze IV and the Cryo-Cox Maze III created leaps in accessibility without diminishing effectiveness. In fact, the execution has been refined to allow any of us to effectively perform the lesions defining what remains the most reliable approach to eradicating atrial fibrillation.

As a discipline, cardiac surgery has run out of excuses for not addressing concomitant atrial fibrillation. Still, data examining frequency of concomitant therapy reveal continued barriers to treatment for patients with their chest open and atria fibrillating. Even the surgical arrythmia purist must recognize that to fully integrate concomitant treatment into the behavior of the broadest range of surgeons facing a variety of patient scenarios, there must be further movement in operative design, seeking to gain the greatest benefit from the least complexity. As paths diverge, it is crucial to document the procedures performed and their efficacy. Indeed, defining efficacy in atrial fibrillation is as contentious as anything in medicine. However, we owe our past champions and our future patients a commitment to stay on the mission.

The second barrier is to lessen the invasiveness of surgical or hybrid procedures treating stand-alone arrhythmia to optimize the patient experience, while building toward the greatest success. Whereas we as individual surgeons may justly believe we can successfully address atrial fibrillation as sole therapy through a small incision, on cardiopulmonary bypass; enough time has passed to know such superb operations will remain employed for a tiny fraction of patients. However, merging our skill sets with advancing technology and electrophysiology partners has produced some wonderful and still changing procedures that are taking their place in the algorithm of patient management. Understanding the applicability of and overlap between these new procedures is the ongoing subject of a never ending but healthy debate, creating a matrix of opportunity in a field that is simply busting at the seams. In fact, its rate limitation is the number of dedicated investigators and providers.

There is a sort of risk that accompanies any new path taken as a cardiac surgeon. Not the risk to the patient, but the risk of investing your energy and emotions into a pursuit that may bear no fruit, while consuming you and leaving behind time you could be spending doing the heart surgery you love. What was it like for the first multidisciplinary team of Drs. Cox, Boineau, and Schuessler to map an unmappable non-rhythm in animals using Grass recorders, while engineering the electrode arrays themselves? Fortunately, there continue to be surgeons and electrophysiologists willing to take the risk and grow the field of surgical arrythmia therapy. It would be impossible to include all of the brilliant contributors around the globe generating the confluent wave of knowledge breaking onto the shore of our future. Let this grouping of presentations serve as a window into the expansive field of surgical treatment of arrhythmia.

Sincerely,

Marc W. Gerdisch, MD
Heart Valve Center at Franciscan Health
Loyola University Medical Center

Guest Editor Series Contributor Videos

1. Non Atriotomy Epicardial Ablation for AF by Eric Okum, MD
2. How to Perform a Hybrid Endocardial / Epicardial Mapping and Ablation for IST/POTS by  Marc La Meir, MD
3. The Historical Perspective of the Cox Maze III by Patrick McCarthy, MD
4. Cox-Maze IV by Ralph J. Damiano Jr., MD, and Lauren Barron, MD
5. Hybrid Ablation of Atrial Fibrillation With Advanced Epi-Endocardial Mapping by Gianluigi Bisleri, MD
6. Contemporary Strategies in Surgical Ablation for Atrial Fibrillation: Concomitant Ablation in Patients Without Mitral Valve Disease by Niv Ad, MD
7. New! Convergent Hybrid Ablation by Christian Shults, MD
8. New! Journey of an Afib Surgeon by Armin Kiankhooy, MD